Doing More With Less

Technique for Exposing Lumbar Discs in Anterior Approach Using Steinmann Wires:
Arthroplasties or Arthrodesis
Aecio Rubens Dias Pereira Filho

- BACKGROUND: Due to increasing longevity, the inci- INTRODUCTION

dence of degenerative lumbar disc diseases has increased,
and surgical treatment is often necessary. In this context,
the anterior approach becomes an important technique.
However, one of the main limitations of this method is the
A s a result of changing habits and increasing survival rate
due to the aging population, degenerative lumbar spine
disease has become increasingly prevalent, leading to
axial and sciatica pain. Often, this pain is refractory to conservative
treatments and therefore requires surgical treatment for lumbar
need for dedicated retractors, which requires larger in-
cisions for its positioning and increases the cost of the arthrodesis.1
Lumbar intersomatic fusion is the fifth most commonly per-
procedure. The objective of the present study was to
formed procedure in the United States, with >450,000 annual
describe a technique for retracting abdominal structures by
surgeries.2 It can be performed through several approaches
anterior approaches to the lumbar spine using Steinmann (anterior, posterior, oblique, lateral, transforaminal, and variants).3
wires. Anterior lumbar interbody fusion (ALIF) was initially described in
- METHODS: This manuscript consists of a technique 1932 by Capener.6 However, due to high complication rates, it
remained forgotten for a long time. This technique is basically
description of anterior approach for lumbar spine.
used for spondylolisthesis.4-6 As a result of the development of new
- RESULTS: Surgical treatment of degenerative lumbar radiologic techniques and surgical instruments in the last 20 years,
spine disease is often necessary when the patients have several authors have reported significant outcomes from procedures
symptoms refractory to conservative treatments. Many of by the anterior route alone, or in combination with other routes, such
them will be candidates for surgical treatment with anterior as the posterior route.7-16 This fact produced an increase in in-
dications of the technique for degenerative disease, recurrent lumbar
approach, either for arthrodesis/anterior lumbar interbody
disc herniation, failure of posterior route/pseudoarthrosis, post-
fusion or arthroplasty. Small incisions are performed for
laminectomy syndrome, tumors, or infections.8,17-19
positioning the modified Langenbeck retractors and the The objective of the present study was to describe a safe,
Steinmann wires. These retractors are easily positioned and accessible, and easily reproducible method for retracting abdominal
provide good exposure of the lumbar discs making it structures by anterior approaches to the lumbar spine (arthrodesis
possible to implant appropriate cages for restoring the and arthroplasty) using Steinmann and Kirschner wires.
necessary height, lordosis, and sagittal balance.
- CONCLUSIONS: The technique described is safe, inex-
METHODS
pensive, and reproducible. Simple and easily accessible
instruments are required in most hospital complexes. This manuscript consists of a technique description for anterior
approach for lumbar spine surgery20 respecting all ethical
principles, and no image or video from which the patient can be

Key words Departmental and Institutional Affiliations, Clinart Ltda, São Paulo, SP, Brazil
- Anterior lumbar interbody fusion/ALIF To whom correspondence should be addressed: Aecio Rubens Dias Pereira Filho, M.D.
- Lumbar arthroplasty [E-mail: [email protected]]
- Lumbar disc disease
Citation: World Neurosurg. (2021) 148:189-195.
- Lumbar fusion https://doi.org/10.1016/j.wneu.2020.12.113
- Steinmann wires
Journal homepage: www.journals.elsevier.com/world-neurosurgery
- Surgical technique
Available online: www.sciencedirect.com
Abbreviations and Acronyms 1878-8750/$ - see front matter ª 2021 Elsevier Inc. All rights reserved.
ALIF: Anterior lumbar interbody fusion
rhBMP-2: Recombinant bone morphogenetic protein

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 DOING MORE WITH LESS
AECIO RUBENS DIAS PEREIRA FILHO ANTERIOR APPROACH FOR LUMBAR DISCS

identified is included. All patients undergoing the procedure were

submitted to the consent form.

RESULTS
Initially, a targeted evaluation is performed based on anamnesis
(complaints, comorbidities, previous abdominal and spine sur-
geries, etc.) and physical examination (weight, height, abdom-
inal inspection and palpation, pulse palpation, assessment of
distal perfusion, and search for vasculopathies). Subsequently,
the patients are placed in the supine position, under general
anesthesia, and with arms crossed over the chest to facilitate the
positioning of the fluoroscopy arch. A cushion is placed under
the thighs for relaxation of the psoas muscle and, if indicated,
with intermittent pneumatic compression and electroneuro
myographic monitoring.
Deep palpation of the abdomen or fluoroscopy (x-ray) will
determine the levels that need to be approached, and the inci-
sion sites are marked. This technique can be used to approach
the lumbar spine from L2-L3 to L5-S1 (Figure 1). The incision
should preferably be longitudinal median to avoid injury to
nerves and vessels of the abdominal wall. A transverse
suprapubic incision can be used to approach L5-S1 only,
mainly in female patients to ensure better aesthetics.
The incision is then made opening the anterior layer of the
rectus abdominis muscle (aponeurosis of the external oblique
muscle, and anterior layer of the aponeurosis of the internal
Figure 1. Incisions. oblique muscle [Figure 2A]), slightly lateral to the midline. The
approach is preferentially performed from the left, except in the

Figure 2. (A, B) Abdominal wall structures e axial section.

