Anterior Spine Exposure Lessons Learned & Relearned Charles - - PDF document

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Sep 12, 2022 122 likes •391 views

UC SF Anterior Spine Exposure Lessons Learned & Relearned Charles Eichler , MD UCSF Division of Vascular Surgery VASCULAR SURGERY UC SAN FRANCISCO UC SF No Disclosues VASCULAR SURGERY UC SAN FRANCISCO 1 UC SF VASCULAR

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VASCULAR SURGERY • UC SAN FRANCISCO

Anterior Spine Exposure

Lessons Learned & Relearned Charles Eichler , MD UCSF Division of Vascular Surgery

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VASCULAR SURGERY • UC SAN FRANCISCO

No Disclosues

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Why Go Anterior

Direct access to lowest lumbar disc

spaces L2-S1

Thorough discectomy
Major deformity correction
Improved fusion rates

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Routine cases carry a very low risk
f complication
Operative time of one or two level

ALIF relatively short

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ALIF

Effective method to achieve fusion
Allows for correction of deformities
Can be utilized in tumor and

infection cases

But
Critical part of the case is exposure

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How can we do high risk/complex cases with low complication rates?

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Preop evaluation

Discuss with exposure surgeon CT angiogram

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Complications

Vascular
Abdominal
Urologic

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Abdominal complications

Hernias
Ileus/bowel obstruction
Bowel injury

RARE!! CTA

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Urologic complications

Ureter
Place ureteral stent if any concern

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Vascular Complications

Arterial
Venous

Direct venous injury, DVT, PE

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Can we safely do the most complicated spine cases with low complication rate?? YES

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Master the simple, straightforward cases first !!

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Set up

General anesthesia-complete

paralysis

Supine-arms abducted
Sat monitor on left great toe

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Left paramedian incision
Move to midline reflecting rectus

muscle laterally

Incise posterior rectus sheath

longitudinally

Identify and mobilized the ureter

and protect with fixed table retractor

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L5-S1

Work between the left and right iliac

vein

Very easy level
Minimal risk of complication

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L4-L5

Mobilization is lateral/left of vessels
Requires division of the lowest

segmental artery & vein

Must divide ilio-lumbar vein

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How do we do the high risk cases? Do it exactly the same, but with a bit more attention to the anatomy and potential risks

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More iv access
Arterial line
Ureteral catheter
Retrievable ivc filter
Blood products/cell saver

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case

57yo m-hx of previous failed multiple procedures at OSH, but never from anterior TLIF and posterior screws in past Can create severe inflammation

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35yo m –needed L4-S1 ALIF--

noted some venous abnormality on spine MRI

CTA –left sided IVC

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case

50 yo 1 month post op from 2L4-S1

ALIF

Cage extrusion

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case

Failed TLIF –two levels-at OSH
Hx of PE

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Conclusion

Understand basics and anatomy
Full preop w/u with CTA if any

concern

complex cases can be done safely