Laparoscopic approaches to fusion of the lumbosacral spine: latest techniques

The particular advantages of interbody cages include the beneficial effects on bone healing associated with the anterior column location (Wolff's Law), the stabilization potential in appropriate motion segments, the ability to restore anterior column height and foraminal volume, and the avoidance of the fusion disease phenomenon. These advantages do not depend on whether the approach of insertion is open or laparoscopic. The specific and demonstrated chief benefit of the laparoscopic approach to interbody cage insertion is the reduction in surgical morbidity. This is especially evident when the laparoscopic technique is combined with the use of bone morphogenetic protein (rhBMP-2). It is the author's belief that this significant diminution in patient morbidity drives the further acceptance of the laparoscopic approach in a manner similar to the evolution of arthroscopic orthopedic surgery and laparoscopic general surgery. The main disadvantage of the laparoscopic approach is the initial learning curve of the surgical team with the technique. The anterior approach to cage placement (open or laparoscopic) also is limited regarding the inability to decompress the spinal canal directly. It is recommended that the interbody cages be considered as only one option in the stabilization of symptomatic motion segments. With care in patient selection, their ability to function in a stand-alone configuration has been demonstrated successfully. To evolve to the laparoscopic placement technique of interbody cages, the access surgeon or spine surgeon should begin as part of a team with the open approach placing the particular instrumentation system they plan to use laparoscopically. Together, the access surgeon and spine surgeon team should attend a hands-on laparoscopic course for the specific instrumentation system. Finally, in terms of initial case selection, one should begin with nondeformity L5-S1 cases and, most importantly, allow time.