[ NEWS - SPINE ]
COMMENTATOR Ralph Mobbs , M . D .
COMMENT
“ I ’ ve done over 1,200 ALIFs and it is a remarkably robust procedure . The rate of retrograde ejaculation is well under 2 % if you use blunt dissection laterally on L5 / S1 and avoid unipolar = technique . It is the perfect operation for recurrent disc herniation and yes , you can decompress the neurological elements = technique . Big red & blue ? Sure you can get into grief but be prepared for this = technique . Difficult revision cases I agree only done by those who are v experienced , but again = technique . Sympathetic ? Sure … but not more than OLIF and almost always gets better in 3 / 12 . When my L5 / S1 goes to crap = I only want an ALIF . Simon Sandler , M . D . Best disc clearance and graft site preparation .
Thomas Errico , M . D . I was persuaded to get on the TLIF train and had marked increase in hardware and pseudo problems . Inherent to TLIF is destabilizing unilaterally the spine at that level which in short segments is not a problem but in long fusions at the bottom is undesirable . Alif ’ s worth the time and trouble and possibly additional short-term issues .
Anthony Ghosh , M . D .
Patrick Knight , M . D .
Lali Sekhon , M . D ., M . B . A .
Orlando Zamora , M . D .
Marcelo Perocca , M . D .
Andrew Vivas , M . D .
Mike Selby , M . D .
Jim Yousef , M . D .
Rao Prasanth , M . D . Mike Selby , I do it routinely too . Ray Ross , M . D .
Robert Foster , M . D .
Zhi Wang
Charbel Moussallem , M . D .
Also having to work with a good vascular access surgeon is a bonus not a negative . Good teamwork . Allows the spine surgeon to focus on the spine and nerves
This is the problem with approach surgeons as they have little responsibility to the patient . I think it ’ s better to do the approach oneself .
“ How about the hassle of coordinating with the access surgeon when everyone wants him ?? ( also working on obese big-bellied people is like trying to fix something at the back of your freezer ).
In my experience I never see a revision surgery for ALIF . There are more myths than real complications with vascular , sympathetic or ejaculation issues Compare how many revisions do you do in posterior vs anterior approach .
Complications of the posterior route are much more frequent than the anterior ! I had 300 cases of lumbar disc prosthesis and another 280 cases of ALIF and only 4 revisions without any complications due to this . Two cases of sympathetic dysfunction and no cases of retrograde ejaculation . The technique is more refined and without the muscle and bone damage of the posterior approach .
With respect to my great mentor , I disagree with point number four ! Resection of the PLL , retrieval of sequestered disc fragments , resection of osteophytes , and direct decompression of ventrally , compressive elements within the foramen can be done through the disk space with a little bit of patience , practice , and skill . Just like a big ACDF
Andrew Vivas completely agree . Juan is wrong on this one . PLL release gives great visualization and is now routine for me in ALIF . If you can do an ACDF , you can release the PLL in an ALIF !!
Andrew Vivas Agree 100 %. Any remaining fragments will resolve or be treated with indirect decompression due to restored disc and foraminal height .
Agree 100 % with Dr Daniel ’ s . MIS ALIF or lateral ALIF is preferable over TLIF or PLIF . Juan , why would you neglect the decades of work on lumbar lordosis correction or preservation with improved fusion rates ? Your list of concerns has been addressed in the literature and most are negligible . Be well my friend !
Once the annulus is reached in an ALIF it ’ s just an ACDF . I realised that in 1992 but pleased to learn some others have cottoned on . Pity it ’ s still about fusion and not replacement . And I don ’ t mean those technologies based on hips and knees- you need viscoelastic devices to improve on fusion .
Did my own exposure for years . Including thoracotomy and sternotomy L4-5 is the problem level , the complication rate is the same with an experienced spine surgeon , and an access surgeon . Dr . Holt has proven this . However , if you have a complication you can ’ t deal with , you will be criticized by your colleagues . The drawing shows the bifurcation of the aorta at 5-1 which is wrong . It ’ s almost always L3-4 . The cable bifurcation is a little bit more midline and is usually right above the L5 S1 . Space . The superior , hypo , gastric plexus , follows the vessels and is identifiable , there ’ s an arcane issue of surgery , and gynecology , that shows this . It is the ultimate minimally invasive surgery but is a pain in the ass .
In Canada : we do our own approach . You just do more and see more , like everything in surgery , your anxiety decreases after x number of cases . I think I got quite comfortable doing them even in patients with previous abdominal surgery at about 35-40 cases solo . With probably over 100 alif : one venous injury minor , one ejaculation problem . Touching wood !!! But I still try to do from posterior if I can .
https :// pubmed . ncbi . nlm . nih . gov / 22275156 / ALIF is amazing
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