Malham Gregory M, Wagner Timothy P, Claydon Matthew H
Epworth Hospital, Melbourne, Australia.
J Spine Surg. 2019 Dec;5(4):433-442. doi: 10.21037/jss.2019.09.09.
Multilevel lumbar interbody fusion (LIF) surgery in obese patients is problematic, with positioning and anaesthetic risks during posterior approaches, vascular and visceral complications during anterior approaches, and lack of access to L5/S1 during lateral approaches. Modified anterior LIF (ALIF) via an anterolateral retroperitoneal approach in the lateral decubitus position permits access to L3/4, L4/5, and L5/S1 levels without patient repositioning. This study reports our initial experience with this lateral ALIF in obese patients and describes modifications of existing lateral and anterior techniques.
We retrospectively analysed a prospectively maintained registry including the first 30 consecutive patients who underwent lateral ALIF. In all patients, supine ALIF was relatively contraindicated because of obesity or previous abdominal surgery. All patients had a body mass index (BMI) ≥30 kg/m. Fusion was assessed by high-definition computed tomography. Patient-reported outcomes included visual analogue scale pain scores, Oswestry Disability Index (ODI), and 36-Item Short-Form Survey (SF-36) physical and mental component scores (PCS and MCS). All patients underwent ≥2 years follow-up.
At last follow-up (mean, 35.0 months) mean back pain improved 64%, leg pain improved 67%, ODI improved 54%, and PCS and MCS both improved 37% (P<0.05 versus preoperative for all). Mean BMI was unchanged postoperatively (P=0.83). Complications occurred in 7 (23%) patients: dysesthesia [2], retroperitoneal hematoma [2], radiculopathy [1], and subsidence [2]. Solid interbody fusion occurred in 19 (63%) patients at 12 months postoperatively and in 26 (87%) patients at 24 months.
Lateral ALIF enables L5/S1 anterior fusion in obese patients and permits multilevel fusion using a single position. Satisfactory clinical outcomes and complication rates are achieved despite unchanged BMI and 87% radiological fusion rates. Lateral ALIF appears to be a reasonable alternative to posterior, lateral, and supine-position anterior approaches for L3/4, L4/5, and L5/S1 interbody fusions.
肥胖患者的多节段腰椎椎间融合术（LIF）存在问题，后路手术存在定位和麻醉风险，前路手术存在血管和内脏并发症，侧路手术难以到达L5/S1。在侧卧位通过前外侧腹膜后入路进行改良前路LIF（ALIF），无需重新摆放患者体位即可到达L3/4、L4/5和L5/S1节段。本研究报告了我们在肥胖患者中开展这种侧方ALIF的初步经验，并描述了对现有侧方和前方技术的改良。
我们回顾性分析了一个前瞻性维护的登记数据库，纳入了连续30例接受侧方ALIF的患者。所有患者因肥胖或既往腹部手术，相对禁忌仰卧位ALIF。所有患者的体重指数（BMI）≥30kg/m²。通过高清计算机断层扫描评估融合情况。患者报告的结局指标包括视觉模拟量表疼痛评分、Oswestry功能障碍指数（ODI）以及36项简明健康调查（SF-36）身体和精神成分评分（PCS和MCS）。所有患者均接受了≥2年的随访。
在最后一次随访时（平均35.0个月），平均背痛改善了64%，腿痛改善了67%，ODI改善了54%，PCS和MCS均改善了37%（与术前相比，所有P<0.05）。术后平均BMI无变化（P=0.83）。7例（23%）患者发生并发症：感觉异常[2例]、腹膜后血肿[2例]、神经根病[1例]和下沉[2例]。19例（63%）患者术后12个月实现了坚固的椎间融合，26例（87%）患者术后24个月实现了坚固融合。
侧方ALIF能够在肥胖患者中实现L5/S1前路融合，并允许在单一体位下进行多节段融合。尽管BMI未改变且放射学融合率为87%，但仍取得了满意的临床结局和并发症发生率。对于L3/4、L4/5和L5/S1椎间融合，侧方ALIF似乎是后路、侧路和仰卧位前路手术的合理替代方案。
