Objective: To describe a minimally invasive midline approach, retroperitoneal or transperitoneal, to the lumbar spinal levels L2-L5.
Indications: Degenerative disc disease (DDD) with or without disc herniation that may require a total lumbar disc replacement; also for fusion-cases like degenerative instability, tumors, isthmic and degenerative spondylolisthesis of all grades (after dorsal reduction), fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-discectomy)
Contraindications: Relative contraindications are previous abdominal surgeries; aortic bifurcation and/or venous confluens directly in front of the disc space L4/5; infections with the formation of a large prevertebral granulation tissue or psoas abscess; adipositas permagna.
Surgical technique: Anterior midline incision over the relevant disc space with a left retro- or transperitoneal approach. Transperitoneal approach: mini laparatomy with dissection of the peritoneum and mobilization of the bowels laterally; retroperitoneal mobilization of the peritoneal sac towards the contralateral side; preparation of the anterolateral circumference of the disc space and mobilization of adjacent vessels depending on the vessel anatomy; discectomy and preparation of the graft bed.
Postoperative management: Early mobilisation from the first postoperative day for combined ALIF/posterior instrumentation procedures. Thromboembolic prophylaxis with fractioned heparin. Light meals up until recovery of bowel activities. No brace is needed for total lumbar disc replacement procedures. A brace is recommended depending on the type of intervention (fusion) for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period.
Results: A minimally invasive midline approach was performed in 686 patients (19-84 years; 94-320 pounds). In 444 cases the levels L2-L5 were exposed. The average time of exposure to these levels was 22.7 minutes. 6 months postoperatively the approach related complications were evaluated. A total of 3.8% major complications were observed overall.