Artificial disk and disk replacement of the lumbar spine

The anterior retroperitoneal approach

Indications for anterior surgery

The  anterior approach to the lumbar spine allows access to the intervertebral discs of the lumbar spine through a small incision in the patient’s belly (abdomen).

This approach avoids the dissection of muscles, bone structures and nerves that one would find going through the back (posterior approach). Hence, the risk of damaging these structures is less with the anterior approach.

Anterior spine surgery
Layout (left image) of the anterior approach to a lumbar spine disc. A large interbody cage can be placed in the disc  with the anterior approach (right image).

The advantages of the anterior approach is that it allows an excellent exposure of the lumbar spine. This allows introducing large interbody cages and artificial discs with a much larger surface area compared to those introduced with the posterior approach.

Dr. Morgentern (back left) performing the anterior retroperitoneal approach.

The retroperitoneal anterior approach is a minimally invasive spine surgery, as all the structures contained in the peritoneal sac (intestines, organs, etc.) are bypassed. Therefore, the patient’s post-operative recovery time is usually very fast. The patient resumes walking the same day of surgery and can go home (hospital discharge) usually just 2 days after the surgery.

Dr. Morgenstern has been trained in Germany to perform anterior spine surgery. This new surgical technique complements the endoscopic and percutaneous surgical techniques and helps us avoiding other invasive surgeries of the lumbar spine.

Tiger Woods by Keith Allison

One of the most popular cases of a successful surgery performed through a previous approach is the case of the golfer Tiger Woods, champion of the Augusta Masters 2019. He returned to playing as pro-golfer successfully after having undergone an operation on the lumbar spine through an anterior route in the USA.

Dr. Morgenstern has been trained in Germany to perform this intervention. This new technique complements the other interventions already described and allows to avoid large approaches, dissections and fixation of the lumbar spine.

In cases of degenerative disc disease (DDD) the interbody discs between two vertebrae loses height progressively until finally collapsing. This degenerative process often causes intensive pain in the lower back and buttock area. Disc height collapse can also lead to foraminal stenosis. In foramina stenosis the bony structures surrounding the exiting nerve roots collapse and impinge the nerve roots, causing sciatic pain that radiates down the leg.

This figure shows an intra-operative X-ray image of an interbody cage placed at level L5/S1. Note the screws attaching the cage to the upper and lower endplates of the adjacent vertebrae.

The disc height can now be restored using an interbody cage placed by the anterior approach. After surgery the patient usually resumes walking the same day and hospital discharge within two days after surgery. It is indicated for acute and chronic low back pain with or without radicular leg pain.

Low back pain and radiating leg pain usually are relieved immediately or in less than 24 hours after surgery.

Final X-ray control of the interbody cage placed anteriorly at level L5-S1 and attached with three screws to the upper and lower vertebral endplates.

Clinical Case Ventrodorsal Approach

© Copyright – Morgenstern Institute of Spine, 2019.