Midline anterior approach from the right side to the lumbar spine for interbody fusion and total disc replacement: a new mobilization technique of the vena cava.

STUDY DESIGN

Prospective study.

OBJECTIVE

To describe a midline anterior approach to the lumbar spine from the right side, below the aortic bifurcation to L5-S1, and by mobilizing the vena cava from right to left between L2 and L5. Feasibility and complication rate related to the approach have been studied.

SUMMARY OF BACKGROUND DATA

Midline anterior approach to the lumbar spine has developed during these last years, mainly for interbody fusion and disc arthroplasty surgery. This retroperitoneal approach is well described in publications and classically made from the left side. Major complications associated with the approach are known: retrograde ejaculation, venous injuries, and arterial thrombosis.

METHODS

A total of 469 patients were included in a prospective study between August 2003 and November 2010, either for interbody fusion by anterior approach or for total disc replacement, on one or several levels between L2-L3 and L5-S1.

RESULTS

On the 154 patients who had a mobilization of the vena cava, no injury occurred. Only 4 major venous injuries occurred. There was no arterial complication, and the oxygen saturation signal was interrupted in only 1 case. No case of retrograde ejaculation was found.

CONCLUSION

The midline anterior retroperitoneal approach from the right side is a safe alternative compared with the classical approach from the left side. The low rate of venous injury is explained by the sidewall thickness of the vena cava compared with the left iliac vein sidewall. Contrary to what happens by left-sided approach, the vascular retraction required for access to L4-L5 and above does not lead to arterial occlusion and therefore diminishes the risk in atheromatous patients. The absence of retrograde ejaculation confirms previous studies conducted on the left anastomosis of the superior hypogastric plexus, suggesting that its approach and mobilization by the left side are delicate.