UC UC SF SF Anterior Spine Exposure Expanding Treatment Options - - PDF document

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Sep 17, 2022 407 likes •610 views

UC UC SF SF Anterior Spine Exposure Expanding Treatment Options No Disclosues Charles Eichler , MD UCSF Division of Vascular Surgery VASCULAR SURGERY UC SAN FRANCISCO VASCULAR SURGERY UC SAN FRANCISCO UC UC SF SF Can we get

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VASCULAR SURGERY • UC SAN FRANCISCO

Anterior Spine Exposure

Expanding Treatment Options Charles Eichler , MD UCSF Division of Vascular Surgery

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

No Disclosues

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Can we get you here safely? UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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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

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

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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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VASCULAR SURGERY • UC SAN FRANCISCO

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VASCULAR SURGERY • UC SAN FRANCISCO

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VASCULAR SURGERY • UC SAN FRANCISCO

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

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VASCULAR SURGERY • UC SAN FRANCISCO

Preop evaluation

Discuss with exposure surgeon CT angiogram

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Complications

Vascular
Abdominal
Urologic

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Abdominal complications

Hernias
Ileus/bowel obstruction
Bowel injury

RARE!! CTA

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Urologic complications

Ureter
Place ureteral stent if any concern

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VASCULAR SURGERY • UC SAN FRANCISCO

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Vascular Complications

Arterial
Venous

Direct venous injury, DVT, PE

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VASCULAR SURGERY • UC SAN FRANCISCO

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VASCULAR SURGERY • UC SAN FRANCISCO

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

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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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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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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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VASCULAR SURGERY • UC SAN FRANCISCO

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VASCULAR SURGERY • UC SAN FRANCISCO

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OLIF 5-1 UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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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

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

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VASCULAR SURGERY • UC SAN FRANCISCO

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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

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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VASCULAR SURGERY • UC SAN FRANCISCO

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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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VASCULAR SURGERY • UC SAN FRANCISCO

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VASCULAR SURGERY • UC SAN FRANCISCO

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VASCULAR SURGERY • UC SAN FRANCISCO

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

and with low risk

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

UC SF

VASCULAR SURGERY • UC SAN FRANCISCO