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 DOING MORE WITH LESS
AECIO RUBENS DIAS PEREIRA FILHO ANTERIOR APPROACH FOR LUMBAR DISCS

Figure 3. Aécio Dias retractors.

case of L5-S1 alone, when the approach is performed from the

right. As a result, in case of need for revision or disease at adjacent
levels, the approach from the left side would remain preserved.
The rectus abdominis muscle is detected and pulled ante-
rolaterally using Aécio Dias adapted retractors (Figure 3), which Figure 4. Vessels and retroperitoneal structures.
are modified Langenbeck retractors. They are 3-cm width with 4
available lengths (11, 13, 18, and 22 cm) according to depth of the
surgical field. They also have a pin for fitting the Steinmann wire.
Epigastric vessels are detected and pulled anteriorly to the muscle, intersomatic devices (cages for arthrodesis/ALIF, or prostheses
and ligations are not normally required. The arcuate line is for arthroplasties).
detected through blunt dissection in the posterior layer of the To approach the L2-L3, L3-L4, and/or L4-L5 levels (Figure 7), the
rectus abdominis muscle (posterior layer of the aponeurosis of the left common iliac artery and the distal aorta are detected, and the
internal oblique muscle [Figure 2A]) in the caudal direction, and dissection is performed laterally until identification of the left
penetration is performed into the retroperitoneum. Thereafter, common iliac vein and the vena cava, which are displaced
being careful not to injure the peritoneum, it is rebound medially and delicately to avoid arterial, venous, ureter, and
together with the intraperitoneal content, in the proximal direc- sympathetic fiber injuries. During this time, in case the
tion (Figure 2B). For better exposure, the aponeurosis of the insertion of the left iliolumbar vein (Figure 4) occurs close to
internal oblique muscle is sectioned next to the muscle. This the L4-L5 disc, usually <5 mm, its ligation should be performed
way, the retroperitoneal structures will be observed. to avoid its rupture during retraction. This way, a good field is
To approach the L5-S1 level, the promontory is palpated, and obtained for positioning the Steinmann wires in L4 and L5. Nor-
using retractors a space is detected between the iliac vessels. mally, for exposure of this level, there is displacement and
Taking special care to avoid injuries, especially venous, this space compression of the left common iliac vein, which can momen-
is dissected, requiring ligation of the middle sacral vessels (usually tarily lead to the venous compartment syndrome that causes a
1 artery and 2 veins) for better exposure. The ureter crosses the decrease in sensory potentials (in case of intraoperative electro-
anterior face of the common iliac artery (Figure 4) and it also neuromyographic monitoring). However, this condition is
requires attention during dissection. completely reversed after the release of this vein.
The Aécio Dias retractors are then positioned with the 3-mm In case that approach to L2-L3 or L3-L4 levels is also required,
Steinmann wires in L5 (lower quadrant) and S1 (upper quad- dissection is performed laterally to the aorta in a cranial direction,
rant) to provide ample access to the L5-S1 disc (Figure 5). In the requiring ligatures of the corresponding segmental/lumbar veins
absence of Aécio Dias retractors, long Langenbeck retractors can and arteries. It is worth mentioning that simultaneous exposure of
be used, fixed to Steinmann wires with sterile elastics, or even L2-L3, L3-L4, and/or L4-L5 can be performed (Figure 8). Although
using only Steinmann wires in the case of slimmer individuals this tactic saves surgical time, compression of the inferior vena
(Figure 6). After the spine procedure is completed by a spine cava may occur, leading to a decrease in venous return. Thus
surgeon, the Steinmann wires are removed and the hemostasis attention should be paid to low flow signals, such as
reviewed after treating the intervertebral disc and positioning hypotension or tachycardia.

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 DOING MORE WITH LESS
AECIO RUBENS DIAS PEREIRA FILHO ANTERIOR APPROACH FOR LUMBAR DISCS

Figure 5. Approach to L5-S1. (A) Before discectomy, (B) fluoroscopy image L5-S1, (C) after discectomy.

