Laparoscopic discectomy with anterior lumbar interbody fusion. A preliminary review.

STUDY DESIGN: Patients presenting with L5-S1 anterior column disease with or without herniation into the spinal canal but without stenosis underwent magnetic resonance imaging screening before surgery to determine surgical suitability for laparoscopic anterior lumbar interbody fusion relative to the aortic bifurcation and approach to the disc space. OBJECTIVES: To analyze and evaluate the laparoscopic approach, technique, and benefit of anterior lumbar discectomy and interbody fusion by distraction and compression-loading of autograft only as compared with cage-spacer-enhanced autograft fusion. SUMMARY OF BACKGROUND DATA: Advancement in minimally invasive spine surgery techniques has provided options with less morbidity for posterior lumbar procedures. General surgical advancements in laparoscopy and advantages of traditional anterior lumbar interbody fusion, including restoration of disc height and exposure for safe nerve decompression, provided a basis for an integrated procedure that would address anterior column abnormality with low surgical morbidity. METHODS: Five patients underwent technically successful laparoscopic anterior lumbar interbody fusion with approach to the disc space by an experienced laparoscopic general surgeon. A sixth patient in the study group was unable to undergo laparoscopic fusion because of an iliac vein tear during the surgical approach. After the approach, a spine surgeon followed with complete manual discectomy and interbody autogenous fusion laparoscopically. Two to three Cloward-type dowels were obtained by separate incision from the anterior iliac crest. RESULTS: All patients by 6-month follow-up examination were clinically fused with no motion on flexion-extension radiographs. One patient had slight anterior retropulsion of one dowel without the necessity of reoperation. CONCLUSIONS: Laparoscopic L5-S1 anterior lumbar interbody arthrodesis may represent a viable option for patients with abnormality, including anterior column and degenerative disc disease.

Pudendal nerve palsy complicating intramedullary nailing of the femur.

A prospective study of 106 patients who had static interlocking nailing of the shaft of the femur was performed to determine the relationship between the duration and magnitude of intraoperative traction and the development of a pudendal nerve palsy. A strain-gauge, mounted in the countertraction post, measured the magnitude of the perineal pressure over time. All nailings were performed with the patient in the supine position. Postoperatively, the patients were interviewed by one of us, who had been blinded from the results of the recordings of intraoperative pressure, for a history of erectile dysfunction and changes in labial, scrotal, or penile sensation. A light-touch sensory examination of the genitalia was performed on all patients. Ten patients (six men and four women) had a pudendal nerve palsy: nine had sensory changes only, and one complained of erectile dysfunction. The symptoms had resolved at the three-month follow-up evaluation in all patients except one man who complained of dysesthesia six months postoperatively. The patients in whom a palsy did not develop had been positioned on the fracture-table and the perineal post for an average of 2.6 hours (range, 1.4 to 5.2 hours) compared with an average of 2.8 hours (range, 2.0 to 4.3 hours) for those in whom a palsy did not develop (p = 0.15). The magnitude of the total traction forces averaged 34.9 kilogram-hours for the patients who did not have a palsy compared with 73.3 kilogram-hours for those who did (p < 0.03). Adduction of the hip, as well as manipulations for reduction of the fracture, significantly increased the traction forces.(ABSTRACT TRUNCATED AT 250 WORDS)