Vascular complications of exposure for anterior lumbar interbody fusion

The purpose of this study is to document the incidence of vascular complications during anterior lumbar interbody fusion (ALIF) in 212 consecutive patients treated at the Scripps Clinic and determine what factors adversely affected outcome.

We reviewed the prospectively maintained database of all ALIF procedures performed at Scripps Clinic between August 2004 and June 2009. All procedures were performed by a spine surgeon in conjunction with a vascular surgeon who performed the exposure portion of the operation, and protected the vessels from injury during the instrumentation phase of the operation.

Two hundred twelve ALIF operations were identified. The mean age of the patients was 53.8 years, and 120 (56.6%) were female. The mean body mass index (BMI) was 29.6 (range, 18.1 to 47.8). Twenty-two (10.4%) operations were performed at the L4-5 disc space, 149 (70.3%) at L5-S1, and 41 (19.3%) involved L4-L5 with L5-S1. The mean estimated blood loss (EBL) was 143 milliliters. There was a significant direct correlation between increasing BMI and EBL (P = .018). Thirteen (6.1%) vascular injuries occurred of which five were major (38.5%). One major arterial injury (0.5%) occurred and required arterial thrombectomy and stent placement. Four of the major vascular injuries were venous in nature and required a multi-suture repair. The remaining eight injuries (61.5%) were venous, the majority of which required a suture repair. There were no mortalities. There was an increase risk of vascular injury when both L4-L5 and L5-S1 were exposed (P = .003) and with the male gender (P = .013). Calcification of the aorto-iliac system did not exert an effect on EBL or vascular injury. In four cases, the surgeon was unable to expose the appropriate disc levels.

Anterior exposure of the spine for ALIF can be performed safely with a team approach that includes a vascular surgeon. Preoperative evaluation by a vascular surgeon is advisable. Patients with increased BMI and bi-level exposures should be approached with caution.