Presacral retroperitoneal approach to axial lumbar interbody fusion: a new, minimally invasive technique at L5-S1: Clinical outcomes, complications, and fusion rates in 50 patients at 1-year follow-up

Abstract

BackgroundThe presacral retroperitoneal approach to an axial lumbar interbody fusion (ALIF) is a percutaneous, minimally invasive technique for interbody fusion at L5-S1 that has not been extensively studied, particularly with respect to long-term outcomes.ObjectiveThe authors describe clinical and radiographic outcomes at 1-year follow-up for 50 consecutive patients who underwent the presacral ALIF.MethodsOur patients included 24 males and 26 females who underwent the presacral ALIF procedure for interbody fusion at L5-S1. Indications included mechanical back pain and radiculopathy. Thirty-seven patients had disc degeneration at L5-S1, 7 had previously undergone a discectomy, and 6 had spondylolisthesis. A 2-level L4-S1 fusion was performed with a transforaminal lumbar interbody fusion at L4-5 in 15 patients. AxiaLIF was performed as a stand-alone procedure in 5 patients and supplemented with pedicle screws in 45 patients. Pre- and postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were evaluated and complications were tracked. Fusion was evaluated by an independent neuro-radiologist.ResultsAt 1-year follow-up, VAS and ODI scores had significantly improved by 49% and 50%, respectively, versus preoperative scores. By high-resolution computer tomography (CT) scans, fusion was achieved in 44 (88%) patients, developing bone occurred in 5 (10%), and 1 (2%) patient had pseudoarthrosis. One patient suffered a major operative complication–a bowel perforation with a pre-sacral abscess that resolved with treatment.ConclusionOur initial 50 patients who underwent presacral ALIF showed clinical improvement and fusion rates comparable with other interbody fusion techniques; its safety was reflected by low complication rates. Its efficacy in future patients will continue to be monitored, and will be reported in a 2-year follow-up study of fusion.

Presacral Approach for L5-S1 Fusion

“…1A). 4,12,[17][18][19][20]22 Similarly, the fusion rates for AxiaLIF and ALIF are also comparable and range from 88% to 100% (see Fig. 1B).…”

“…In 2010, Bohinski et al 12 reported clinical outcomes and fusion rates on 50 AxiaLIF patients with an 1-year follow-up.…”

“…Overall, 88% of patients showed some degree of fusion, with only 1 patient (2%) demonstrating pseudarthrosis at L5-S1, which necessitated a return to surgery. 12 This patient had both S1 pedicle screws replaced at L5-S1 and was given a bone growth stimulator. The axial rod was not revised in this procedure.…”

“…The average preoperative VAS and ODI scores were 77 mm and 56%, respectively; these scores decreased to 39 mm and 28% at 1-year follow-up. 12 Relevant operative data included an average hospital stay of 2.5 days and an estimated blood loss of 234 mL for patients who had a concurrent posterior fixation. EBL for standalone AxiaLIF was 29 mL.…”

“…11 The AxiaLIF technique preserves the annulus, in addition to muscles and soft tissues, resulting in reduced healing time and lower complication rates. 4,7,8,12 The AxiaLIF technique uses the presacral space that is relatively free of impeding tissues, thus providing easy access to the S1 vertebral segment. [4][5][6] This study will give an overview of the approach, potential complications, and the unique benefits that AxiaLIF may have compared with traditional open surgery for degenerative conditions of the lumbar spine.…”