Exposure Related Outcomes And Complications In Patients Undergoing Anterior Lumbar Interbody Fusion
Jesse Manunga, Jr., MD1, Christopher Alcala, MD2, Jason Alexander, MD1, Nedaa Skeik, MD1, Elliot Stephenson, MD1, Senthil Jayarajan, MD1, Aleem Mirza, MD1, Titus Jessica, MD1, Joseph Karam, MD1, Xiaoyi Teng, MD1, Timothy M. Sullivan, MD1.
1Minneapolis Heart Insitute at Abbott Northwestern Hospital, Minneapolis, MN, USA, 2Twin City Spine Center at Abbott Northwestern Hospital, Minneapolis, MN, USA.
Objective: To evaluate access related complications and factors contributing to adverse outcomes in patients undergoing retroperitoneal anterior lumbar interbody fusion (ALIF).
Methods: The study is a retrospective analysis of patients undergoing ALIF at our institution from January 2010 to December 2017. Access was performed by a vascular surgeon, who remained present for the duration of the case. Data collected included patients’ demographics, comorbidities, and exposure-related complications. Study endpoints included major adverse events (MAEs) and minor complications. MAEs included any vascular injuries requiring repair, bowel and ureter injuries, arterial embolization, postoperative bleeding requiring reoperation, myocardial infarction, stroke, pulmonary embolism/deep venous thrombosis, wound dehiscence and death. Minor complications included postoperative ileus, urinary tract infection and superficial wound infections. Incidence of incisional hernia was also evaluated.
Results: during this period, 800 patients (Male: 358; F: 442, mean age: 53.1 ± 13.7) underwent a total of 1457 levels ALIF at our institution (single level: 205 patients, 2 levels: 307, 3 levels: 103, 4 levels: 73, 5 levels: 6, 7 levels: 1). Median estimated blood loss was 25 mL [25, 40]. There were 45 (5.6%) exposure-related complications, including vascular injuries (venous: 8, arterial: 4) in twelve patients (1.5%), bowel injuries in three patients (serosa tear in two and arterial embolization with subsequent bowel ischemia in one). Seven of the eight venous injuries (87.5%) occurred while exposing the L4-L5 lumbar level. Three of the 4 patients with arterial injuries developed acute limb ischemia requiring embolectomy. Nine patients (1.13%) developed deep venous thrombosis/pulmonary embolism, two of which had sustained left iliac vein injury during exposure. Eleven patients (1.4%) developed retroperitoneal hematoma/seroma with nine requiring evacuation in the operating room. Twenty-tree patients (2.9%) developed postoperative ileus, defined as inability to tolerate diet on postoperative day 4. Three patients (0.4%) had a postoperative myocardial infarction, 2 had a stroke and one (0.1%) died within the first 30 postoperative days. Seven patients developed incisional complications, including superficial wound infection in two and incisional hernia in five.
Conclusions: Our findings suggest that ALIF can be performed safely with a relatively low overall complication rate. The majority of vascular injuries associated with this procedure are venous in nature, occurring predominantly while exposing the L4-L5 level and can be safely addressed by an experienced vascular team.
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