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Mini-open anterior spine surgery for anterior lumbar diseases.

Lin RM, Huang KY, Lai KA - Eur Spine J (2008)

Bottom Line: Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%).There were no major complications.Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopedics, College of Medicine, National Cheng Kung University Hospital, 138 Sheng Li Road, Tainan 70428, Taiwan. linrm@mail.ncku.edu.tw

ABSTRACT
Minimally invasive surgeries including endoscopic surgery and mini-open surgery are current trend of spine surgery, and its main advantages are shorter recovery time and cosmetic benefits, etc. However, mini-open surgery is easier and less technique demanding than endoscopic surgery. Besides, anterior spinal fusion is better than posterior spinal fusion while considering the physiological loading, back muscle function, etc. Therefore, we aimed to introduce the modified "mini-open anterior spine surgery" (MOASS) and to evaluate the feasibility, effectiveness and safety in the treatment of various anterior lumbar diseases with this technique. A total of 61 consecutive patients (46 female, 15 male; mean age 58.2 years) from 1997 to 2004 were included in this study, with an average follow-up of 24-52 (mean 43) months. The disease entities included vertebral fracture (20), failed back surgery (13), segmental instability or spondylolisthesis (10), infection (8), herniated disc (5), undetermined lesion for biopsy (4), and hemivertebra (1). Lesions involved 13 cases at T12-L1, 18 at L1-L2, 18 at L2-L3, 22 at L3-L4 and 11 at L4-L5 levels. All patients received a single stage anterior-only procedure for their anterior lumbar disease. We used the subjective clinical results, Oswestry disability index, fusion rate, and complications to evaluate our clinical outcome. Most patients (91.8%) were subjectively satisfied with the surgery and had good-to-excellent outcomes. Mean operation time was 85 (62-124) minutes, and mean blood loss was 136 (minimal-250) ml in the past 6 years. Hospital stay ranged from 4-26 (mean 10.6) days. Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%). Most cases (95%) achieved solid or probable solid bony fusion. There were no major complications. Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.

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Related in: MedlinePlus

aDashed line (a, b, c, d) indicates possible incisions for mini-open anterior spinal surgery. The level could be below the 12th rib, between the 11th and 12th ribs or even up to the 9th or 10th rib. Severance of muscle layers was the rule to avoid injuries to the intercostal or subcostal nerves, and usually 2–3 cm below the target provided adequate exposure; b the ENT forceps indicate the dissected intercostal muscles between the 10th and 11th ribs; a short segment of the 11th rib was already cut. Directly under the intercostalis is the fibrotendinous portion of the transverse abdominal muscle (arrow); c splitting this fibrotendinous portion, the retroperitoneal space was exposed
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Fig1: aDashed line (a, b, c, d) indicates possible incisions for mini-open anterior spinal surgery. The level could be below the 12th rib, between the 11th and 12th ribs or even up to the 9th or 10th rib. Severance of muscle layers was the rule to avoid injuries to the intercostal or subcostal nerves, and usually 2–3 cm below the target provided adequate exposure; b the ENT forceps indicate the dissected intercostal muscles between the 10th and 11th ribs; a short segment of the 11th rib was already cut. Directly under the intercostalis is the fibrotendinous portion of the transverse abdominal muscle (arrow); c splitting this fibrotendinous portion, the retroperitoneal space was exposed

Mentions: The anatomy in this area is widely varied. Incision could be made below the 12th rib, between the 11th and 12th ribs or even up to the 9th or 10th rib. Due to anatomical variations, not all muscle layers were visible during each operation. For example, if the 11th or 12th rib route was used, we were sometimes unable to see the internal oblique abdominal muscle during the operation. Basically, the latissimus dorsi and external oblique abdominal muscle are at the same level and continuously interdigitated. The diaphragm and transverse abdominal muscle are also interdigitated and at the same muscular level. Severance of muscle layers was the rule to avoid injury to intercostal or subcostal nerves (Fig. 1a). Sometimes, 2–3 cm had to be cut from the free ends of the 11th or 12th rib. Because the diaphragm and transverse abdominal muscle layers are mostly at the same level, part of the diaphragm was incised on occasion to enter the retroperitoneal space. This had to be done when entering through the 10th and 11th or even the 9th and 10th intercostal space (Fig. 1b, c). In this way, the chest cavity was rarely opened, once the pleura are opened, it is easily sutured and sealed off securely. We will exsufflate the chest cavity at the end of the procedure, so no chest tube is needed. The MOASS technique is a retroperitoneal extrapleural approach. If the target is T12 or L1, the crus of the diaphragm must be dissected longitudinally to expose their vertebral bodies. We can reach the lower part of the T12 vertebra without opening the diaphragm.Fig. 1


Mini-open anterior spine surgery for anterior lumbar diseases.

