Laparoscopic lumbar spine surgery

Abstract

IntroductionThere have been very rapid advances in the last decade in the surgical management of lumbar spinal disease. Whilst clinical assessment and decision making continue to play the most important role in determining the outcome of interventions, modern technology has played a key role in this revolution. It seems inevitable that the advances in the next decade will be biological rather than mechanical, and the changes in the last few years may be the last major contribution that clinic-based operating surgeons will be able to make in this field.Advances in surgical technique can be considered either in relation to approaches to the spine or in relation to the nature of the surgical procedure performed on the spinal column.The posterior approaches to the spine have evolved by the use of the posterolateral percutaneous portal.The anterior approach to the spine, which previously had been open, either transperitoneal or retroperitoneal, has changed rapidly because of the development of endoscopic and retractor technology. The catalyst for this development has undoubtedly been the application of transperitoneal endoscopic techniques to approaching the lumbosacral disc. The approach, which was first described for discectomy in 1991 [11], was further developed to perform anterior lumbar intervertebral fusion (ALIF) [6,8,15,20]. This was partly brought about by the use of cylindrical fusion cages and the ability to introduce them through cannulae.In most surgeons' hands, the transperitoneal endoscopic or laparoscopic technique proved practicable only at the lumbosacral disc level, and because of the steep learning curve and significant complications many groups have moved on to retroperitoneal endoscopic techniques, or mini-open techniques, with specialised retractor systems [7], which are covered elsewhere in this paper.Nonetheless, it has been the development of the laparoscopic techniques that has opened up the whole field, and there are many useful lessons to be learnt from its history, albeit short lived.Throughout the development of these techniques, the importance of general surgical support for these approaches, and for careful supervised training, including animal, cadaveric and simulation models, has been emphasised. AbstractThe use of transperitoneal endoscopic approaches to the distal segments of the lumbar spine has recently been described. This has been the catalyst for the development of other minimally invasive anterior approaches to the spine. This review looks at the published results so far, and highlights the principles, techniques and complications. The limitations of laparoscopic approaches have meant that surgeons are moving on to endoscopic extraperitoneal and mini-open approaches, but important lessons have been learnt during this short rapid phase of development. The efficacy and safety of minimal access techniques in the spine have been established, and outcome standards set by which future techniques can be judged. The importance of proper training is emphasised.

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review

“…What image does this project to the public, who observe medical costs escalating, and some doctors seemingly benefiting with vast sums. Industry does not like failure, so for example some years ago when we reported the poor results of the BAK cage (now a generally discredited cage) [45,46] our industrial supporters (an international firm) [46] removed from our unit all financial support within 3 weeks, research fellow, equipment, and secretarial support. Perhaps, this was sensible industrial policy, but the message was clear….…”