Access strategies for revision in anterior lumbar surgery

Study Design. Sixty-two consecutive patients undergoing anterior lumbar revision surgery from February 2000 to September 2007 were evaluated for approach strategies and complications. Objective. To determine the incidence of complications in these patients and to make recommendations on future revisions based on the results obtained. Summary of Background Data. Only 2 articles exist in the literature that address this situation and they have widely varying results in a small number of patients. This larger series may help give more certainty to the expectations for complications in patients undergoing revision anterior lumbar surgery. Methods. A concurrent database was maintained on these 62 consecutive patients. Preoperative strategies were evaluated and complications were tabulated as they occurred and later analyzed to arrive at recommendations for future similar cases. Results. Twenty-three patients had the same level revised and 39 patients had adjacent levels operated on. There were 3 venous injuries (4.8%), 3 arterial injuries ( 4.8%), and 1 ureteral injury (1.6%). All 3 arterial injuries occurred while approaching L3-L4 after L4 to S1 prior fusion or disc replacement. All 3 venous injuries and the ureteral injury occurred while approaching a previously operated level or levels. Six of these patients had the injuries repaired and the procedures completed with full recovery. One L5-S1 revision had the procedure aborted after a venous injury. There were no deaths. Conclusion. Although the incidence of complications in revisions is much greater than for index cases, the actual percentage of venous, arterial, and ureteral complications is certainly acceptable for patients who must have this type of surgery. Only very experienced access surgeons should attempt revision surgery.