This document discusses the anterior lumbar approach for lumbar total disc arthroplasty and fusion. It provides advantages of the anterior approach including minimal invasiveness, reduced blood loss and risk of infection compared to posterior approaches. The anterior approach respects lumbar musculature and prevents iatrogenic fibrosis. It allows for complete disc removal and restoration of disc height and sagittal balance. Anterior lumbar interbody fusion and circumferential fusion are described. Outcomes of mobile lumbar disc prostheses are presented as an alternative to fusion while preserving mobility.

1. ANTERIOR LUMBAR APPROACH
LUMBAR TOTAL DISC ARTHROPLASTY
LEFLOT JEAN-LOUIS M.D.

2. Tooperatethe
back, thebestis
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3. ANTERIOR LUMBAR APPROACH
More than 1200 cases
between 2001 and 2017
LEFLOT Jean-Louis M.D.
Brugmann UHC (Brussels)
Namur UHC (Yvoir)
VIVALIA (Marche-en-Famenne)

4. ANTERIOR LUMBAR APPROACH : WHEN ?
• Absence of posterior decompression gestures
• Absence of disc fragment excluded or having
migrated
• Absence of CI (some abdominal surgeries and
obesity)
N.B. The anterior approach is frequently associated with a
posterior approach (circumferential arthrodesis)

5. PHYSIOLOGICAL LOGIC
“Minimal Invasive Surgery”
• Respect of the lumbar musculature ( Isolated
anterior approach - ALIF )
• Prevents epidural and periradicular "iatrogenic"
fibrosis

6. BIOLOGICAL LOGIC
Complete Disc Resection
Degenerative disk > Cytokines > Inflammation

7. MECHANICAL LOGIC
• Restitution of the intersomatic height
• Restitution of the foraminous height
• Restitution of the sagittal balance

8. ISOLATED ANTERIOR LUMBAR APPROACH
ALIF
• Highly degenerative disc and / or associated with
posterior facet osteoarthritis
Total Disc Prosthesis (Mobile)
• Discopathy WITHOUT significant arthrosis
remodeling

9. COMBINED LUMBAR APPROACH (ANTERIOR AND
POSTERIOR)
ALIF + Posterior Fusion
• Highly degenerative disk and associated with
posterior facet osteoarthritis
• spondylolisthesis

10. LUMBAR ANTERIOR APPROACH: RISKS

11. LUMBAR ANTERIOR APPROACH :
INSTALLATION

12. LUMBAR ANTERIOR APPROACH : L5S1
(PFANNENSTIEL)

13. LUMBAR ANTERIOR APPROACH : L5S1
(PFANNENSTIEL)

14. LUMBAR ANTERIOR APPROACH : L3 TO S1
(PARA-RECTAL LEFT)

15. ANTERIOR LUMBAR INTERBODY FUSION (ALIF)

16. CIRCUMFERENTIAL LUMBAR FUSION
(ALIF + POSTERIOR FUSION)
• Male 32 y
• Collapsed and inflammatory disc disease
• Foraminous stenosis

17. CIRCUMFERENTIAL LUMBAR FUSION
(ALIF + POSTERIOR FUSION)
• Female 54 y
• Spondylolisthesis L4L5
• Collapsed discopathy
• Disc herniation L4L5
• Foraminous stenosis

18. CIRCUMFERENTIAL LUMBAR FUSION
(ALIF + POSTERIOR FUSION)
• Male 76 y
• 5 neuro-surgeries
• Epidural and peri-radicular
iatrogenic fibrosis
• Foraminous stenosis
• Disc herniation L3L4 and L5S1

19. CIRCUMFERENTIAL LUMBAR FUSION
(ALIF + POSTERIOR FUSION)
Female 42 y
Collapsed and inflammatory
disc diseases L2 to L5
Foraminous stenosis L4L5
Severe sagittal static disorder
(hypolordosis)
Considered as a fibromyalgic patient
Followed in «Pain Clinic»

20. CIRCUMFERENTIAL LUMBAR FUSION
• Male 64 Y
• 3 neurosurgical surgeries (Discectomy
(2x) + laminectomy)
• Severe spinale stenosis L3L4
• Anterolisthesis L3L4 + arthrosynovial
cyst
• Foraminal stenosis
• Loss of physiological lordosis
• ALIF L3 S1
• Revision of laminoforaminotomy
• Posterior fusion L3 to S1
• Circumferential Fusion L3 to S1

21. MOBILE LUMBAR DISC PROSTHESIS
• All advantages of anterior lumbar approach
• Preserve or Restore Function (Mobility)
• Limiting constraints on adjacent segments

22. MOBILE LUMBAR DISC PROSTHESIS
MAVERICK MEDTRONIC

23. MOBILE LUMBAR DISC PROSTHESIS
DILEMMA FUSION VERSUS PROSTHESIS

24. LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMMER-BIOMET

25. HYBRID ANTERIOR LUMBAR STABILIZATION
MOBIDISC & ROI-A CAGE LDR ZIMMER-BIOMET

26. LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMMER-BIOMET
To Restore or Preserve the function

27. LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMMER-BIOMET
• Male 31 y
• Right postero-lateral disc herniation L5S1
• Black Disc L4L5
• No effect of conservative treatment

28. LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMMER-BIOMET
• Male 52 y
• Collapsed and inflammatory disc disease
• Disc protrusion
• Foraminous stenosis L5S1
• Non-conflictual discopathy L4L5

29. LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMMER-BIOMET

30. LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMMER-BIOMET

31. LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMMER-BIOMET

32. CONCLUSIONS
Advantages :
• Minimal invasive approach
• Minimal blood loss
• Simpler anesthesia (patient in supine position, no support on the chest or abdomen)
• Preserves the lumbar musculature
• No risk of tearing the dura or injuring a nerve root (no contact with the nervous
elements), no epidural or periradicular fibrosis
• Risk of less nosocomial infection (<0.2% versus 2% for posterior fusions)

33. CONCLUSIONS
Contraindications :
• Morbid obesity
• Surgical history (vascular and abdominal surgery)
• History of infections
• Narrow lumbar channel
Risks :
• Vascular (L4L5)
• Retrograde ejaculation or vaginal dryness (0.4% in
L5S1)

34. LUMBAR DISC PROSTHESIS
A REAL MINIMAL INVASIVE SURGERY
Respect anatomy & preserve function
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