Overview
This topic reviews three anterior approaches to the thoracolumbar spine: thoracotomy, retroperitoneal flank approach, and the pararectus retroperitoneal approach.
Thoracotomy is used to expose vertebral bodies from T3-T12; debride vertebral osteomyelitis or diskitis; for anterior vertebral body tumor excision; for corpectomy for thoracic burst fractures; for thoracic diskectomies or fusion; and for anterior release with or without instrumentation in surgery to correct deformity.
The retroperitoneal flank approach is used for fusions from L1-4 with placement of lateral interbody implants; for debridement of vertebral osteomyelitis or diskitis; for vertebral body tumor excision; for decompression and stabilization in fractures from T12 to L4; and for anterior release and stabilization for scoliosis.
The pararectus retorperitoneal approach is used to expose the anterior aspect of vertebral bodies from L4 to S1; for interbody fusion of L4-5 and L5-S1; for débridement of vertebral osteomyelitis or diskitis; for anterior vertebral body tumor excision; and for anterior release for deformity. It is not considered to be appropriate if there is prior inflammatory or infectious disease in the anatomic region; if there is prior surgery with consequent adhesions or endometriosis, or if exposure of vertebral bodies difficult, even hazardous.
Surgical Procedure
What happens during the operation?
Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.
The patient is positioned on his or her back with a pad placed under the low back. An incision is made through one side of the abdomen. The large blood vessels that lie in front of the spine are gently moved aside. Retractors are used to gently separate and hold the soft tissues apart so the surgeon has room to work.
The surgeon inserts a needle into the disc. By taking an X-ray with the needle in place, the correct disc is identified. Forceps are used to open the front of the disc. Next, a tool is attached to the vertebrae to spread them apart. This makes it easier for the surgeon to see between the two vertebrae. A small cutting tool (a burr) is used to carefully remove the front half of the disc. A special surgical microscope may be used to help the surgeon see while removing pieces of disc material near the back of the disc space.
The surgeon shaves a layer of bone off the flat surfaces of the two vertebrae. This causes the surfaces to bleed. Bleeding stimulates the bone graft to heal and join the bones together.
The surgeon measures the depth and height between the two vertebrae. Making a separate incision, the surgeon takes a section of bone from the top of the pelvis to use as a graft. The graft is measured to fit snugly in the space where the disc was taken out. The surgeon uses a traction device to spread the two vertebrae apart, and the graft is tamped into place.
What might go wrong?
As with all major surgical procedures, complications can occur. Some of the most common complications following ALIF include:
- problems with anesthesia
- thrombophlebitis
- infection
- nerve damage
- blood vessel damage
- problems with the graft or hardware
- nonunion
- ongoing pain
This is not intended to be a complete list of possible complications.
After Surgery
What happens after surgery?
Patients are sometimes placed in a rigid body brace after surgery. This may not be necessary if the surgeon attached metal hardware to the spine during the surgery.
Patients usually stay in the hospital after surgery for up to one week. During this time, patients work daily with a physical therapist. The therapist demonstrates safe ways to move, dress, and do activities without putting extra strain on the back. The therapist may recommend that the patient use a walker for the first day or two. Before going home, patients are shown ways to help control pain and avoid problems.
Patients are able to return home when their medical condition is stable. However, they are usually required to keep their activities to a minimum in order to give the graft time to heal. Patients should avoid activities that cause the spine to bend back for at least six weeks. Patients are also cautioned against bending, lifting, twisting, driving, and prolonged sitting for up to six weeks. Outpatient physical therapy is usually started a minimum of six weeks after the date of surgery.
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