The anterior approach to the lumbar spine is a versatile exposure that can be utilized to access the lumbar vertebrae and disc spaces for multiple indications and is a preferred method of approach for a variety of spinal conditions and procedures [
While the intraoperative surgical complications (bowel and vascular injury) related to the anterior lumbar approach have been well documented [
The purpose of this study is to analyze the approach-related outcomes following midline anterior lumbar surgery, including patient satisfaction, patient perceived complications, and factors associated with patient perceived complications. A new newly developed Anterior Lumbar Surgery Questionnaire (ALSQ) was designed to specifically address these issues and is evaluated for correlation with previously established patient outcome measurements.
This is a retrospective cohort analysis of adult patients who underwent anterior lumbar spine surgery in 2009. One vascular surgeon (MN) performed all of the retroperitoneal anterior lumbar approaches. After the institutional review board approval, chart information was gathered from all patients with the preoperative diagnosis of lumbar degenerative disc disease (DDD) or spondylolisthesis. Surveys were sent out to all patients as well as phone calls and 58 were available for followup. All male and female patients of age 18–80 years with lumbar DDD or spondylolisthesis treated with anterior lumbar fusion were included. Exclusion criterion was patients with prior spinal surgery at the same vertebral levels, trauma, ankylosing spondylitis, rheumatoid arthritis or chronic autoimmune conditions, idiopathic scoliosis, neoplasm, or preoperative spinal infection.
The demographic characteristics included age, gender, BMI, smoking status, worker’s compensation status, prior surgery status, postoperative complications, and revisions. Intraoperative information collected included interbody device type (allograft, metal, and PEEK), bone morphogenetic protein use, number of fusion levels, specific fusion levels, if a posterior procedure was performed, if the posterior procedure was open or percutaneous, and intraoperative complications. A Pfannenstiel incision was performed for all isolated L5-S1 procedures as well as a vertical midline incision for all other procedures. Thus, data about incision type is included with the specific fusion levels information. The medical records were reviewed for instances of postoperative complications prior to discharge and in the follow-up period.
The newly developed Anterior Lumbar Surgery Questionnaire (ALSQ), shown in Appendix
The data were analyzed using SPSS version 17 software (Chicago, IL). Statistical analysis was performed in the following manner. For most variables for which data were collected preoperatively and postoperatively, paired
There were 58 patients, 27 women and 31 men, with an average age at surgery of 49.2 years (
Patient demographics.
Age at surgery | 49.2 years |
Gender | |
Women | 47% |
Men | 53% |
BMI | 29.1 |
Smokers | 17% |
Worker’s compensation | 16% |
Primary diagnosis | |
DDD | 74% (43) |
Spondylolisthesis | 26% (15) |
Number of fusion levels* | |
1 | 28 |
2 | 24 |
3 | 3 |
Specific levels | |
L3/4 or L3-L5 | 7 |
L4/5 or L4-S1 | 28 |
L5/S1 | 23 |
Anterior only | 8 |
Anterior-posterior | 50 |
Posterior approach | |
Percutaneous | 40 |
Open | 18 |
Intraoperative patient characteristics.
Interbody device | |
FRA | 52.8% |
Polyetheretherketone (PEEK) | 26.4% |
Metal | 15.1% |
TDR | 5.7% |
BMP used | |
Yes | 50% |
No | 50% |
Anterior approach specific complications | |
None | 89.7% |
Vascular complication | 6.7% |
Incisional hernia | 1.7% |
Retrograde ejaculation | 3.2% |
Anterior wound revisions | |
None | 98.3% |
Abdominal hernia repair | 1.7% |
Of the 58 total patients available for followup, 23 had preoperative EuroQol and ODI values, 14 men and 9 women. In this group, the average preoperative ODI was 58.78 and the average preoperative EuroQol was 0.41. All patients sustained a statistically significant improvement in both ODI and EuroQol as shown by an average 3-year change in ODI which was 34.9 (
Changes in HRQOL measures.
