Abstract
Purpose
The anterior approach is widely used for access to the lumbar spine in the setting of adult deformity either as a stand-alone procedure or in combined anterior–posterior procedures. Access-related complication rates have so far not been reported in an elderly patient population, in which it has been suggested that anterior lumbar surgery is indicated with caution. Here, the complication rates in patients over 60 years of age are reported.
Methods
A retrospective chart review in a consecutive series of 31 patients over 60 years of age and in which a retroperitoneal access to the lumbar spine was performed. All charts including anaesthetic charts were reviewed and the patients’ demographics, exact surgical procedure, comorbidities, and potential risk factors, as well as intraoperative and vascular complications noted. Patients who had revision anterior surgery, anterior surgery for tumour resection, trauma or infection were excluded.
Results
The average age of patients was 64.9 years, ranging 60–81. Eighteen patients were female and 13 male. The average body mass index was 26.7 ranging 18.5–44.0. The indications for surgery were degenerative scoliosis (12 patients), degenerative spondylosis (7 patients), degenerative spondylolisthesis (5 patients), iatrogenic spondylolisthesis following prior posterior decompression (5 patients), and pseudarthrosis following posterolateral instrumented fusion (2 patients). In 10 patients, a single-level anterior lumbar interbody fusion (ALIF) was carried out (1 L3/4, 5 L4/5, 4 L5/S1) and in 11 patients ALIF was performed on two levels (1 L2–4, 1 L3–5, 9 L4–S1). In three patients, 3 levels from L3 to S1 were approached and in seven patients 4 levels from L2 to S1. Patients with three- and four-level anterior lumbar surgery had higher blood loss than two- and one-level surgery (616 ± 340 vs 439 ± 238, p = 0.036). The overall complication rate was 29 % (9/31), which included four vascular injuries and one pulmonary embolism. The vascular complication rate was 13 % (4/31) with two arterial and two venous injuries requiring repair. No major blood loss over 2,000 ml occurred.
Conclusions
Anterior lumbar surgery in an elderly population does not necessarily have higher overall complication rates than in a younger population. The risk of vascular injury requiring repair was higher, but has not resulted in major blood loss and the procedure therefore can be carried out safely. The overall complication rate and blood loss compare favourably to complication rates in posterior adult deformity procedures.
Similar content being viewed by others
References
Behrbalk E, Uri O, Parks RM, Musson R, Soh RC, Boszczyk BM (2013) Fusion and subsidence rate of stand alone anterior lumbar interbody fusion using peek cage with recombinant human bone morphogenetic protein-2. Eur Spine J. doi:10.1007/s00586-013-2948-5
Strube P, Hoff E, Hartwig T, Perka CF, Gross C, Putzier M (2012) Stand-alone anterior versus anteroposterior lumbar interbody single-level fusion after a mean follow-up of 41 months. J Spinal Disord Tech 25:362–369
Dorward IG, Lenke LG, Bridwell KH, O’Leary PT, Stoker GE, Pahys JM, Kang MM, Sides BA, Koester LA (2013) Transforaminal versus anterior lumbar interbody fusion in long deformity constructs: a matched cohort analysis. Spine (Phila Pa 1976). doi:10.1097/BRS.0b013e31828d6ca3
Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G (2006) Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: prevalence and risk factor analysis of 144 cases. Spine (Phila Pa 1976) 31:2329–2336
Weistroffer JK, Perra JH, Lonstein JE, Schwender JD, Garvey TA, Transfeldt EE, Ogilvie JW, Denis F, Winter RB, Wroblewski JM (2008) Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients. Spine (Phila Pa 1976) 33:1478–1483
