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Presacral Anterior Lumbar Interbody Fusion 145 PRESACRAL ANTERIOR Aspects Spine Surgery: Current Minimally Invasive LUMBAR INTERBODY FUSION (AXIALIF), MINI ALIF 25 Bayram Cırak MD ack pain is one of the most common condi- autograft (patient’s own bone source), or allograft tions in any population and have a variety from a donor.7-10 1 of etiologies. The costs for treatment and The first lumbar anterior interbody fusion was B 2 absence from work are tremendous. Low back pain reported in the 1930s.11 That was open technique. originates from paraspinal muscles, facet joints, spi- The development of new techniques and technol- nal ligaments, failed endplates, or degenerative in- ogies and better understanding of surgical anat- tervertebral discs.3 Current strategy for back pain omy gave rise to minimally invasive spine surgery aims to alleviate the symptom and to resolve eti- (MISS).11-13 ology itself. Surgical options have been considered 4 when conservative treatment fails. Conservative A. Presacral ALIF (anterior lumbar interbody therapies include reduced activity and bed rest, analgesics, muscle relaxants, nonsteroidal antiin- fusion) flammatory drugs (NSAID) and/or rehabilitation Presacral ALIF or AXIALIF is performed for the in- programs.5 When the conservative therapies fail, terbody fusion of the lower lumbar vertebrae. In- Patients undergo a surgical treatment, which in- stability due to degenerative disc disease and spon- ludes decompression, stabilisation and / or fusion.6 dylolisthesis is frequently seen at L4–L5 and L5–S1 Spinal fusion is the surgical connection of two or levels. which may require fusion to achieve stability more adjacent vertebrae to immobilise. To relieve and relieve symptoms. Presacral ALIF or transaxial pain, correct deformity, and improve stability. In- anterior lumbar interbody fusion involves an inci- dications for spinal fusion include evidence of in- sion either midline or lateral to the coccyx. The sa- stability, stenosis that may result in progressive crum is separated from the rectum with a mesorec- deformity after surgical decompression, i.e. iat- tum covered by visceral fascia. This plane serves as rogenic instability, and recurrent disc herniations the minimally invasive route to the sacrum and the in some patients caused by segmentary instabil- anterior lower lumbar vertebrae. A guide pin intro- ity. Spinal fusions have been performed for condi- ducer is advanced gently along the anterior midline tions such as infection, trauma, deformity, degen- of the sacrum. Tactile feedback and fluoroscopic guid- erative conditions, resection for spinal tumours for ance is essential during the entire AXILIF process to more than a century.8 Surgical fusion requires bone avoid iatrogenic complications of vascualture and in- graft use to facilitate fusion.Bone grafts are either trapelvic organs.. Once a tunnel is achieved to the Bayram Cırak MD 146 inferior endplate of L5 through the sacrum discec- vertebrae (the one which will be fused) then a tita- tomy is performed using specially designed cutting- nium-threaded rod is implanted. The system is of- loop devices and wire brushes, then bone graft ma- ten strenghtened with posterior percutaneous pedi- terial is packed directly into the disc space. (figure 1-5) cle screws.14-16 Finally, a drill is used to penetrate the upper lumbar Minimally Invasive Spine Surgery: Current Aspects Spine Surgery: Current Minimally Invasive Figure 1: Direction of the fixation screw and anatomic relations Figure 2: Opening and dissecting the presacral space to place working cannel. Figure 3: Drilling upto the above vertebrae to be fused to place screw. Presacral Anterior Lumbar Interbody Fusion (AXIALIF), Mini ALIF 147 Minimally Invasive Spine Surgery: Current Aspects Spine Surgery: Current Minimally Invasive Figure 4: Cutters and wire brushes for discectomy, and bone grafting. Figure 5: Placing the fixation screw , xray with AXIALIF and posterior percutaneous facet screws Disadvantages of the AXIALIF The abdominal cavity is not entered and mobil- Most of the spinal surgeons are less familiar with pre- isation or retraction of the vasculature or intra-ab- 10-12 sacral anatomy than general or colorectal surgeons dominal viscera is not necessary. are; therefore,evaluating the presacral anatomy it is AXIALIF process or interbody fusion can be critical before performing the procedure in order to achieved through open or minimally invasive ap- reduce the risk of complications.10 proaches. Open techniques involve dissection, retrac- tion, and mobilization of soft tissues and vital struc- Direct visualization of the discectomy directly is tures such as nerve roots, major vessels, ligaments, not posssible due to the minimally invasive nature annuli, and abdominal viscera. The traditional open of the procedure.12 approach is often associated with significant postop- erative pain, disability, and dysfunction. Minimally Advantages of the AXIALIF invasive techniques are more technically challenging Reduced injury and disruption of the posterior for inexperienced surgeons but they provide