vascular surgery • uc san francisco

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VASCULAR SURGERY • UC SAN FRANCISCO

Anterior Spine Exposure

Getting There Safely

Charles Eichler , MD

UCSF

April 7, 2017

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No Disclosues

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Can we get you here safely? UCSF


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Why Go Anterior• Direct access to lowest lumbar disc

spaces L2-S1

• Thorough discectomy

• Major deformity correction

• Improved fusion rates

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• Routine cases carry a very low risk of complication

• Operative time of one or two level ALIF relatively short

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ALIF• Effective method to achieve fusion

• Allows for correction of deformities

• Can be utilized in tumor and infection cases

• But• Critical part of the case is exposure

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How can we do high risk/complex cases with low complication rates?

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Preop evaluationDiscuss with exposure surgeon

CT angiogram

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Complications• Vascular

• Abdominal

• Urologic

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Abdominal complications• Hernias

• Ileus/bowel obstruction

• Bowel injury

RARE!!

CTA

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Urologic complications• Ureter

• Place ureteral stent if any concern

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Vascular Complications• Arterial

• Venous

Direct venous injury, DVT, PE

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Can we safely do the most complicated spine cases with low complication rate??

YES

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Master the simple, straightforward cases first !!

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Set up• General anesthesia-complete

paralysis

• Supine-arms abducted

• Sat monitor on left great toe

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Step by Step• Left paramedian incision

• Move to midline reflecting rectus muscle laterally

• Incise posterior rectus sheath longitudinally

• Identify and mobilized the ureter and protect with fixed table retractor

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L5-S1• Work between the left and right iliac

vein

• Very easy level

• Minimal risk of complication

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L4-L5• Mobilization is lateral/left of vessels

• Requires division of the lowest segmental artery & vein

• Must divide ilio-lumbar vein

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L4-L5• After division of the iliolumbar vein

and the L4 lumbar art & vein

• Slowly retract vessels to right of spine.

• Place renal type retractor on the right side of the spine

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L2-L3 & L3-L4• L2 likely the highest level

obtainable

• Divide the additional lumbar artery & vein for each level

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OLIF 5-1

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How do we do the high risk cases?

Do it exactly the same, but with a bit more attention to the anatomy and potential risks

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• More iv access

• Arterial line

• Ureteral catheter• Retrievable ivc filter

• Blood products/cell saver

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case57yo m-hx of previous failed multiple procedures at OSH, but never from anterior

TLIF and posterior screws in past

Can create severe inflammation

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• 35yo m –needed L4-S1 ALIF--noted some venous abnormality on spine MRI

• CTA –left sided IVC

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New bailout• 75yo m ankylosing spodilitis

• Lumbar frx after a fall

• Rx:minimally invasive TLIF thru right flank exposure

• Massive arterial bleeding after fragment removal

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• Explporation after enlarging incision

• Hole in aorta –severe inflammation

• Partial control-packed and flipped onto angio table

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Conclusion• Understand basics and anatomy

• Full preop w/u with CTA if any concern

• complex cases can be done safely and with low risk

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Endovascular rx can add an option for preventing or treating major vascular problems

vascular surgery • uc san francisco

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