Lin RM, Huang KY, Lai KA - Eur Spine J (2008)

aDashed line (a, b, c, d) indicates possible incisions for mini-open anterior spinal surgery. The level could be below the 12th rib, between the 11th and 12th ribs or even up to the 9th or 10th rib. Severance of muscle layers was the rule to avoid injuries to the intercostal or subcostal nerves, and usually 2–3 cm below the target provided adequate exposure; b the ENT forceps indicate the dissected intercostal muscles between the 10th and 11th ribs; a short segment of the 11th rib was already cut. Directly under the intercostalis is the fibrotendinous portion of the transverse abdominal muscle (arrow); c splitting this fibrotendinous portion, the retroperitoneal space was exposed
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2367411&req=5

Fig1: aDashed line (a, b, c, d) indicates possible incisions for mini-open anterior spinal surgery. The level could be below the 12th rib, between the 11th and 12th ribs or even up to the 9th or 10th rib. Severance of muscle layers was the rule to avoid injuries to the intercostal or subcostal nerves, and usually 2–3 cm below the target provided adequate exposure; b the ENT forceps indicate the dissected intercostal muscles between the 10th and 11th ribs; a short segment of the 11th rib was already cut. Directly under the intercostalis is the fibrotendinous portion of the transverse abdominal muscle (arrow); c splitting this fibrotendinous portion, the retroperitoneal space was exposed
Mentions: The anatomy in this area is widely varied. Incision could be made below the 12th rib, between the 11th and 12th ribs or even up to the 9th or 10th rib. Due to anatomical variations, not all muscle layers were visible during each operation. For example, if the 11th or 12th rib route was used, we were sometimes unable to see the internal oblique abdominal muscle during the operation. Basically, the latissimus dorsi and external oblique abdominal muscle are at the same level and continuously interdigitated. The diaphragm and transverse abdominal muscle are also interdigitated and at the same muscular level. Severance of muscle layers was the rule to avoid injury to intercostal or subcostal nerves (Fig. 1a). Sometimes, 2–3 cm had to be cut from the free ends of the 11th or 12th rib. Because the diaphragm and transverse abdominal muscle layers are mostly at the same level, part of the diaphragm was incised on occasion to enter the retroperitoneal space. This had to be done when entering through the 10th and 11th or even the 9th and 10th intercostal space (Fig. 1b, c). In this way, the chest cavity was rarely opened, once the pleura are opened, it is easily sutured and sealed off securely. We will exsufflate the chest cavity at the end of the procedure, so no chest tube is needed. The MOASS technique is a retroperitoneal extrapleural approach. If the target is T12 or L1, the crus of the diaphragm must be dissected longitudinally to expose their vertebral bodies. We can reach the lower part of the T12 vertebra without opening the diaphragm.Fig. 1

Bottom Line: Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%).There were no major complications.Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopedics, College of Medicine, National Cheng Kung University Hospital, 138 Sheng Li Road, Tainan 70428, Taiwan. linrm@mail.ncku.edu.tw

ABSTRACT
Minimally invasive surgeries including endoscopic surgery and mini-open surgery are current trend of spine surgery, and its main advantages are shorter recovery time and cosmetic benefits, etc. However, mini-open surgery is easier and less technique demanding than endoscopic surgery. Besides, anterior spinal fusion is better than posterior spinal fusion while considering the physiological loading, back muscle function, etc. Therefore, we aimed to introduce the modified "mini-open anterior spine surgery" (MOASS) and to evaluate the feasibility, effectiveness and safety in the treatment of various anterior lumbar diseases with this technique. A total of 61 consecutive patients (46 female, 15 male; mean age 58.2 years) from 1997 to 2004 were included in this study, with an average follow-up of 24-52 (mean 43) months. The disease entities included vertebral fracture (20), failed back surgery (13), segmental instability or spondylolisthesis (10), infection (8), herniated disc (5), undetermined lesion for biopsy (4), and hemivertebra (1). Lesions involved 13 cases at T12-L1, 18 at L1-L2, 18 at L2-L3, 22 at L3-L4 and 11 at L4-L5 levels. All patients received a single stage anterior-only procedure for their anterior lumbar disease. We used the subjective clinical results, Oswestry disability index, fusion rate, and complications to evaluate our clinical outcome. Most patients (91.8%) were subjectively satisfied with the surgery and had good-to-excellent outcomes. Mean operation time was 85 (62-124) minutes, and mean blood loss was 136 (minimal-250) ml in the past 6 years. Hospital stay ranged from 4-26 (mean 10.6) days. Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%). Most cases (95%) achieved solid or probable solid bony fusion. There were no major complications. Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.

Show MeSH
Related in: MedlinePlus