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Anterior longitudinal ligament release from a posterior approach: an alternative to three-column osteotomy

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Abstract

Purpose

Expansion of the anterior column and compression of the posterior column restores lordosis and sagittal imbalance. Anterior longitudinal ligament (ALL) release has been described from lateral and anterior approaches as a technique to improve lumbar lordosis; however, posterior approach to release the ALL has not been adequately assessed.

Methods

We demonstrate a case series of ALL release using a posterior approach performed in conjunction with posterior column osteotomy (PCO), with or without transforaminal lumbar interbody fusion (TLIF) for spinal deformity. Eleven cases were identified from billing records between 2010 and 2019. Retrospective review was conducted for perioperative complications and revision surgery. Overall and segmental lumbar lordosis (LL) correction was measured from pre- and postoperative imaging.

Results

Eleven patients underwent ALL release with a PCO. Kyphosis, scoliosis, and flat back syndrome were the most common spinal deformities. On average, patients had 9 ± 3 levels fused and a single level ALL release. ALL release was most commonly performed at L1-L2 and L2-L3 levels. An overall LL correction of 28.6° ± 19.8o was achieved; ALL release introduced 16.7° ± 11.9° of lordotic correction and accounted for 49.2 ± 30.4% of the overall lordotic correction. Average blood loss was 1030 ± 573 mL.

Conclusions

ALL release as an adjunct to PCO and TLIF is a viable technique for providing increased deformity correction without subjecting the patient to a more invasive three-column osteotomy. While this approach may not be appropriate for all patients, it represents a useful option in spinal deformity correction while limiting blood loss and additional anterior surgery.

Level of Evidence

IV

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Data availability

The data generated and analysed during the current study are available upon reasonable request to the corresponding author.

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Funding

No external financial support was received for this work.

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Authors and Affiliations

  1. Department of Neurosurgery, University of Maryland Medical Center, 22 S. Greene St, Baltimore, MD, 21201, USA

    Nathan Han, Nathan Pratt, Erik Hayman, Salazar Jones, Timothy Chryssikos, Ashish Sharma, Joshua Olexa & Charles Sansur

  2. Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, USA

    M. Farooq Usmani, Alexandra E. Thomson, Ivan Ye, Daniel L. Cavanaugh, Eugene Y. Koh, Kendall Buraimoh & Steven Ludwig

  3. Department of Orthopaedics, Cooper University Hospital, Camden, NJ, USA

    Parker Johnsen

Authors
  1. Nathan Han
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  2. Nathan Pratt
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  3. M. Farooq Usmani
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  4. Erik Hayman
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  5. Salazar Jones
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  13. Eugene Y. Koh
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  16. Charles Sansur
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Contributions

Nathan Han, Nathan Pratt, M. Farooq Usmani, Erik Hayman, Salazar Jones, Parker Johnsen, Alexandra E. Thomson, Ivan Ye, Timothy Chryssikos, Ashish Sharma, Joshua Olexa, Daniel L. Cavanaugh, Eugene Y. Koh, Kendall Buraimoh, Steven Ludwig, and Charles Sansur made substantial contributions to the study concept or design; or the collection, analysis, or data interpretation. All authors contributed to drafting, revising, and critical review of the work. All authors approved the final version for publication and agree to be accountable for the accuracy and integrity of the work.

Corresponding author

Correspondence to Nathan Han.

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Conflicts of interest

EK is a consultant for Biomet. SL is a board member for the American Board of Orthopaedic Surgery, the American Orthopaedic Association, the Cervical Spine Research Society, and the Society for Minimally Invasive Spine Surgery; is a consultant for DePuy Synthes and K2M/Stryker; is a board member for Nuvasive; receives payment for lectures and travel accommodations from DePuy Synthes and K2M/Stryker; receives payment for patents and royalties from DePuy Synthes; has stock in Innovative Surgical Designs and the American Society for Investigative Pathology; receives research support from AO Spine North America Spine Fellowship support and AOA Omega Grant; is a board member of Maryland Development Corporation; receives royalties from Thieme, Quality Medical Publishers; and is on the editorial board of Journal of Spinal Disorders and Techniques, The Spine Journal, and Contemporary Spine Surgery. CS received royalties from Stryker spine and is a consultant for Stryker and Nuvasive; he has ownership of Maryland Development Center. AT, IY, DC, and KB have nothing to disclose.

Ethical approval

IRB approval was obtained by the University of Maryland IRB (Protocol: HP-00076962) due to the retrospective nature of the study consent requirement was waived by the IRB. This study was conducted in accordance with the 1964 Helsinki Declaration, its amendments, and other equivalent ethical standards.

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Institutional IRB deemed this study was exempt from a written participant consent requirement due to the retrospective nature of the study.

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Institutional IRB deemed this study was exempt from a written participant consent requirement due to the retrospective nature of the study.

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Han, N., Pratt, N., Usmani, M.F. et al. Anterior longitudinal ligament release from a posterior approach: an alternative to three-column osteotomy. Eur Spine J 31, 2196–2203 (2022). https://doi.org/10.1007/s00586-021-07100-y

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  • DOI: https://doi.org/10.1007/s00586-021-07100-y

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