Anterior Laparoscopic Lumbar Fusion

with Stephen Robbins, M.D., Orthopaedic Spine Surgeon, Columbia St. Mary’s

Posted: April 1, 2005

Surgeons at the Milwaukee Institute of Minimally Invasive Surgery (MIMIS) have established a long track record of success in their use of laparoscopic surgery to correct back problems such as degenerative disk disease.

According to Dr. Stephen Robbins, an orthopaedic spine surgeon with Columbia St. Mary’s and a member of that institution’s MIMIS team, their surgeons have performed anterior laparoscopic lumbar fusions on approximately 140 patients over the past 10 years.

Degenerative disk disease may cause severe pain when a disk wears out, he explained. But spinal surgery is usually a last resort, undertaken after more conservative treatment has been tried, said Dr. Robbins.

Stephen Robbins, M.D., Orthopaedic Spine Surgeon, Columbia St. Mary’s

Most of the time these conservative methods work. But when they don’t, and a patient is still in significant pain, it’s time to see a spinal surgeon for an evaluation.

The best relief, he said, may come from spinal fusion surgery. In this procedure, two vertebrae are linked so they can’t move. The fusion eliminates motion, which stops the pain.

“In general, spinal fusions have been most commonly performed in the lumbar or lower back area. We now use minimally invasive surgery in that area, to reduce the morbidity of a surgical procedure,” he said.

“Traditionally, spine operations were performed by making an invasive, four or five-inch incision in the posterior aspect of the back and utilizing screws and rods to secure the fusion. There was a fair amount of residual pain after that surgery.

“There was also a need in some individuals to perform an anterior fusion, which involves a second surgical procedure to fuse the front of the spine. Traditionally, that was done with a long incision. And when we did a front-to-back operation — an anterior-posterior procedure — two big incisions were necessary along with prolonged retraction of muscles, abdominal contents and vascular structures.”

Laparoscopic techniques for spinal surgery were initially developed in Milwaukee under the multi-disciplinary team of general, vascular and laparoscopic surgeons: Drs. Lyle Henry, Richard Cattey, and Robbins. Recently Dr. Joseph Regan, a general, laparoscopic and bariatric surgeon at Columbia St. Mary’s, joined the MIMIS team.

“The surgical approach to the lumbar spine is begun with two small abdominal incisions by a surgeon to allow the spinal specialist access to perform the fusion with the use of cages and or interbody spacers,” says Dr. Robbins.

Unlike other types of laparoscopic surgeries, it’s not done through a gas medium. A typical laparoscopy requires injecting carbon dioxide through a long, one-inch diameter tube to enlarge the body cavity.

Working within that long tube hampers the surgeon’s ability to utilize some of the larger, state-of-the-art instruments necessary to do a spinal fusion. That procedure involves removing a portion of the disk and inserting cages in front of the spine.

“So we started to perform a minimally invasive laparoscopic-assisted, gasless procedure where we create an enlarged cavity with two small incisions and use balloons for retraction.

“A laprolift — a device that lifts up the skin and maintains the cavity — enables us to do our normal surgery through a minimally invasive approach into the disk space.

“We’re now able to insert titanium cylinders called cages, and plates, thereby holding the vertebrae together,” Dr. Robbins said.

Cages are porous so that in time the patient’s own bone will grow through them, acting as cement to hold the fused vertebrae in place.

The cages are packed with bone morphogenic protein (BMP), a hormonal substance that stimulates bone growth and allows more rapid fusion of the spine. BMP replaces the need for a bone graft, speeds recovery time and improves fusion rates.

“Because today’s fusions use smaller incisions, there’s less risk to the patient and less trauma to the muscles,” Dr. Robbins said. “The technique results in a shorter hospital stay and less postoperative pain and discomfort. A faster recovery results in an overall earlier resumption of work and normal activities.”

According to Dr. Robbins, today, spinal fusions have about an 80% to 90% success rate. They can usually be performed with a one to two-day hospital stay.

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