symp- musculature, ligaments, because the disc space is tomatic relief equivalent to that of open approaches accessed through small incision to access the pre- based on short-term clinical data. Moreover, clinical sacral space.12 benefits of minimally invasive techniques include Bayram Cırak MD 148 significantly reduced blood loss, postoperative pain, the retroperitoneal area at the linea arcuata. The an- hospital stays, and narcotic usage.16-19 terior lumbar spine is exposed medial to the psoas muscle. Retractors are either fixed to the vertebrae by screws or pins or to the table. (figure 6,7) Mini-ALIF B. Mini Anterior Lumbar Interbody Fusion followed by percutaneous PF is an efficacious alter- (ALIF): native for low-grade isthmic spondylolisthesis, and posterior decompression is not necessary to relieve This surgical procedure is performed for lumbar leg symptoms. This minimally invasive combined spinal fusion. Approach is from the anterior (front) procedure offers many advantages, such as pres- of the patient. L2-3-4-5-S1 levels can be approached ervation of posterior arch, no nerve retraction, less through a limited anterior abdominal incision . A blood loss, excellent cosmetic results, high fusion surgical microscope or an open video endoscopy rate and early discharge.15-17,20,21 can be helpful in ALIF procedure. Mini ALIF is first described in 1995 15,16 and first preliminary re- sults have been released in 1997.17 The advantages of this technique are as follows: Since it is a retro- peritoneal spinal procedure this technique is not un- Minimally Invasive Spine Surgery: Current Aspects Spine Surgery: Current Minimally Invasive known for spinal surgeons, with the use of retractors only one asistant is enough fort he procedure, the risk for intraabdominal structures is minimal since it is a retroperitoneal approach, ositioning and sur- gery: Patient is positioned supine and a roll under the back to exaggerate the lumbar has been placed or the table is breaked to increase lordosis which is very important to expose disc space and to capture the implant inserted in the disc space in compres- sion after excess lordosis has been corrected to pre- vent graft and implant slippage. Generally a lower midline abdominal oblique incision is performed at the level of disc under realtime C-arm scopy. Sur- geon generally stands on the right of the patient. Rectus abdominus sheath has been identified and Figure 7: Postoperative x-ray of the mini L5-S1 transversely incised after the skin incision. Then lat- ALIF erally under the rectus dissection is carried to enter Figure 6: Anatomic relations and the entry route for the mini ALIF procedure Presacral Anterior Lumbar Interbody Fusion (AXIALIF), Mini ALIF 149 Indications for Mini- ALIF Patients are candidates for mini ALIF. It may be Aspects Spine Surgery: Current Minimally Invasive 1. Degenerative disc disease (DDD) with or with- performed either open mini- ALIF or with the help 15 out disc herniation that may require a total lum- of microscope or endoscopy. bar disc replacement; As a result, If a patient has pure mechanical 2. For fusion-cases like degenerative instability, tu- backache an anterior fusion and stabilization is a mors, isthmic and good choice to preserve the disc height, achieve fu- sion, preserve the Posterior stabilizing soft tissues to 3. Degenerative spondylolisthesis: with prevent iatrogenic instability and adjacent segment a. Instability degeneration. However there is a high incidance b. Backpain due to instability of graft slippage and subsidence risk has been re- 4. Fractures, spondylodiscitis, ported in the stand alone grafting and fusion cases. So implants to help the stabilization and to decrease 5. Failed back syndrome (pseudoarthrosis, post-dis- the risk of subsidance and graft slippage have been cectomy) developed such as cages and anterior instrumenta- tion including plates, screws and rods. Bone graft- Relative Contraindications ing and fusion process can be achieved either pos- 1. Previous abdominal surgeries; teriorly or anteriorly directly between the vertebral 2. Aortic bifurcation and/or venous confluens di- bodies. When it is processed anteriorly, first inter- rectly in front of the disc space; vertebral disc is removed entirely,then the space is 3. Infections with the formation of a large preverte- filled with a spinal implant and bone graft to form bral granulation tissue or psoas abscess a cast and a support in between vertebral bodies during fusion period. Eventhough there is a contro- 4. No radiculopathy versy in naming the fusion processes the site of the 5. No resting backpain surgery to the spinal column has a pivot role in the 6. Absence of complete block on myelography naming. Such as ALIF or AXIALIF.5-7,20-23 Bayram Cırak MD 150 References 13. Marotta N, Cosar M, Pimenta L, Khoo LT. A novel minimally invasive presacral approach and instru- 1. Atlas SJ, Deyo RA. Evaluating and managing acute mentation technique for anterior L5-Si interver- low back pain in the primary care setting. J Gen In- tebral discectomy and fusion. Neurosurg Focus tern Med. 2001;16(2):120-31 2006; 20(1): 1-8.
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