In this procedural case review, vascular surgeon Dr. Samuel Steerman and neurosurgeon Dr. Shannon Clark collaborate to perform an anterior lumbar interbody fusion (ALIF). Dr. Steerman provides anterior spinal exposure while carefully mobilizing and protecting critical vascular structures, allowing Dr. Clark to safely access the lumbar spine and complete the fusion. The video includes pre- and postoperative imaging, key surgical steps, and insights into the multidisciplinary approach that helps optimize outcomes for patients requiring lumbar spine reconstruction.
I'm Shannon Clark. I'm a neurosurgeon at Virginia Beach General Hospital. What makes our anterior lumbar antibody fusion program truly special is what you see here two subspecialty surgeons working together to help patients achieve their improvement in low back pain from the beginning of the surgery to the end. I'm Sam. I'm a vascular surgeon and Dr. Clark has the most important portion of fixing the spinal problem that we have today. I help with exposure of the spine and protecting the blood vessels to make sure that it's a safe case. We are now reviewing the preoperative X-rays and imagings together. This patient had previous fusion all the way. Down to L5, but on subsequent surgery, his pedicle screw at L5 was removed. This makes L5-S1 the adjacent level disease. On this MRI you can see that the L5-S1 has disc desiccation with loss of disc height and end plate signal changes consistent with modic pathology. This adjacent segment disease is a result of previous fusion, and now this level needs to be addressed. Given the patient's BMI of only 20, we have decided to proceed with an A, anterior lumbar antibody fusion, using stand-alone instrumentation, avoiding the need to extend the posterior fusion construct. The goals of these surgeries are to reduce his chronic low back pain and to indirectly decompress the nerve roots by restoring this height. An anterior-only approach also means less posterior dissection and less postoperative low back pain. The surgery starts with a left lower quadrant incision just to the left of the midline. We find this is most aesthetic as well as giving us the best view of the L5-S1 space. The skin is dissected free and in subcutaneous tissue. This is the fascia, the anterior fascia that's divided, and this is the rectus abdominal muscle beneath it. That's the end of the cutting that's really necessary for this, as we'll be moving the rectus muscle and the abdominal contents medially. This is a self-retaining retractor, and through this keyhole incision, we expose the L5-S1 inner space. And the value of having a vascular surgeon here is not necessarily to expose the area, but to avoid injury, which is successfully done. Here you can see the anterior longitudinal ligament and the anterior annulus being incised. A complete aneurotomy is performed, taking down the anterior annulus to allow full access to the disc space. Discectomy is now underway. Using curettes and disc shavers. We are systematically removing the disc material and degenerative nucleus. The end plates are being prepared meticulously. Note the curate working along the superior and inferior end plates, scraping down to viable bleeding bone. Thorough end plate preparation is essential to maximize the biological environment for fusion. Fluoroscopy is then brought to guide implant size. On the lateral fluoroscopic image, you can see the trial inserter being advanced into the disc space under real-time imaging. Confirming appropriate depth and trajectory at L5-S1. This ensures the final implant will be well positioned at the posterior third of the disc space to restore low dorsis and maximize end plate contact. The CM is then removed out of the field and we transition to implant insertion. The stand-alone airlift cage packed with bone graft is introduced into the prepared disc space. You can see the insertion handled and impactor being used to carefully advance the implants implant to its final position. The retractor system visible at the field edges is maintaining safe vessel retraction throughout this critical step. With the cage seated, attention now turns to screw fixation. Here we see the integrated screw holes of the stand-alone cage. The screws are being placed sequentially, 2 into the L5 vertebral body superiorly and 1 into S1 inferiorly, locking the construct in place without the need for supplemental posterior fixation. The screwdriver is engaged and each screw is fully seated under direct visualization. At the conclusion of the fusion, I re-enter. I have sure hemostasis, and here we are getting a nice closure of both the fascia, the subcutaneous tissue, and the skin. Typically a little bit of glue is placed on top at the end of this, and the patient has minimal incisional discomfort during the recovery period.
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