Elsevier

The Spine Journal

Volume 11, Issue 5, May 2011, Pages 389-394
The Spine Journal

Clinical Study
Comparison of perioperative parameters and complications observed in the anterior exposure of the lumbar spine by a spine surgeon with and without the assistance of an access surgeon

https://doi.org/10.1016/j.spinee.2011.03.014Get rights and content

Abstract

Background context

The anterior approach to the spine is becoming an increasingly important avenue to treat spine conditions. Most of the literature reporting on the exposure uses an access surgeon assisting the spine surgeon to expose and prepare the spine for implant.

Purpose

To compare perioperative parameters and complications in anterior lumbar spine surgery with the exposure performed either by a spine surgeon or a general surgeon.

Study design

A retrospective cohort study comparing perioperative parameters and complications of anterior lumbar spine surgery.

Methods

A retrospective review was completed on 96 consecutive patients who underwent anterior spine surgery between Levels L3 and S1 from 1995 to 2008. Patient and surgery characteristics including demographics, comorbidities, perioperative parameters, and complications were logged. In the first 56 consecutive patients, a general surgeon completed the exposure, with an additional patient who later had the exposure performed by a general surgeon because of extensive prior abdominal surgeries. In the next 39 patients, the orthopedic surgeon completed the exposure.

Results

When the operation was performed solely by a spine surgeon, the estimated blood loss, operative time, and hospital stay was 204 mL, 2.80 hours, and 3.5 days, respectively. In the procedures completed with the aid of a general surgeon, it was found that the same parameters were 420 mL, 3.93 hours, and 4.7 days, respectively, and statistically significantly less in the group without the assistance of the general surgeon (p=.0007, p=.0003, and p=.0006, respectively). Fewer complications also were observed in that group (p<.00001). The most common complication was an ileus. Major complications including retrograde ejaculation, iliac vein bleeding, peritoneal rent requiring repair, dyspareunia, or scrotal/penile swelling were only observed in the group with the assistance of the general surgeon.

Conclusions

This study indicated that a spine surgeon can successfully and safely carry out the anterior exposure to the spine without the aid of an access surgeon.

Introduction

Evidence & Methods

Depending on the medical center and the surgeons, the anterior approach to the lumbar spine is generally either carried out by a so-called access surgeon (vascular or general surgeon) or by the spine surgeons themselves.

In this single-center retrospective report, spine surgeons performing the approach reported fewer complications, less blood loss, less operative time, and shorter hospital stays compared to when the approach was carried out by a general surgeon. Some complications (such as ileus) were frequently identified in cases involving an access surgeon but were rarely identified in cases treated by spine surgeons alone.

Given the study design (single-center, non-randomized trial with a small number of surgeons), apparent variability in complication reporting (eg, ileus), and the wide variations in surgical training and experience, these data may not be generalized. Surgeons’ skills (general, vascular, or spine) vary, and patient factors complicating exposure should be individually assessed to determine best surgical practice. That said, despite some medico legal fears, it is clear that experienced, skillful spine surgeons can comfortably perform this approach and equally clear that vascular surgeon availability may be prudent.

—The Editors

The anterior approach to the lumbar spine is a relatively versatile exposure that can be used for multiple indications. It can be useful for the treatment of degenerative disc disease, spondylolisthesis, pseudarthrosis, scoliosis, tumor, infection, and fracture [1], [2], [3]. These disorders can be treated accordingly with anterior lumbar interbody fusion, corpectomies or, when appropriate, lumbar disc arthroplasty.

Approaches to the lumbar spine for fusion can be divided into anterior, posterior, and lateral exposures. The anterior approach to the lumbar spine generally is dichotomized between transperitoneal and extraperitoneal dissection [4]. The extraperitoneal approach can be further divided into paramedian and anterolateral access [5]. The complications of anterior spine surgery have been reported previously, and the approach appears to be safe and effective [4], [6], [7].

It seems, however, that anterior lumbar surgery often places a spine surgeon in a territory with which they are unfamiliar [4]. Many spine surgeons use the service of a general surgeon or vascular surgeon to perform the surgical exposure—the so called “access surgeon.” A review of the English-language literature reveals a lack of direct comparisons addressing the perioperative complications of anterior spine surgery performed with and without the assistance of an access surgeon.

The aim of this retrospective review was to investigate two hypotheses regarding the perioperative complications of anterior lumbar spine surgery. Our first hypothesis is that the rates of perioperative complications of anterior lumbar spine surgery would be similar when an access surgeon is used compared with a spine surgeon completing the approach. Our second hypothesis is that it is safe and effective for a spine surgeon to perform the exposure for anterior spine surgery.

Section snippets

Patient population

A retrospective chart review from 1995 to 2008 for patients who underwent anterior lumbar spine surgery from L3 and below by the two senior authors (RS and KR) who are fellowship-trained spine surgeons resulted in 96 consecutive patients for the study. Two patients were excluded because they had exposure into the thoracic spine. Four others were excluded because they had lumbar procedures extending cephalad to L3 and, therefore, were not homogenous with the remainder of the group. In the first

Results

Fifty-eight patients (60%) had an anterior-only procedure, whereas the remaining 38 patients (40%) underwent anterior and posterior approaches. Degenerative disc disease was the most common diagnosis in both groups (Table 1). Gender distribution was identical with 48 men (50%) and 48 women (50%) in the study and was similar between the two groups. The mean age for the “with assistance” group was 42.9 years old compared with the “without assistance” group at 38.0 years old (p=.036). In

Discussion

The anterior approach to the spine has been performed for a number of indications and has had reasonable success in the literature [1]. With the advent of pedicle screw fixation, posterior spinal fusion has become popular, especially because some spine surgeons generally avoid operating in proximity to the abdomen. The anterior approach, however, is still a very viable and safe procedure as it has been found to be associated with potentially less blood loss, lower transfusion rates, less

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Cited by (0)

FDA device/drug status: not applicable.

Author disclosures: MWS: Nothing to disclose. KAR: Stock Ownership: Allograft Innovations (5%), Titan (A). RMS: Nothing to disclose. CDB: Nothing to disclose. KSS: Nothing to disclose. IC: Consulting: Medtronic (A); Speaking/Teaching Arrangements: Stryker Spine (A); Scientific Advisory Board: NuVasive (A); Grants: Medtronic (D), Stryker Spine (D).

The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

Source of funding: There was no external funding source for this study.

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