21 Anterior Lumbar Interbody Fusion A 35-year-old woman presents to the office with long-standing axial low back pain. The pain radiates to the bilateral lower extremities, including the right posterior thigh, right lateral calf, and left posterior thigh. Pain is persistent at baseline, but worsens with ambulation and changes in temperature. She denies any trauma or recent infections. Conservative therapy with physical therapy, narcotics, and muscle relaxants provided minimal pain relief. Lumbar magnetic resonance imaging (MRI) was obtained (Fig. 21.1). Fig. 21.1 Sagittal T2-weighted MRI demonstrating L5–S1 retrolisthesis with disk space collapse, central disk protrusion, and a posterior annular tear. • Spondylolisthesis (grade I or II). • Degenerative disk disease. • Postdiskectomy collapse with neuroforaminal stenosis. • Revision of posterior pseudoarthrosis or postlaminectomy kyphosis. • Coronal and/or sagittal imbalance. • Supine. • Landmarks: – Umbilicus: opposite the L3–L4 disk space. – Pubic symphysis: pubic tubercle is located lateral to the midline. • Superficial dissection: – Skin incision is midline, located between the umbilicus and pubic symphysis (Fig. 21.2): ∘ The internervous plane is in the midline, as the abdominal musculature is innervated segmentally by the 7th to 12th intercostal nerves. – Musculus rectus abdominis fascia incised and the muscle belly is mobilized. – The rectus sheath is then incised → exposes the retroperitoneum. Fig. 21.2 Top-down view. Skin incision with depiction of underlying anatomic structures. (Reproduced with permission from Singh K, Vaccaro AR, eds. Pocket Atlas of Spine Surgery. 2nd ed. New York, NY: Thieme; 2018).
21.1 Case Presentation and Preoperative Imaging
21.2 Indications
21.3 Position
21.4 Approach
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