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 SURGERY • UC SAN FRANCISCO UC SF Why Go Anterior • Direct access to lowest lumbar disc spaces L2-S1 • Thorough discectomy • Major deformity correction • Improved fusion rates VASCULAR SURGERY • UC SAN FRANCISCO 2

UC SF • Routine cases carry a very low risk of complication • Operative time of one or two level ALIF relatively short VASCULAR SURGERY • UC SAN FRANCISCO UC SF 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 VASCULAR SURGERY • UC SAN FRANCISCO 3

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 4

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 5

UC SF How can we do high risk/complex cases with low complication rates? VASCULAR SURGERY • UC SAN FRANCISCO UC SF Preop evaluation Discuss with exposure surgeon CT angiogram VASCULAR SURGERY • UC SAN FRANCISCO 6

UC SF Complications • Vascular • Abdominal • Urologic VASCULAR SURGERY • UC SAN FRANCISCO UC SF Abdominal complications • Hernias • Ileus/bowel obstruction • Bowel injury RARE!! CTA VASCULAR SURGERY • UC SAN FRANCISCO 7

UC SF Urologic complications • Ureter • Place ureteral stent if any concern VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 8

UC SF Vascular Complications • Arterial • Venous Direct venous injury, DVT, PE VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 9

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 10

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF Can we safely do the most complicated spine cases with low complication rate?? YES VASCULAR SURGERY • UC SAN FRANCISCO 11

UC SF Master the simple, straightforward cases first !! VASCULAR SURGERY • UC SAN FRANCISCO UC SF Set up • General anesthesia-complete paralysis • Supine-arms abducted • Sat monitor on left great toe VASCULAR SURGERY • UC SAN FRANCISCO 12

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 13

UC SF • 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 VASCULAR SURGERY • UC SAN FRANCISCO UC SF L5-S1 • Work between the left and right iliac vein • Very easy level • Minimal risk of complication VASCULAR SURGERY • UC SAN FRANCISCO 14

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 15

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 16

UC SF L4-L5 • Mobilization is lateral/left of vessels • Requires division of the lowest segmental artery & vein • Must divide ilio-lumbar vein VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 17

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 18

UC SF 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 VASCULAR SURGERY • UC SAN FRANCISCO UC SF • More iv access • Arterial line • Ureteral catheter • Retrievable ivc filter • Blood products/cell saver VASCULAR SURGERY • UC SAN FRANCISCO 19

UC SF 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 VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 20

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF • 35yo m – needed L4-S1 ALIF-- noted some venous abnormality on spine MRI • CTA – left sided IVC VASCULAR SURGERY • UC SAN FRANCISCO 21

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 22

UC SF case • 50 yo 1 month post op from 2L4-S1 ALIF • Cage extrusion VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 23

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF case • Failed TLIF – two levels-at OSH • Hx of PE VASCULAR SURGERY • UC SAN FRANCISCO 24

UC SF VASCULAR SURGERY • UC SAN FRANCISCO UC SF VASCULAR SURGERY • UC SAN FRANCISCO 25

UC SF Conclusion • Understand basics and anatomy • Full preop w/u with CTA if any concern • complex cases can be done safely and with low risk VASCULAR SURGERY • UC SAN FRANCISCO 26