Before op | Change | After op |
|
|
---|---|---|---|---|
EuroQol | 0.41 | 0.28 | 0.66 | 0.0001 |
ODI | 58.79 | 34.94 | 31.99 | 0.0001 |
The entire questionnaire with percentage of responses is shown in Appendix
In relation to patient function, 19% of patients state that the anterior incision limits their daily functions. Eighty-one percent of patients stated that their bowel function is the same as prior to surgery. Of the patients who stated that their bowel function had changed, 72% stated that their main complaint was constipation. When asked about the frequency of their bowel complaints, only 8% of patients describe it as daily. Thirteen percent of patients have sought advice from a gastroenterologist for their new bowel complaints.
For urinary issues, 22% of patients state that their urinary habits are worse after surgery and 14% have sought the advice of urologist. For changes in sexual function after surgery, the questions were divided into gender specific issues, but combined for statistical analysis. In general, 48% of patients have an unchanged sex life postoperatively, 50% of men have no difficulty in achieving an erection, and 78% of women have no difficulty with genital moistness. One male patient reported having no ejaculation with orgasm after surgery, which meets the criteria of retrograde ejaculation.
When comparing the responses on the ALSQ to the postoperative EQ-5D and ODI responses for all 64 patients, we found that the responses were significantly similar. We paired specific questions on the ALSQ to specific questions on both EQ-5D and ODI and evaluated similar responses across all three questionnaires. There is a significant association with all of the questions, and the results are shown in Table
Comparison of specific questions on the anterior lumbar surgery survey to EQ-5D and ODI questions.
ODI pain | EQ-5D pain/discomfort | ODI personal care | EQ-5D self-care | ODI walk/sit/stand/travel | EQ-5D usual activities | ODI social life | ODI sex life | EQ-5D anxiety/depression | |
---|---|---|---|---|---|---|---|---|---|
Anterior incision pain | 0.05 | 0.011 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 |
Anterior incision pain limits ADLS | >0.05 | >0.05 | 0.0001 | 0.003 | 0.0001/0.012/0.015/0.0001 | 0.002 | >0.05 | >0.05 | >0.05 |
Normal sex life | 0.0001 | 0.0001 | >0.05 | >0.05 | >0.05 | >0.05 | 0.0001 | 0.0001 | 0.0001 |
Change in erection | 0.024 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | 0.019 |
Maintain erection | 0.008 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | 0.018 |
Ejaculate/maintain moisture | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | 0.014 | 0.011 |
Achieve orgasm | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | >0.05 | 0.046 | 0.046 | 0.021 |
Change in genital sensation | 0.011 | 0.002 | >0.05 | >0.05 | >0.05 | >0.05 | 0.004 | 0.017 | 0.003 |
The ALSQ responses were evaluated for association with demographic, intraoperative, and postoperative factors. The statistical significance level for association with complications was set to
The risk factor of age older than 50 years old was associated with a worse response on 1 question and a better response on three questions. Patients older than 50 years old are more likely than patients younger than 50 years old to answer yes to anterior incision pain (90% versus 58% resp.,
Male gender, as a risk factor, was associated with having a worse response than women on seven questions on the survey. Men are more likely to complain of anterior incision pain “everyday” or “frequently” (88% versus 61%,
The risk factor of BMI greater than 30 was associated with a worse response compared to patients with a BMI less than 30 on three questions. Patients with a BMI
Smoking is the greatest risk factor for poorer outcome. It was associated with worse responses than nonsmokers or prior smokers on thirteen questions. On the questions related to pain and appearance, smokers are more likely to complain of anterior incision pain (56% versus 30%,
The risk factor of a worker’s compensation claim was associated with a worse response on eight questions and a better response on one question compared to nonworker’s compensation patients. On the pain and appearance questions, worker’s compensation patients are more likely to have numbness or sensitivity at the anterior scar (78% versus 53%,
Degenerative disc disease, as a risk factor, was associated with a worse response than spondylolisthesis patients on seven questions. On the pain and functions questions, patients with degenerative disc disease are more likely to have pain at their anterior scar (38% versus 19%,
Bone morphogenetic protein use as a risk factor, compared to patients in whom BMP was not used, was associated with a worse response on one question and a better response on five questions. Patients in whom BMP was used are more likely to complain of urinary incontinence as their urinary complaint when they complained of worsening urinary function (40% versus 8%,
The different interbody devices, as a risk factor for worse patient outcomes, were associated with significantly different patient response on only three questions. Patient in whom FRA was used had a significantly higher rate of poor sexual function (67%, compared to 45% in PEEK, 25% in metal, and 33% in TDR,
