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      Stand-alone anterior lumbar interbody fusion – complications and perioperative results Translated title: Artrodese lombar intersomática anterior por via única – Complicações e resultados perioperatórios

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          Abstract

          Objectives

          Historically, anterior lumbar interbody fusion (ALIF) was related to high rates of intraoperative complications and adverse events related to interbody devices. In recent decades, there have been technical adjustments, and cages that are more suitable have emerged. The aim of this study is to evaluate the efficacy and complication rate of the use of stand-alone mini-ALIF using a self-locking cage.

          Methods

          Retrospective single center study. Inclusion criteria: retroperitoneal mini-ALIF for single-level fusion (L5S1); self-locking cage; DDD/stenosis and grade I spondylolisthesis. Exclusion criteria: posterior supplementation, previous fusion/arthroplasty. Endpoints: surgery data, intraoperative and perioperative adverse events related both to surgical access and to the intersomatic device.

          Results

          Eighty-seven cases were enrolled. Median surgical time was 90 min; median blood loss was 100 mL. The median length of stay in the ICU was zero days; median hospital stay was one day. Ten cases had an adverse event (11.5%): four major adverse events (4.6%; 3 L bleeding; DVT; retroperitoneal haematoma; incisional hernia), and seven minor events (8%; peritoneum injury; minor vascular injury; events related to the cage). No cases of retrograde ejaculation were observed. There was improvement in pain, physical restriction, and quality of life ( p < 0.001).

          Conclusions

          The mini-ALIF procedure performed for single-level fusion at the distal lumbar level demonstrated low adverse event rates related to both the surgical approach and to the intersomatic device, with reduced hospital stay and satisfactory perioperative clinical results.

          Resumo

          Objetivos

          Historicamente, a fusão intersomática lombar anterior (ALIF) esteve relacionada a altas taxas de complicações intraoperatórias e eventos adversos relacionados aos dispositivos intercorporais. Nas últimas décadas, ocorreram ajustes técnicos que propiciaram o surgimento de cages mais adequadas. Este estudo teve como objetivo avaliar as complicações e eficácia do uso de via única por mini-ALIF com uso de cage autobloqueante.

          Métodos

          Estudo retrospectivo de centro único. Critérios de inclusão: mini-ALIF retroperitoneal para a fusão de nível único (L5S1); cage autobloqueante; DDD/estenose e espondilolistese de baixo grau (grau I). Critérios de exclusão: suplementação posterior; fusão/artroplastia prévia. Foram analisados dados de cirurgia, complicações intra e perioperatórias relacionadas ao acesso cirúrgico e ao dispositivo intersomático.

          Resultados

          Foram incluídos 87 casos, todos no nível lombar distal. Mediana de tempo cirúrgico: 90 min; mediana de perda sanguínea: 100 mL. A mediana do tempo de internação na UTI foi zero dia; a mediana de internação hospitalar foi de um dia. Dez casos (11,5%) apresentaram eventos adversos, quatro maiores (4,6%; sangramento de 3 L; TVP; haematoma retroperitoneal; hérnia incisional) e sete menores (8%; lesão de peritônio; lesão vascular menor; ocorrências relacionadas ao implante). Nenhum caso de ejaculação retrógrada foi observado. Houve melhoria em dor, restrição física e qualidade de vida (p < 0,001).

          Conclusões

          O procedimento mini-ALIF feito em um único nível distal lombar apresentou baixas taxas de eventos adversos intra e perioperatórios, tanto quanto à abordagem e ao dispositivo, reduzida estada hospitalar e bons resultados clínicos perioperatórios.

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          Most cited references32

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          Subsidence after anterior lumbar interbody fusion using paired stand-alone rectangular cages.