Jarrett CD, Heller JG, Tsai L (2009) Anterior exposure of the lumbar spine with and without an “access surgeon’’: morbidity analysis of 265 consecutive cases. J Spinal Disord Tech 22:559–564
Quraishi NA, Konig M, Booker SJ, Shafafy M, Boszczyk BM, Grevitt MP, Mehdian H, Webb JK (2013) Access related complications in anterior lumbar surgery performed by spinal surgeons. Eur Spine J 22(Suppl 1):S16–S20
Hamdan AD, Malek JY, Schermerhorn ML, Aulivola B, Blattman SB, Pomposelli FB Jr (2008) Vascular injury during anterior exposure of the spine. J Vasc Surg 48:650–654
Jagannathan J, Chankaew E, Urban P, Dumont AS, Sansur CA, Kern J, Peeler B, Elias WJ, Shen F, Shaffrey ME, Whitehill R, Arlet V, Shaffrey CI (2008) Cosmetic and functional outcomes following paramedian and anterolateral retroperitoneal access in anterior lumbar spine surgery. J Neurosurg Spine 9:454–465
Inamasu J, Guiot BH (2006) Vascular injury and complication in neurosurgical spine surgery. Acta Neurochir (Wien) 148:375–387
Wood KB, Devine J, Fischer D, Dettori JR, Janssen M (2010) Vascular injury in elective anterior lumbosacral surgery. Spine (Phila Pa 1976) 35:S66–S75
Brau SA, Delamarter RB, Schiffman ML, Williams LA, Watkins RG (2004) Vascular injury during anterior lumbar surgery. Spine J 4:409–412
Konig MA, Leung Y, Jurgens S, MacSweeney S, Boszczyk BM (2011) The routine intra-operative use of pulse oximetry for monitoring can prevent severe thromboembolic complications in anterior surgery. Eur Spine J 20:2097–2102
Fantini GA, Pappou IP, Girardi FP, Sandhu HS, Cammisa FP Jr (2007) Major vascular injury during anterior lumbar spinal surgery: incidence, risk factors, and management. Spine (Phila Pa 1976) 32:2751–2758
Fu KM, Smith JS, Burton DC, Shaffrey CI, Boachie-Adjei O, Carlson B, Schwab FJ, Lafage V, Hostin R, Bess S, Akbarnia BA, Mundis G, Klineberg E, Gupta M, International Spine Study G (2013) Outcomes and complications of extension of previous long fusion to the sacro-pelvis: is an anterior approach necessary? World Neurosurg 79:177–181
Schwab FJ, Hawkinson N, Lafage V, Smith JS, Hart R, Mundis G, Burton DC, Line B, Akbarnia B, Boachie-Adjei O, Hostin R, Shaffrey CI, Arlet V, Wood K, Gupta M, Bess S, Mummaneni PV, International Spine Study G (2012) Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J 21:2603–2610
Auerbach JD, Lenke LG, Bridwell KH, Sehn JK, Milby AH, Bumpass D, Crawford CH 3rd, O’Shaughnessy BA, Buchowski JM, Chang MS, Zebala LP, Sides BA (2012) Major complications and comparison between 3-column osteotomy techniques in 105 consecutive spinal deformity procedures. Spine (Phila Pa 1976) 37:1198–1210
Hassanzadeh H, Jain A, El Dafrawy MH, Ain MC, Mesfin A, Skolasky RL, Kebaish KM (2012) Three-column osteotomies in the treatment of spinal deformity in adult patients 60 years old and older: outcome and complications. Spine (Phila Pa 1976). doi:10.1097/BRS.0b013e31827c2415
Baker JK, Reardon PR, Reardon MJ, Heggeness MH (1993) Vascular injury in anterior lumbar surgery. Spine (Phila Pa 1976) 18:2227–2230
Brewster L, Trueger N, Schermer C, Ghanayem A, Santaniello J (2008) Infraumbilical anterior retroperitoneal exposure of the lumbar spine in 128 consecutive patients. World J Surg 32:1414–1419
Shim CS, Lee SH, Shin HD, Kang HS, Choi WC, Jung B, Choi G, Ahn Y, Lee S, Lee HY (2007) Charite versus ProDisc: a comparative study of a minimum 3-year follow-up. Spine (Phila Pa 1976) 32:1012–1018
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Rothenfluh, D.A., Koenig, M., Stokes, O.M. et al. Access-related complications in anterior lumbar surgery in patients over 60 years of age. Eur Spine J 23 (Suppl 1), 86–92 (2014). https://doi.org/10.1007/s00586-014-3211-4
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-014-3211-4