DISCUSSION Lumbar intersomatic fusion through the anterior route alone or

Surgical treatment of degenerative lumbar spine disease is in combination with other routes has been progressively
necessary when the patients have symptoms owing to instability used.14,21-23 By this means, it is possible to achieve good exposure,
and/or neural compression refractory to conservative treatments. enabling greater disc extraction and allowing the use of larger
Many of them will be candidates for surgical treatment due to devices with restoration of disc height and spinal lordosis. In
anterior approach to the lumbar spine, either for arthrodesis/ALIF addition, it increases foraminal distraction, which indirectly
or arthroplasty (replacement of the intervertebral disc with a de- decompresses neural elements, and may lead to similar or
vice that simulates it). better biomechanical outcomes in comparison to other
techniques.4,12,24-26
Lumbar arthrodesis through the anterior route has had high
success rates, in addition to preserving the posterior musculature,
which is essential for spinal stabilization, and preventing neural
injuries. Iatrogenic degeneration of adjacent segments caused by

Figure 7. Approach to L3-L4-L5. (A) Anterior approach to L3-L4-L5, (B)

Figure 6. Approach to L5-S1 using elastic. fluoroscopy image L3-L4-L5.

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 DOING MORE WITH LESS
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Figure 8. Approach to L2-L3-L4-L5-1. (A) Approach to L2-L3-L4-L%, (B) before discectomy, (C) after discectomy, (D) after
placement of a cage.

other techniques,17,19,27-34 perhaps because they do not achieve the unsightly. However, transverse incisions are aesthetically better,
expected sagittal rebalancing, should also be considered. but limit the approach in cases of multiple levels. The most used
Traditionally, approaches have been performed by specialized arched incision is the Pfannenstiel, allowing approaching to the 5/
surgeons, or even spine surgeons who are well trained and 1 level alone, but it is not feasible for others levels. Another risk of
familiar with the technique. The most used incisions are para- approaching by means of the external pararectal technique
median, whether longitudinal, transverse, or oblique, with (approaching the retroperitoneum from the outside of the rectus
approach to the retroperitoneum achieved through the external muscle) are injuries caused to the innervation of the rectus
pararectal retraction of the rectus abdominis muscle. Longitudinal abdominis muscle, which can lead to hypotonia, with laxity and
and oblique incisions do not obey the force lines and are therefore wall flaccidity.

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The performance of longitudinal incisions in the midline, and injuries, among others.7,9,11,37-39 Vascular injuries are the most
retraction through the medial face of the rectus muscle, preserves common, occurring in up to 15% of patients,36,40 and can be
the innervation of this muscle, allows access to multiple levels hemorrhagic or thrombotic. Venous involvement is the most
with smaller incisions (which does not occur in transverse in- common, with lesion of the left common iliac vein being the
cisions), and results in scars with better aesthetics, especially in most frequent, especially during dissection of the L5-S1 disc.
men owing to pilification. Another advantage of median and Another complication described is deep vein thrombosis, which
medial approaches to the rectus muscle is that, during retraction, can be observed during postoperative follow-up. Among urologic
the resistance force of this muscle does not act against the injuries, the most worrying would be retrograde ejaculation result-
retractors. ing from injury in the upper hypogastric plexus, in which incidence
Regarding the retractors used for this type of surgery, the most is conflicting in the literature, ranging from 0.42%e6.3%, and more
common autostatic surgical retractors are Synframe, Condor, and associated with the use of recombinant bone morphogenetic protein
Thompson.16,32,35,36 Such devices are expensive and not all of them (rhBMP-2), transperitoneal approach, and re-approaches.38,41
are certified by regulatory agencies. Assembling them can be Although ureteral detachment is necessary for the approaches,
complex in cases of little prior knowledge about the devices. Parks et al.42 suggest that this traction alone would not be
Even after being located in the operating field, they responsible for injuries. Among the neurologic injuries related to
inadvertently allow structures adjacent to the vertebral disc to approaches, it is possible to mention sympathetic plexus injury.
invade it. There are also Hohmann retractors, which are This complication leads to redness and feeling of heat in the lower
embedded in the vertebral bodies, making the surgical field limb, being a differential diagnosis of deep venous thrombosis.
static; however, their strength is insufficient for maintaining As this procedure is performed with minimal dissection, post-
exposure in situations of greater traction. operative pain is usually easily managed, leading to rapid recovery
Previously, the retractors described earlier were necessary for with early hospital discharge.31 Studies comparing open and
performing the procedure, increasing both surgical time and laparoscopic techniques have failed to show superiority of one
costs. With the use of Steinmann wires as retractors, it is possible route over another. However, teams tend to prefer the open
to work with smaller incisions, as they do not occupy much space technique due to greater technical ease, better exposure, and
in the field. Another advantage is that, when stuck in the vertebral apparently lower rates of retrograde ejaculation.37,39
bodies, they have a high radial force, and are hardly detached
during surgery. As for practicality, they have low cost, and are
widely available and easy to handle. After fixing the wires with CONCLUSIONS
sterile elastics to Aécio Dias or Langenbecks, the retraction can be The technique described in the present study for anterior
established without being lost over time as seen in Figure 2. approach to the lumbar spine is safe, inexpensive, and repro-
Although considered a safe route, there are reports of several ducible. Simple and easily accessible instruments are required in
complications, such as vascular, visceral, urologic, and neurologic most hospital complexes.

6. Capener N. Spondylolisthesis. Br J Surg. 1932;19: biometrical results and own experiences. Neurosurg
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