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

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

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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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Anterior Spine Exposure

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

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

No Disclosues

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Why Go Anterior

  • Direct access to lowest lumbar disc

spaces L2-S1

  • Thorough discectomy
  • Major deformity correction
  • Improved fusion rates
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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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

ALIF relatively short

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Preop evaluation

Discuss with exposure surgeon CT angiogram

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Complications

  • Vascular
  • Abdominal
  • Urologic

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Abdominal complications

  • Hernias
  • Ileus/bowel obstruction
  • Bowel injury

RARE!! CTA

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Urologic complications

  • Ureter
  • Place ureteral stent if any concern

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Vascular Complications

  • Arterial
  • Venous

Direct venous injury, DVT, PE

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Master the simple, straightforward cases first !!

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Set up

  • General anesthesia-complete

paralysis

  • Supine-arms abducted
  • Sat monitor on left great toe
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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

  • 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

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

L5-S1

  • Work between the left and right iliac

vein

  • Very easy level
  • Minimal risk of complication
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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

L4-L5

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

segmental artery & vein

  • Must divide ilio-lumbar vein

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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

VASCULAR SURGERY • UC SAN FRANCISCO

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

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

  • 35yo m –needed L4-S1 ALIF--

noted some venous abnormality on spine MRI

  • CTA –left sided IVC
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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

case

  • 50 yo 1 month post op from 2L4-S1

ALIF

  • Cage extrusion

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

case

  • Failed TLIF –two levels-at OSH
  • Hx of PE
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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Conclusion

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

concern

  • complex cases can be done safely

and with low risk