Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications.
BACKGROUND
The anterior approach to the lumbar spine is increasingly used to accomplish various surgical procedures. However, the incidence and risk factors for complications associated with anterior lumbar spine surgery (ALS) have not been fully elucidated.


OBJECTIVE
To identify and document types of complications and complication rates associated with ALS, determine risk factors for these events, and evaluate the effect of measures used to decrease complication rates.


METHODS
Systematic review and meta-analysis.


METHODS
A systematic review of the English-language literature was conducted for articles published between January 1992 and December 2013. A MEDLINE search was conducted to identify articles reporting complications associated with ALS. For each complication, the data were combined using a generalized linear mixed model with a binomial probability distribution and a random effect based on the study. Predictors used were the type of procedure (open, minimally invasive, or laparoscopic), the approach used (transperitoneal vs. retroperitoneal), use of recombinant bone morphogenetic protein-2, use of preoperative computed tomography angiography (CTA), and the utilization of an access surgeon. Open surgery was used as a reference category.


RESULTS
Seventy-six articles met final inclusion criteria and reported complication rates in 11,410 patients who underwent arthrodesis and/or arthroplasty via laparoscopic, mini-open, and open techniques. The overall complication rate was 14.1%, with intraoperative and postoperative complication rates of 9.1% and 5.2%, respectively. Only 3% of patients required reoperation or revision procedures. The most common complications reported were venous injury (3.2%), retrograde ejaculation (2.7%), neurologic injury (2%), prosthesis related (2%), postoperative ileus (1.4%), superficial infection (1%), and others (1.3%). Laparoscopic and transperitoneal procedures were associated with higher complication rates, whereas lower complication rates were observed in patients receiving mini-open techniques. Our analysis indicated that the use of recombinant bone morphogenetic protein-2 was associated with increased rates of retrograde ejaculation; however, there may be limitations in interpreting these data. Data regarding the use of preoperative CTA and an access surgeon were limited and demonstrated mixed benefit.


CONCLUSIONS
Overall complication rates with ALS are relatively low, with the most common complications occurring at a rate of 1% to 3%. Complication rates are related to surgical technique, approach, and implant characteristics. Further randomized controlled trials are needed to validate the use of preventative measures including CTA and the use of an access surgeon.
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA. Electronic address: dexterbateman@gmail.com.
Dexter K
DK
Bateman
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
Paul W
PW
Millhouse
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
Niti
N
Shahi
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
Abhijeet B
AB
Kadam
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
Mitchell G
MG
Maltenfort
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
John D
JD
Koerner
Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
Alexander R
AR
Vaccaro
D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D013123:Spinal Fusion / Q000009:adverse effects* / Q000379:methods
Anterior approach; Bone morphogenetic protein; Complications; Lumbar spine surgery; Retrograde ejaculation; Systematic review