Evaluation of number of fusions levels found that 2-fusion levels were associated with worse responses than 1-fusion level on four questions. Two-level fusion patients had a higher rate of diarrhea after surgery (29% compared to 17%,
When evaluating the specific fusion levels, there was association with worse outcomes on 4 questions. Fusions at L3/4 or L3-L5 level were associated with both sensitivity and numbness at the incision, as well as bulging or asymmetry (75%,
A comparison of anterior only and anterior-posterior surgeries was performed. Anterior only surgeries were associated with higher rate of answering improving abdominal shape after surgery. (80% versus 9%,
Of the patients who underwent posterior procedures, a comparison of open and percutaneous approaches was performed and a difference was found on 4 questions. Open posterior procedures had a higher rate of bulging or asymmetry of the anterior incision (39% versus 17%,
The risk factor of complications was associated with a worse response than patients without complications on two questions. Patients who had complications are more likely to seek a medical evaluation for changes in bowel habits after surgery (33% versus 11%,
Prior surgery status was associated with a worse response than primary surgery patients on five questions. Patients who had undergone a prior surgery are more likely to have pain at the anterior incision (45% versus 28%,
Outcomes from this study are similar to those in the literature for the anterior approach and demonstrate that overall patients do well after anterior lumbar surgery with an average 3-year change in ODI of 34.3 and average EQ-5D change of 0.29. The overall anterior approach related complications rate was 10.7%. The complication rate of vascular injury in this study was 6.2%, which is similar to 7% described by Rajaraman et al. in 1999 [
Retrograde ejaculation occurs when the bladder sphincter is unable to prevent semen from entering the urinary bladder during ejaculation. Our rate of retrograde ejaculation of 2.9% is substantially lower than previously described rates in the literature, 4.1–11.6% in the total patient population [
The results of this study demonstrate that this questionnaire is useful in assessing patient reported outcomes specific to the midline anterior lumbar approach. The correlation of the specific question on the ALSQ to the corresponding questions on the ODI and EQ-5D demonstrate that we adapted the concepts for the anterior midline approach. The EQ-5D, also known as the EuroQol, is a good general health survey used commonly in European registries due to its brevity [
When evaluating risk factors for worse outcome, after anterior lumbar surgery using the ALSQ, smokers demonstrated the highest rate of worse patient response than their nonsmoking counterparts. This occurred on 13 questions. This is similar to many studies that show that patients who smoke have worse clinical outcome scores [
A few anatomic risk factors for worse outcomes after anterior lumbar surgery were determined from this study. The increased rate of bulging or asymmetry that is associated with the L3/4 level may be related to an anatomic finding at that level such as anterior abdominal wall innervation usually overlying that area. Additionally, a significant association was found between sexual dysfunction and the fusion levels of L4-5 or L4-S1. The fusion level of L5-S1 has been previously shown as a higher risk for sexual dysfunction due to the presacral superior hypogastric plexus [
Our newly proposed Anterior Lumbar Surgery Questionnaire directly assesses issues specific to patients undergoing anterior lumbar surgery. At 3 years of followup, the revision rate for anterior wound complications was only 1.6%, the overall complication rate was 10.7%, and there was one male patient (2.9%) with retrograde ejaculation. BMP use did not correlate with retrograde ejaculation or other sexual dysfunctions, and smoking was the risk factor associated with the highest rate of poor responses. Our survey was significantly associated with similar response on the ODI and EuroQol for similar questions types. The results of this survey demonstrate anterior specific considerations before attempting surgery. A patient must be informed of the potential side effects specific to the anterior approach such as incisional location, scarring, hernia, and pain, as well as potential bowel, bladder, and sexual function changes.
Do you have pain in the area of your anterior incision?
Yes, 35%/no, 65% If “yes,” please rate your pain: If “yes” to anterior incisional pain, how often do you have it?
Everyday, 45% Frequently, but not daily (2-3 times a week), 27% Occasionally (once a week), 5% Rarely (once a month or less), 23% Since the first year following your surgery, has the pain/discomfort around your anterior incision changed?
No change, 25% Improving, 30% Getting worse, 10% Never had any pain, 35% Do you have any persistent sensitivity or numbness along the anterior incision?
Yes, sensitivity only, 7% Yes, numbness only, 20% Yes, both, 30% No, neither, 43%
Do you have any bulging or asymmetry near your anterior scar?
