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Spine surgeons can safely perform anterior lumbar surgery without access surgeons
Investigators found a complication rate of 82% when a general surgeon assisted with the exposure.
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SAN FRANCISCO — Although spine surgeons who perform anterior lumbar surgery may use a vascular or general surgeon to perform the exposure, a recently presented study reveals a significantly greater rate of complications when an access surgeon is used.
“The anterior approach to the spine can be safely performed by a spine surgeon,” Micah Smith, MD, an orthopedist at Stanford University School of Medicine in Redwood City, Calif., said during his presentation at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. “An access surgeon is not required for this approach if the spine surgeon has appropriate training.”
Retrospective study
Smith and colleagues conducted a retrospective study of 96 patients who underwent anterior lumbar surgery between L3 and S1 by two spine surgeons between 1995 and 2008. General surgeons completed the exposure in 57 patients, while spine surgeons performed the exposure in 39 patients.
“For all the cases, even the ones where the general surgeon provided the access, the spine surgeon was present for the entire procedure from incision to closure, and the closure was always done by the spine surgeon,” Smith said.
Patients underwent either anterior lumbar interbody fusion or artificial disc replacement using either a paramedian incision with retroperitoneal dissection down to the level of pathology, Smith said. He added that some of the patients underwent posterior surgery as a single-stage procedure.
The investigators analyzed the groups for differences in age, gender, diagnoses, levels of pathology, body mass index (BMI), estimated blood loss, operative time, hospitalization time, comorbidities and complications related to surgery. The patients mainly required surgery for degenerative disc disease, but some had pseudoarthrosis, infection or scoliosis.
Safe without access surgeons
The investigators found no statistically significant differences between the groups in terms of age, gender, BMI, number of levels treated or the use of tobacco, alcohol or perioperative steroids. However, more patients in the access surgeon group had diabetes.
They found less blood loss and shorter surgical times when surgeons performed procedures alone. The length of patient stay was similar between groups, but slightly lower in the group that did not use access surgeons. Patients who underwent both anterior and posterior procedures showed significantly less blood loss, shorter hospital stays and less operative time when spine surgeons completed the exposures.
“When we took out the groups that were done for scoliosis or pseudoarthrosis, and only looked at patients who have degenerative disc disease, the same trends in significance were found,” Smith said.
In the group in which an access surgeon performed the exposure, 82% of patients experienced complications compared to 28% in the group without access surgeons. Major complications included one deep venous thrombosis, two with retrograde ejaculation, one bleeding iliac vein and one with dyspareunia. The minor complication most patients reported were ileuses, which occurred in 58% of patients in the access surgeon group compared to 2.6% in the group without access surgeons, “but these all resolved with medical management,” Smith said. – by Renee Blisard
Reference:
- Smith M, Rahn KA, Shugart RM, et al. Complications after anterior lumbar spine exposure by a spine surgeon with and without an access surgeon. Paper #287. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb 7-11. San Francisco.
For more information:
- Micah Smith, MD, can be reached at the Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St., Redwood City, CA 94063; 650-723-5463; email: smith@stanford.edu.
- Disclosure: Smith has no relevant financial disclosures.
Perspective
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Todd J. Albert, MD
In this study, the authors look at complications comparing anterior lumbar surgery done with and without access surgeons. While it is clear that surgery can be performed well without an access surgeon, as is demonstrated here, caution should be excercised in the interpretation of the results from one institution in a relatively small number of patients. Tremendous bias can be injected in a nonrandomized study with influences from individuals’ surgical talents and patient selection. Many surgeons gain comfort utilizing talented access surgeons to offset liability, allow performance of alternative tasks, and complication and medical management. The bottom line is that, as always , surgeons should do what they are most comfortable with and best at. This will serve both them and their patients well.Perspective
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Scott D. Boden, MD
The use of an access surgeon for anterior lumbar surgery should take several factors into consideration. These factors include the frequency that the spine surgeon (or access surgeon) performs the surgical approach to be used, whether the vessel anatomy is permissive or obstructive, history of previous surgery and body habitus. This study has a relatively small sample size to definitively comment on the safety of an event like vascular injury, which occurs in less than 10% of cases and is also dependant directly on the surgical skill set of the surgeons at the single institution. A larger, multicenter dataset might make the conclusions more generalizable.Click Here to Manage Email Alerts