Interbody spinal Fusion
What is it?
The surgical procedure, performed under general anesthesia, involves the execution of an interbody vertebral arthrodesis (using minimally invasive anterior, anterolateral, lateral or posterior approaches) that may or may not be associated with a posterior instrumented arthrodesis obtained by fixation of the vertebrae involved using special instruments consisting of screws and rods, and the application of a bone graft, in order to allow a permanent fusion between the vertebrae of the selected area previously crucified.
When is this procedure indicated?
Patients with DDD have an indication for surgical treatment when they present with disabling pain symptoms resistant to medical and physical therapies, have been present for at least 3 months, and especially if there is irradiation of pain to the lower extremities with or without the presence of neurologic claudication or a neurologic deficit.
It is very important to carry out evaluation of the clinical picture and the analysis of the radiological picture that allow for establishing the severity of the pathology and therefore choosing the surgical program.
The primary purpose of the surgery is to stabilize the affected spinal tract, which serves to prevent progression of the pathology and improve pain. In the presence of neurological pain symptoms or neurological deficits, it is necessary to intervene also with the decompression of the neurological structures involved.
How is it performed?
Intercomatic arthodesis using minimally invasive techniques:
- ALIF: Anterior lumbar interbody fusion: patient in supine decubitus, slightly in Trendelenburg, disinfection and preparation of the surgical field; mini Pfannestiel (7 cm) or peri-umbilical incision, retroperitoneal access, identification/isolation and protection of the great vessels (aorta-cava-iliacs) and ureters. Using the endoscope, vertebral limiting discectomy/cruction and lordotic cage implantation plus bone substitute for interbody arthrodesis are performed. Lavage, hemostasis control and suture for plans with drainage.
- XLIF: extreme lateral interbody fusion: patient in lateral decubitus (right or left side as needed), disinfection and preparation of the operating field. Under control with a brightness amplifier, a skin incision of about 5 cm is made on the projection of the intervertebral disc to be treated (from L2 to L5), as well as subcutaneous dieresis, digitochlasia of the muscle bellies and access to the retroperitoneal space and then to the disc.
After neurological monitoring of the lumbar plexus, discectomy, cruentation of the vertebral limiting factors and cage implantation plus bone substitute for interbody arthrodesis are performed. Suture for posterior 2nd half planes as already described. Neurological monitoring with motor and sensory evoked potentials during deformity correction maneuvers.
Average duration of hospitalization is 3-4 days. Patients undergo their first outpatient follow-up 10 days after discharge, at which time stitches are removed, dressing is performed, medical therapies are monitored and, if necessary, modified, and advice is given for the continuation of the postoperative course. After discharge, a home convalescence period of 2 to 4 weeks is still required before fully resuming previous activities. During this period, the patient should avoid lifting loads with the spine, perform flexion-extension and rotation movements of the upper body. In this period, it is important to gradually resume physical activity, and try to take short walks.
A second checkup is normally scheduled about 1 month later with a follow-up x-ray. At this time, if the patient's clinical and radiographic conditions permit, the brace can be removed and the rehabilitation program can be started.
Subsequent clinical and radiographic outpatient follow-ups are scheduled at 3 months, 6 months, 1 year, 2 years, 5 years, and 10 years. In case of special needs, outpatient checks are scheduled according to specific needs.
Possible risks and side effects related to surgery in general are: bleeding, allergic reactions, infection, deep vein thrombosis (vein obstruction), embolism, skin irregularities around the area of surgery.
The clinical condition immediately following the planned treatment can be expected to be characterized by some sequelae, and, in particular, persistence of algic symptoms, hyperpyrexia.
Predictable risks and complications specific to the proposed surgery in the short and long term are: neurological injury (of nerve roots, dura mater), vascular and pleural injury, hematoma formation.
Among the complications in the medium- and long-term period is a possible lack of consolidation of the bone graft and, since instrumentation is used, breakage or loosening of the implant may occur, which may require a second operation for the partial or total removal of the same.
The factors in this case that make surgery more complex and therefore increase the risks are: advanced age, high degree of slippage, presence of anatomical abnormalities, association of other acquired or congenital morbid conditions, previous surgery at the affected level, presence of scar tissue, obesity, smoking, taking antiplatelet or anticoagulant therapy.
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