Yes, 30%/no, 70% Please rate the appearance of your anterior incision and abdominal shape on a scale from 1 to 10.
(1: very unsatisfactory, 10: very satisfactory) Has the shape of your abdomen changed since the first year after surgery?
No change, 66% Improving, 21% Getting worse, 13% Have you had any further treatment specifically for or to your anterior incision?
Yes, nonsurgical (medications, massage, etc.), 14% Yes, surgical repair, 2% No, 84%
Does your anterior incision on your abdominal area limit your ability to perform any activities comfortably (cleaning, cooking, self hygiene, exercise, etc.)?
Yes, 19%/no, 81% If “yes,” what activities? Compared with before your anterior abdominal surgery, how do you rate your current bowel function?
Same, 81% Different-better, 5% Different-worse, 14%
If your bowel function is worse now than before your spine surgery, your primary complaint will be
Constipation, 72% Diarrhea, 21% Other, 7% Since your surgery, how often do you experience problems with your bowel habits?
No change compared to before surgery, 66% Everyday, 8% Frequently, but not daily (2-3 times a week), 10% Occasionally (once a week or so), 7% Rarely (once a month), 10% Since your spine surgery, have you required medical evaluation or treatment for any new GI (Gastrointestinal/bowel) dysfunction?
Yes, 13%/no, 87% Compared with before your anterior abdominal surgery, how do you rate your current urinary function?
Same, 73% Different-better, 5% Different-worse, 22% If your urinary function is worse now than before your spine surgery, is your primary complaint:
Urinary urgency, 33% Difficulty starting urination, 28% Urinary incontinence, 17% Other, 22% Since your surgery, how often do you experience problems with urination?
No change compared to before surgery, 75% Everyday, 12% Frequently, but not daily (2-3 times a week), 8% Occasionally (once a week or so), 2% Rarely (once a month), 3% Since your spine surgery, have you required medical evaluation or treatment for any new urinary dysfunction?
Yes, 14%/no, 86% Since your spine surgery how would you rate your current sexual function?
My sex life is normal and causes no extra pain, 48% My sex life is normal but causes some extra pain, 18% My sex life is nearly normal but is very painful, 7% My sex life is severely restricted by pain, 8% My sex life is nearly absent because of pain, 12% Pain prevents any sex life at all, 7%
Have you noticed any change in your ability to have an erection after the spine surgery?
Yes, it is easier, 4% Yes, it is more difficult, 46% No change, 50% Have you noticed any change in your ability to maintain an erection after the spine surgery?
Yes, it is easier, 4% Yes, it is more difficult, 57% No change, 39% Have you noticed any change in your ability to have an orgasm after the spine surgery?
Yes, it is easier, 8% Yes, it is more difficult, 50% No change, 42% Have you noticed any change in your ability to ejaculate with orgasm since the spine surgery?
Yes, my ejaculation is more, 4% Yes, my ejaculation is less, 36% Yes, I have no ejaculation with orgasm, 4% No change, 56% Have you noticed any change in sensation in your genital region after the operation?
Yes, 34%/no, 66% Did you try but did not succeed in having children before the spine surgery?
Yes, 0%/no, 100% After the spine surgery, have you tried, but not succeeded in having children?
Yes, 0%/no, 100% If you have answered “yes” to any question, please describe the changes that have taken place
Have you noticed any changes in the moistness of your genital area with arousal during sex since your spine surgery?
Yes, I am more moist than before, 3% Yes, I am less moist than before, 19% No change, 78% Have you noticed any change in your ability to have an orgasm after the spine surgery?
Yes, it is easier, 7% Yes, it is more difficult, 16% No change, 77% Have you noticed any changes in sensation in your genital area after the spine surgery?
Yes, 15%/no, 85% Did you try, but not succeed in having children before the spine surgery?
Yes, 0%/no, 100% After the spine surgery, have you tried but did not succeed in having children?
Yes, 0%/no, 100% Have you noticed any other changes in your genital area since the spine surgery?
Yes, 0%/no, 100%
If you have answered “yes” to any question, please describe the changes that have taken place.
Are there any other major problems or concerns regarding your belly or anterior incision that have not been covered?
The authors declare that there is no conflict of interests regarding the publication of this paper.