CENTRE DU RACHIS
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27 Bd Victor Hugo-92200 NEUILLY sur SEINE – FRANCE Tel.: (+33) (0)1.41.43.04.50
ANTERIOR ARTHRODESIS OR ARTHROPLASTY
FOR LUMBAGO
THE OPERATION
The operation is performed under general anaesthetic. The surgeon accesses the vertebral column by
making an incision in the lower part of the abdomen, either centrally or to the side. The length of the
incision depends on the location and number of vertebra that need to be consolidated.
The column is consolidated with the help of various metal implants and bone grafts.
The implants (screws, pins, plates, intersomatic cages, disk prostheses) fix the vertebra position
immediately, enabling the bone to rebuild itself around them. The aim of implants is also to correct an
imbalance in the column, restoring a harmonious curve.
The bone used for the graft is generally taken from the pelvis, and an artificial bone substitute is
sometimes added to increase the volume of the graft. The graft may be deposited on the vertebrae or
in the disk, in which case it will generally be placed in a “cage”. In some cases a simple bone graft will
be sufficient to consolidate the vertebral column without any use of implants.
The wound is closed up, and a drain is left in place. This is a plastic tube connected to a bottle that
draws the blood. It will be removed one to two days after the operation. Sometimes, the diaphragm
(muscle separating the thorax from the abdomen) is opened to enable access to the upper lumbar
vertebrae; an additional “thoracic” drain is introduced in this case, requiring monitoring in intensive
care.
Blood loss during the operation varies depending on the patient, the extent of the arthrodesis, the
length of the operation and whether any complications occur. It may be offset by a self-transfusion
(patients may donate their own blood before the operation), taking erythropoietin (a drug that
stimulates the production of red blood cells) before the operation or by recovering blood during the
operation. Transfusion may, however, be necessary.
SEQUELS AND POST-OPERATORY CARE
Patients experience little post-operatory pain, and this is effectively controlled by painkillers. The
patient should be able to go home three to ten days after the operation. Walking is recommended. Sick
leave will be around 2 to 3 months or more, depending on the patient’s profession.
RISKS
Risks inherent to any surgery:
1.1. Risks specific to anaesthesia will be explained by the anaesthetist.
1.2. Scar formation disorders are very rare. They can make further surgery necessary.
1.3. The patient’s position on the operating table can cause skin, vessel or nerve compression.
1.4. The risk of phlebitis (a vein obstructed by a blood clot) is low. Preventive anticoagulant
treatment is only required when the patient has a predisposition, or when the patient remains bedridden for over 24 hours. Pulmonary embolism may occur in extreme cases.
Risks specific to this operation on the vertebral column:
1.1. By far the most frequently, the result is insufficient, despite perfect technique, an
uncomplicated post-operatory and proper PM&R. Lumbar pains may persist but will often be less
serious than before the operation. However, total painlessness cannot be guaranteed. The same
applies to pains in the lower limbs (sciatica or cruralgia) which are reduced in the large majority of
cases. However, they may persist if the nerve was compressed for a long period or too severely,
causing a lesion of the nerve root. The development of this condition varies but may require prolonged
use of painkillers.
1.2. A breach in the dura mater (envelope containing the cerebrospinal fluid (CSF) and the nerve
roots), may occur during the operation, despite the precautions, notably if there is further surgery. It
can generally be closed by the surgeon. In this case there will be no further consequences. It may be
complicated by a CSF leak, from either the soft tissues (meningocele) or via the scar. This may lead to
a CSF infection; this is a very rare but potentially serious complication requiring specific treatment.
1.3. Bruising may occur along the operatory path; if this is voluminous, it may cause compression of
the nerves contained in the lumbar canal and cause pain, paralysis, anaesthesia, urinary disorders or
anal sphincter disorders (incontinence or retention): cauda equine syndrome. In this case, a further
operation will be required to remove the bruise.
1.4. Neurological complications may occur: sensory disorders (pain, insensitivity, paresthesia);
motor disorders with paralysis, fortunately very rare, subsequent to a compression linked to the
implants (screw, cage, prosthesis) or to manipulation of the nerve root or the spinal cord. These
disorders are very generally transitory, very rarely irreversible and may require further surgery to
reposition an implant, for example.
1.5. Urinary disorders (difficulty or inability to urinate) sometimes appear during the first 24 hours;
the bladder should then be emptied with a catheter. These disorders are very generally transitory.
1.6. Digestive orders may occur (bloating, delayed return to normal defecation, very rarely bowel
obstruction). These are far more usually no more than a source of discomfort rather than a
complication.
1.7. Infection of the surgical site is rare (0.1% to 1% despite the precautions). This is generally a
superficial infection that can be eliminated by appropriate care. Further surgery for local cleansing is
sometimes required. Deep infections are rare but may lead to ablation of the implant. Sequels, notably
pain, can persist irreversibly.
1.8. Lesion of the major abdominal vessels (aorta, vena cave, iliac vessels) located to the front of
the vertebral column, by surgical instruments, or by implants that set the column position, can cause a
serious haemorrhage and, in extreme cases, be fatal.
1.9. The separation of the arteries located in front of the vertebral column may cause a blood clot
to migrate and cause ischemia, i.e. a shortage of blood supply to one or both of the lower limbs
requiring further urgent surgery to remove the obstruction. This risk is higher among smokers and
patients who have previously suffered from arteritis (cholesterol deposits in the arteries).
1.10. Sexual complications: exceptional, caused by injury to the hypogastric plexus during the
operation may cause disorders: retrograde ejaculation among males (misdirected sperm), or vaginal
dryness among females, generally reversible.
1.11. The risk of lesion of an abdominal viscus (intestine, ureter) is extremely low but may lead to
serious, especially infectious complications.
1.12. The risk of major haemorrhage during the operation is low but cannot be excluded. In
extreme cases a blood transfusion may be needed. This carries a risk of contamination (hepatitis,
AIDS), which, though negligible, cannot be completely excluded).
1.13. In the long term the obstruction or fusion of one or more vertebrae can cause the adjacent
disks to work harder, thus causing them to age more quickly and possible leading to further
surgery.
1.14. Failed graft consolidation (this risk is especially high among smokers) may lead to persistent
or recurrent pain. Diagnostic is often difficult and requires further examination. A broken implant
(screw, pin or plate, prosthesis) may have to be replaced, requiring further surgery.
1.15. Mobilisation of the material, i.e. the existence of micro-motion causing pain, despite a
consolidated graft may be linked to insufficient bone quality (osteoporosis) liable to lead to a change or
ablation of the material.
1.16. Other complications not yet described.
Some antecedents and specificities, affections or diseases (malformations, diabetes, obesity, arteritis or
other vascular affections, alcoholism, smoking, drug abuse, addictive behaviour, psychiatric affections,
use of certain medication, liver diseases; blood diseases, tumours, operatory sequels or trauma, etc…)
may cause or favour the occurrence of specific complications, sometimes serious and, in extreme
cases, fatal.