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    • br Discussion The first anterior approach to the lumbar

    2018-11-12


    Discussion The first anterior approach to the lumbar spine was reported by Burns in 1933. Since then, various anterior procedures for the treatment of thoracolumbar lesions have been described. Nonetheless, widespread acknowledgment that the anterior approach is an effective procedure was slow because of the high procedure-related complication rate. Harrington asserted that surgeons should be familiar with anterior decompression and stabilization techniques prior to attempting the procedure, and recommended that surgeons lacking experience in thoracic and vascular techniques should seek assistance from surgeons who are experts in those fields. Currently, most of Taiwan\'s neurosurgeons are not formally trained in the anterior approach during their residencies. Instead, the posterior approach is recommended for the management of thoracolumbar lesions when access surgeons are not available. Blindly using the posterior technique may result in inappropriate treatment for patients with thoracolumbar pathology who would have benefited from an anterior approach. Specifically, some patients treated via the posterior approach can, in some cases, suffer from persistent neurologic deficits due to residual spinal cord palmitic acid because of inadequate therapy. Holt et al. reported shorter operative time, less blood loss, and a lower rate of complications when the anterior procedure was performed by an approach-trained spinal surgeon compared to when the procedure was performed by a spinal surgeon with the aid of an access surgeon. A study by Han et al. reported no increased morbidity following anterior approaches performed by an approach-trained spinal neurosurgeon compared with approaches made by access surgeons, in terms of operative time, complication rate, and improvement of neurologic function. Results of the preliminary study reported herein were consistent with their results. Additionally, a comparison between surgeries performed by the self-trained neurosurgeon and those by the neurosurgeons assisted by access surgeons showed similar results with regard to operative time, blood loss, complications, and improvement of neurologic function. These encouraging results indicate that a neurosurgeon can become familiar with the anterior approach after appropriate training (such as the learning process described above). The mean operative time in the current study was 339 ± 154 minutes, which was longer than that reported in the literature (range, 99.3–174 minutes). One reason for the longer operative time is the timing method. In the current study, duration of the procedure began at the onset of general anesthesia rather than at the time of the first incision. Another likely factor contributing to the longer operative time was the steep learning curve of the anterior procedure. The mean blood loss in this study was 953 ± 899 mL, which was also higher than that previously reported in the literature (range, 385–635 mL). One reason could be that the operation was performed on metastatic carcinomas and osteoporotic compression fractures, which were common in the current study; both of these are associated with increased bleeding. The rate of such cases was higher in the study described herein than in the Holt et al\'s series of patients (80% vs. 5.1%, respectively) and may be the main reason for the difference in blood loss. The surgery-related complication rate in the current study was 10%, which is comparable to rates reported by other authors in the literature (4.8–31%). Postoperative pneumonia developed following reconstruction of a T12 osteoporotic compression fracture. That surgery involved an anterior thoracoabdominal corpectomy, a procedure requiring incision of the diaphragm, which is a common cause of pulmonary problems. The neurologic improvement rate in Group 1 was 70%, which was higher than that reported in the literature (33.3%). The reasons for this improved neurologic improvement rate in this study may be the small number of patients and that all patients were treated within 48 hours after a neurosurgical consultation. Three patients\' postoperative neurologic function scores remained unchanged. One of those patients, who had been diagnosed to have schizophrenia years earlier, had suffered from paraplegia for about 3 months due to T7–8 osteomyelitis with an epidural abscess compressing the spinal cord. Although the infected area was removed successfully and antibiotic treatment was administered, the patient\'s postoperative ASIA impairment scale did not change. The other two patients who did not show improvement had osteoporotic compression fractures of T12 and L1. The unbearable back pain in both these patients was relieved following the anterior thoracolumbar corpectomy, but their lower limb weakness remained unchanged.