Minimally Invasive Spine Surgery: Current Aspects 145 - F), F), ALIF Bayram Cırak MD That was open technique. nterior nterior 11 AXIALI Mini A nterbody nterbody I 7-10 ral ral 11-13 c bar bar The first lumbar anterior interbody fusion was was fusion interbody anterior lumbar first The Presacral ALIF (anterior lumbar interbody interbody lumbar (anterior ALIF Presacral fusion) ance is essential during the entire AXILIF process to to process AXILIF entire the during essential is ance and in- avoid iatrogenic complications of vascualture to the is achieved a Once tunnel organs.. trapelvic autograft (patient’s own bone source), or allograft allograft or source), bone own (patient’s autograft from a donor. reported in the 1930s. The development of new techniques and technol- ogies and better understanding of surgical surgery spine anat- invasive minimally to rise gave omy (MISS). A. ALIF AXIALIF Presacral or is performed for the in- terbody fusion of the lower lumbar vertebrae. In- disc disease and spon- stability due to degenerative L5–S1 and L4–L5 at seen frequently is dylolisthesis stability achieve to fusion require may which levels. transaxial or ALIF Presacral symptoms. relieve and anterior lumbar interbody fusion involves an inci- sion either midline or lateral to the coccyx. The sa- crum is separated from the rectum with a mesorec- as serves plane This fascia. visceral by covered tum the and sacrum the to route invasive minimally the A guide anterior pin lumbar lower intro- vertebrae. midline anterior the along gently advanced is ducer fluoroscopic guid feedback and Tactile of the sacrum. Fusion ( Fusion m

u 6 - L resa P Conservative 4 Low back pain pain back Low 2 The and costs for treatment Surgical fusion requires bone bone requires fusion Surgical 1 8 Current strategy for back pain 3 When the conservative therapies fail, 5

- ack pain is one of the most common condi variety a have and population any in tions of etiologies.

25 aims to alleviate the symptom and to considered resolve been eti- have options Surgical itself. ology absence from work are tremendous. rogenic instability, and recurrent disc herniations disc herniations and recurrent instability, rogenic in some patients caused by segmentary instabil- ity. Spinal been fusions performed have for condi- tions such as infection, trauma, deformity, degen- for tumours spinal for resection conditions, erative than a century. more stability, stenosis that may result in progressive deformity after surgical decompression, i.e. iat- programs. Patients undergo a surgical treatment, which in- ludes decompression, stabilisation and / or fusion. therapies include reduced activity and bed rest, analgesics, muscle relaxants, nonsteroidal antiin- drugs (NSAID) flammatory and/or rehabilitation when conservative treatment fails. B graft use to facilitate fusion.Bone grafts are either grafts fusion.Bone use graft to facilitate Spinal fusion is the surgical connection of two is or fusion connection Spinal the surgical To relieve to immobilise. vertebrae adjacent more pain, correct deformity, and improve stability. In- dications for spinal fusion include evidence of in- originates from paraspinal muscles, facet joints, spi- originates from paraspinal muscles, facet nal ligaments, in failed endplates, or degenerative tervertebral discs. 146 Minimally Invasive Spine Surgery: Current Aspects Finally, a drill is used to penetrate thespace. disc the into directly packed is upperterial lumbar ma- graft bone then brushes, wire and devices loop tomy isperformedusingspeciallydesignedcutting- discec- sacrum the through L5 of endplate inferior Bayram CırakMD Figure 2: Figure Figure 3: Figure Figure 1: Figure Opening and dissecting the presacral space to place working cannel. working place to space presacral the dissecting and Opening Drilling upto the above vertebrae to be fused to place screw. place to fused be to vertebrae above the upto Drilling Direction of the fixation screw and anatomic relations anatomic and screw fixation the of Direction (figure1-5)

