Surgical techniques for lumbo-sacral fusion

Abstract

Lumbo-sacral (L5-S1) fusion is a widely performed procedure that has become the reference standard treatment for refractory low back pain. L5-S1 is a complex transition zone between the mobile lordotic distal lumbar spine and the fixed sacral region. The goal is to immobilise the lumbo-sacral junction in order to relieve pain originating from this site. Apart from achieving inter-vertebral fusion, the main challenge lies in the preoperative determination of the fixed L5-S1 position that will be optimal for the patient. Many lumbo-sacral fusion techniques are available. Stabilisation can be achieved using various methods. An anterior, posterior, or combined approach may be used. Recently developed minimally invasive techniques are gaining in popularity based on their good clinical outcomes and high fusion rates. The objective of this conference is to resolve the main issues faced by spinal surgeons in their everyday practice.

Combined Posterior-Anterior Interbody Fusion in the Management of Traumatic Lumbosacral Dissociation: A Case Report and Review of Literature

“…Traumatic lumbosacral dissociation is an unusual spondylolisthesis involving L5-S1 that is estimated to account for approximately 1% of total spinal fractures [5]. It is typically the sequelae of a high-energy distraction injury, such as a motor vehicle collision, most likely involving healthy adults.…”

“…Appropriate identification of this injury requires careful evaluation on admission, utilizing advanced trauma life support (ATLS) guidelines with an appreciation of the variability in clinical manifestations and associated neurological/musculoskeletal damage. The sequential evaluation and use of multi-modality imaging modalities help diagnose these complex injuries [5]. Recent literature reports that a majority of these injuries result in an anterior dissociation of the lumbosacral joint, with posterior dissociation and lateral dissociation being among the least common [4,[12][13][14][15].…”

“…TLSD requires the stabilization of concomitant injuries and patient-specific evaluation of spinal dissociation severity. Due to the complete osseoligamentous complex disruption, surgical stabilization with possible decompression is almost universally required, unless patients are critically injured and unlikely to survive their injury [4][5]16]. The most common approaches used involve anterior lumbar inter-body fusion (ALIF), a posterior lumbar interbody fusion (PLIF), a combined approach using PLIF and transforaminal lumbar interbody fusion (TLIF), circumferential lumbar fusion (CF), or newer and increasingly more popular minimally invasive techniques.…”

“…Current literature on classification and treatment algorithms for high-energy lumbosacral dissociations and fractures is suboptimal, as they are primarily descriptive and lack prognostic value [2]. However, there is a consensus that treatment ordinarily involves surgical decompression and there are several techniques to choose from, which are based on published studies that provide low levels of evidence (level IV) [4][5]16]. Lehman et al provided a novel classification system consisting of thresholds classifying surgical and nonsurgical candidates, determining the optimum operative technique by generating a composite injury severity score based on a weighted score from categories such as injury morphology, posterior ligamentous complex integrity, and neurological status [2].…”

“…The classification of complex lumbosacral injuries remains a controversial topic with various scoring systems taking into account the injury's morphology, posterior ligamentous complex integrity, and the patient's neurological status [1][2][3]. The severity of the injury results in chronic impairments, with early surgical intervention offering significant improvements in early mobilization, reduction in joint pain, mechanical stability, and possibly improved neurological outcomes [4][5]. A morbidly obese (body mass index (BMI) = 47.57) 21-year-old male presented to our emergency department after being involved in a severe single motor vehicle, high-velocity accident.…”