          The authors conducted a study to determine at what stage after surgery the subsidence occurred, and to assess the relationships of radiographic fusion and the recurrence of symptoms with the development of subsidence. Ninety patients underwent a single-level anterior lumbar interbody fusion (ALIF) using paired stand-alone rectangular cages between November 2000 and June 2002. All patients had regular clinical or imaging follow-up for a minimum of 19 months (range 19-38 months, mean = 27 months). The ratio of male to female patients was 1:3.1. The patients' ages at the time of ALIF ranged from 25 to 72 years, with a mean of 53 years. The preoperative and postoperative intervertebral disc heights were serially measured by plain radiographs. The location of cage subsidence into the vertebral body and times until the presence of subsidence were also assessed. The mean preoperative intervertebral disc height was 11.6+/-3.1 mm, which spread immediately after surgery to 16.9+/-2.0 mm. This increase was statistically significant (P = 0.001). At the last follow-up visit, the mean intervertebral disc height had been reduced to 13.2+/-2.4 mm. Sixty-nine of 90 patients (76.7%) developed cage subsidence into the surrounding vertebral body. Subsidence was more often noted in the superior endplate above the cage with regard to the location of cage subsidence [superior endplate: 27 patients (39.1%), inferior endplate: 12 patients (17.3%), both: 30 patients (43.6%)]. The onset of subsidence varied from 0.25 to 8 months after surgery (median, 2.75 months). The 8-, 12-, and 16-week actuarial rates for developing cage subsidence were 38.9, 63.4, and 70.7%, respectively, when using the Kaplan-Meier method. There was no statistical correlation between the recurrence of symptoms (P = 0.3952) and radiographic fusion (P = 0.9518) with the log-rank test in development of subsidence. This study demonstrates that cage subsidence is an expected occurrence after ALIF using stand-alone rectangular cages. The 3- and 4-month actuarial rates for developing cage subsidence were 63.4 and 70.7%, respectively, and cage subsidence had no correlation with recurrence of symptoms and radiographic fusion in our study.
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            Access related complications in anterior lumbar surgery performed by spinal surgeons.

            Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion (ALIF) and artificial disc replacement (ADR). Our aim was to study the exposure related complications for anterior lumbar spinal surgery performed by spinal surgeons.
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              Adjacent segment motion after a simulated lumbar fusion in different sagittal alignments: a biomechanical analysis.

              An in vitro biomechanical study of adjacent segment motion (at L3-L4 and L5-S1) after a simulated lumbar interbody fusion of L4-L5 in different sagittal alignments was carried out. To test the hypothesis that an L4-L5 fixation in different sagittal alignments causes increased angular motion at the adjacent levels (L3-L4 and L5-S1) in comparison with the intact spine. Clinical experience has suggested that lumbar fusion in a nonanatomic sagittal alignment can increase degeneration of the adjacent levels. It has been hypothesized that this is the result of increased motion at these levels; however, to the authors' knowledge no mechanical studies have demonstrated this. Eight fresh human cadaveric lumbar spines (L3-S1) were biomechanically tested. Total angular motion at L3-L4 and L5-S1 under flexion-extension load conditions (7-Nm flexion and 7-Nm extension) was measured. Each specimen was tested intact, and then again after each of three different sagittal fixation angles (at L4-L5): (1) in situ (21 degrees lordosis), (2) hyperlordotic (31 degrees lordosis), and (3) hypolordotic (7 degrees lordosis). The simulated anterior/posterior fusion was performed at L4-L5 with pedicle screws posteriorly, vertebral body screws anteriorly, and an interbody dowel. The averaged values for flexion-extension motion at L3-L4 were as follows: intact specimen 2.0 degrees, in situ fixation 4.0 degrees, hyperlordotic fixation 1.7 degrees, hypolordotic fixation 6.5 degrees. The averaged values for flexion-extension motions at L5-S1 were as follows: intact specimen 2.3 degrees, in situ fixation 2.6 degrees, hyperlordotic fixation 3.6 degrees, hypolordotic fixation 2.9 degrees. Hypolordotic alignment at L4-L5 caused the greatest amount of flexion-extension motion at L3-L4, and the differences were statistically significant in comparison with intact specimen, in situ fixation, and hyperlordotic fixation. Hyperlordotic alignment at L4-L5 caused the greatest amount of flexion-extension motion at L5-S1, and the difference was statistically significant in comparison with intact specimen but not in situ fixation or hypolordotic fixation.
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                Author and article information

                Contributors
                Journal
                Rev Bras Ortop
                Rev Bras Ortop
                Revista Brasileira de Ortopedia
                Elsevier
                2255-4971
                04 September 2017
                Sep-Oct 2017
                04 September 2017
                : 52
                : 5
                : 569-574
                Affiliations
                [a ]Instituto de Patologia da Coluna (IPC), São Paulo, SP, Brazil
                [b ]University of California San Diego (UCSD), San Diego, United States
                Author notes
                [* ] Corresponding author. marchi@ 123456patologiadacoluna.com.br
                Article
                S2255-4971(17)30134-9
                10.1016/j.rboe.2017.08.016
                5643906
                9423dadb-946a-4efd-92e2-88a37dc3f009
                © 2017 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 18 August 2016
                : 6 September 2016
                Categories
                Original Article

                spine,spinal fusion,arthrodesis,lumbar vertebrae,coluna vertebral,fusão espinal,artrodese,vértebras lombares

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