cle screws. cle ten strenghtenedwithposteriorpercutaneouspedi- of- is system The implanted. is rod nium-threaded tita- a then fused) be will which one (the vertebrae 14-16 Minimally Invasive Spine Surgery: Current Aspects 147 - - 10-12 The abdominal cavity is not entered and mobil- AXIALIF process or interbody fusion can be Presacral Anterior Lumbar Interbody Fusion (AXIALIF), Mini ALIF Mini (AXIALIF), Interbody Fusion Lumbar Anterior Presacral tion, and mobilization of soft tissues and vital struc and tissues soft of tion, and mobilization ligaments, vessels, major roots, nerve as such open tures traditional The viscera. abdominal and annuli, approach is often associated with significant postop- Minimally dysfunction. and disability, pain, challenging erative technically more are techniques invasive for inexperienced surgeons but they provide symp- approaches open of that to equivalent relief tomatic clinical Moreover, data. clinical short-term on based benefits of minimally invasive techniques include achieved achieved through open or minimally invasive ap- retrac dissection, involve Open techniques proaches. isation or retraction of the vasculature or intra-ab- dominal viscera is not necessary. 10 Cutters and wire brushes for discectomy, and bone grafting. Figure 4: Placing the fixation screw , xray with AXIALIF and posterior percutaneous facet screws screws facet percutaneous posterior and AXIALIF with , xray screw fixation the Placing 12 12 Figure 5: Direct visualization of the discectomy directly is is directly discectomy the of visualization Direct sacral space. Reduced injury and disruption of the posterior musculature, ligaments, because the disc space is accessed through small incision to access the pre- Advantages Advantages of the AXIALIF Disadvantages of the AXIALIF with pre- familiar are less surgeons the spinal of Most surgeons colorectal or general than anatomy sacral is it anatomy presacral the therefore,evaluating are; to order in procedure the performing before critical reduce the risk of complications. not posssible due to the minimally invasive nature nature invasive minimally the to due posssible not of the procedure. 148 Minimally Invasive Spine Surgery: Current Aspects sults have been released in 1997. in released been have sults first described in 1995 in described first is ALIF Mini procedure. ALIF in helpful be can endoscopy video open an or microscope surgical A . incision abdominal anterior limited a through of the patient. L2-3-4-5-S1 levels can be approached spinalfusion. Approachis from lumbar the for anterior performed (front) is procedure surgical This B. usage. narcotic and stays, hospital significantly reduced blood loss, postoperative pain, Bayram CırakMD erally under the rectus dissection is carried to enter transversely incisedaftertheskinincision.Thenlat- Rectusabdominus sheathbeenidentifiedhas patient. and the of right the on stands generally geon the level of disc under realtime C-arm scopy. Sur- scopy. C-arm realtime under disc of level the midline abdominal oblique incision is performed at ventgraft and implant slippage. Generally lowera pre- to corrected been has lordosis excess after sion compres- in space disc the in inserted implant the veryimportant to expose disc space and to capture orthe table is breaked to increase lordosis which is theback toexaggerate the lumbar has been placed gery:Patient positionedis supine rollandaunder sur- and ositioning approach, retroperitoneal a is it riskfor intraabdominal structures isminimal since onlyasistantone enoughisprocedure,fort he the known for spinal surgeons, with the useperitoneal spinalprocedurethistechniqueisnotun- of retractorsretro- a is it Since follows: as are technique this of (ALIF): MiniAnterior Lumbar Interbody Fusion Figure 6: Figure 15,16 and first preliminary re- preliminary first and Anatomic relations and the entry route for the mini ALIF procedure ALIF mini the for route entry the and relations Anatomic 17 16-19 Theadvantages rate and early discharge. early and rate fusion high results, cosmetic excellent loss, blood ervationposteriorof arch, nerveno retraction, pres- lessas such advantages, many offers procedure leg symptoms.leg Thisminimally invasive combined posteriordecompression is not necessary to relieve native for low-grade isthmic spondylolisthesis, and alter- efficacious an is followedPF percutaneous by (figure table. the screwsorpinsto by 6,7) Mini-ALIF muscle.Retractors areeither fixed thetovertebrae teriorlumbar spine isexposed medial tothe psoas the retroperitonealareaatlineaarcuata.Thean- Figure 7: Figure Postoperativex-ray theofmini L5-S1 ALIF 15-17,20,21 Minimally Invasive Spine Surgery: Current Aspects 149 - 5-7,20-23 15 Patients are candidates for mini ALIF. It may be be may It ALIF. mini for candidates are Patients As a result, If a patient has pure mechanical Presacral Anterior Lumbar Interbody Fusion (AXIALIF), Mini ALIF Mini (AXIALIF), Interbody Fusion Lumbar Anterior Presacral performed either open mini- ALIF or with the help help the with or ALIF mini- open either performed of microscope or endoscopy. versy in naming the fusion processes the site of the the of site the processes fusion the naming in versy the in role pivot a has column spinal the to surgery naming. Such as ALIF or AXIALIF. a cast and a support in between vertebral bodies a contro there is Eventhough period. fusion during backache an anterior fusion and stabilization is a to tissues good choice to soft preserve the disc height, achieve fu- stabilizing Posterior the preserve sion, segment adjacent and instability iatrogenic prevent degeneration. However there is a high incidance of graft slippage and cases. subsidence fusion risk and has grafting been alone re- stand the in ported decrease to and stabilization the help to implants So been have slippage graft and subsidance of risk the developed such as cages and anterior instrumenta- tion including plates, screws and rods. Bone - graft ing and fusion process can be achieved vertebral either the pos- between directly anteriorly or teriorly bodies. When it is processed is anteriorly, space first the inter- entirely,then removed is disc vertebral form to graft bone and implant a spinal with filled Backpain due to instability rectly in front of the disc space; Infections with the formation of a large - preverte bral granulation tissue or psoas abscess No radiculopathy No resting backpain  Degenerative Degenerative disc disease (DDD) with or with- Previous abdominal surgeries; out disc herniation that may require a total lum- bar disc replacement; For fusion-cases like degenerative instability, tu- mors, isthmic and Degenerative spondylolisthesis: with Instability Fractures, spondylodiscitis, (pseudoarthrosis, post-dis- Failed back syndrome cectomy)  Absence of complete block on myelography Aortic bifurcation and/or venous confluens di- 3. 4. 5. 6. 1. 2. Relative Relative Contraindications 2. 3. a. b. 4. 5. Indications for Mini- ALIF 1. 150 Minimally Invasive Spine Surgery: Current Aspects 11. 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