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

2.
The surgery of a low
back pain patient is
classically done via
the posterior
approach. Is this the
most appropriate
approach?

3.
To operate the
back, the best is still
to do it ... by the
belly !

4.
ANTERIOR LUMBAR APPROACH
LEFLOT Jean-Louis M.D.
Brugmann UHC (Brussels)
Namur UHC (Mont-Godinne,Yvoir)
Vivalia (Marche-en-Famenne)

5.
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)

6.
PHYSIOLOGICAL LOGIC
“Minimal Invasive Surgery”
• Respect of the lumbar musculature
( Isolated anterior approach - ALIF )
• Prevents epidural and periradicular
"iatrogenic" fibrosis

7.
BIOLOGICAL LOGIC
Complete Disc Resection
Degenerative disk > Cytokines > Inflammation

8.
MECHANICAL LOGIC
• Restitution of the intersomatic height
• Restitution of the foraminous height
• Restitution of the sagittal balance

9.
ANTERIOR LUMBAR APPROACH
ALIF
• Highly degenerative disc and / or
associated with posterior facet
osteoarthritis
Total Disc Prosthesis (Mobile)
• Discopathy WITHOUT significant
arthrosis remodeling

10.
• The Anterior Approach is
frequently associated
with a posterior
approach
(circumferential arthrodesis)

11.
COMBINED LUMBAR APPROACH (ANTERIOR AND POSTERIOR)
ALIF + Posterior Fusion
• Highly degenerative disk and associated
with posterior facet osteoarthritis
• Spondylolisthesis

12.
COMBINED LUMBAR APPROACH (ANTERIOR AND POSTERIOR)

13.
LUMBAR ANTERIOR APPROACH: RISKS

14.
LUMBAR ANTERIOR APPROACH : INSTALLATION

15.
LUMBAR ANTERIOR APPROACH : L5S1 (PFANNENSTIEL)

16.
LUMBAR ANTERIOR APPROACH : L5S1 (PFANNENSTIEL)

17.
LUMBAR ANTERIOR APPROACH : L3 TO S1
(PARA-RECTAL LEFT)

18.
Essential !
Restoration of sagittal
balance

19.
CLASSICALLY : SUBTRACTION OSTEOMY
WITH RESECTION OF THE PEDICLES

20.
ALIF L4L5 ET L5S1
TLIF L3L4

21.
ANTERIOR LUMBAR INTERBODY SURGERY
Wide and full disc approach
Better possibility of interbody
distraction
Large implant with optimal
contact surface

22.
CIRCUMFERENTIAL LUMBAR FUSION
(ALIF + POSTERIOR FUSION)
Female 54 y
Spondylolisthesis L4L5
Collapsed discopathy
Disc herniation L4L5
Foraminous stenosis

23.
CSM
NEUROSTIMULATOR ?

24.
CIRCUMFERENTIAL LUMBAR FUSION
(ALIF + POSTERIOR FUSION)
Male 32 y
Collapsed and
inflammatory disc
disease
Foraminous stenosis

25.
CIRCUMFERENTIAL LUMBAR FUSION
(ALIF + POSTERIOR FUSION)
Female 42 y
Collapsed and inflammatory
disc diseases L2 to L5
Severe foraminous stenosis
L4L5
Important sagittal static
disorder
Considered as a fibromyalgic
patient followed in «Pain
Clinic»

26.
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

27.
ALIF ? TDA ?
ALIF versus TDA ?
... and why not
BOTH !?

28.
MOBILE LUMBAR DISC PROSTHESIS
All advantages of anterior lumbar
approach
Preserve or Restore Function
(Mobility)
Limiting constraints on adjacent
segments

29.
MOBILE LUMBAR DISC PROSTHESIS

30.
LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMVIE

31.
HYBRID ANTERIOR LUMBAR STABILIZATION
MOBIDISC & ROI-A CAGE LDR ZIMVIE

32.
LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMVIE
To Restore or Preserve the function

33.
LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMVIE
Male 31 y
Right postero-lateral disc herniation L5S1
Black Disc L4L5
No effect of conservative treatment

34.
LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMVIE
Male 52 y
Collapsed and inflammatory disc
disease
Disc protrusion
Foraminous stenosis L5S1
Non-conflictual discopathy L4L5

35.
LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMVIE

36.
LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMVIE

37.
LUMBAR DISC PROSTHESIS
MOBIDISC LDR ZIMVIE

38.
LUMBAR DISC PROSTHESIS
A REAL MINIMAL INVASIVE SURGERY
RESPECT ANATOMY & PRESERVE FUNCTION

39.
ANTERIOR APPROACH
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)

40.
ANTERIOR APPROACH
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)

41.
If the situation is reasonably
favourable, the Anterior
Approach is my preference
both as first intention and for
revision surgery
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