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The Axial Transsacral Approach to Interbody Fusion at L5-S1


Paul S. Issack, M.D., Ph.D.
Oheneba Boachie-Adjei, M.D.


Hospital for Special Surgery, New York
535 East 70th Street
New York, NY 10021
Phone: 212-606-1948
Email: PSIssack@aol.com


Key words: lumbosacral interbody fusion, presacral, transsacral, degenerative, AxiaLIF, adult scoliosis


Abstract
Background: Lumbosacral interbody fusion may be indicated to treat degenerative disc disease at L5-S1, instability or spondylolisthesis at that level, and severe neuroforaminal stenosis resulting from loss of disc space height. In addition, L5-S1 interbody fusion may provide anterior support to a long posterior fusion construct, and help offset the stresses experienced by the distal-most screws. There are three well-established techniques to perform interbody fusion at L5-S1: anterior lumbar interbody fusion, posterior lumbar interbody fusion, and transforaminal lumbar interbody fusion. Each of these has its advantages and pitfalls. A more recently described axial transsacral technique, utilizing the presacral corridor, may provide a minimally invasive approach to obtaining lumbosacral interbody arthrodesis. 
Purpose: To review the biomechanical studies and clinical outcomes on the use of the axial approach for interbody fusion at L5-S1. 
Results: Biomechanical studies demonstrate that the stiffness of the  axial rod is comparable to or greater than existing fixation  devices suggesting that it biomechanically is a good implant for obtaining lumbosacral interbody fusion. Clinical studies have demonstrated good early results with the use of the axial transsacral approach in obtaining lumbosacral interbody fusion for degenerative disc disease, spondylolisthesis and below long posterior fusion constructs. The technique is exacting and complications, though rare, can be major. 
Conclusions: Early clinical studies suggest that the axial procedure may be safely performed to obtain lumbosacral interbody arthrodesis in the setting of degenerative disc disease and spondylolisthesis. There is also evidence that the procedure may provide anterior support caudal to long posterior fusion constructs for deformity correction.

Introduction
Interbody fusion at L5-S1 is indicated for specific pathology including degenerative disc disease  ADDIN EN.CITE <EndNote><Cite><Author>Gerszten</Author><Year>2011</Year><RecNum>21</RecNum><DisplayText>[1]</DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gerszten, P. C.</author><author>Tobler, W. D.</author><author>Nasca, R. J.</author></authors></contributors><auth-address>Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrup St, Pittsburgh, PA 15213, USA.</auth-address><titles><title>Retrospective analysis of L5-S1 axial lumbar interbody fusion (AxiaLIF): a comparison with and without the use of recombinant human bone morphogenetic protein-2</title><secondary-title>Spine J</secondary-title></titles><periodical><full-title>Spine J</full-title></periodical><pages>1027-32</pages><volume>11</volume><number>11</number><edition>2011/11/30</edition><dates><year>2011</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1878-1632 (Electronic)&#xD;1529-9430 (Linking)</isbn><accession-num>22122835</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=22122835</url></related-urls></urls><electronic-resource-num>S1529-9430(11)01324-6 [pii]&#xD;10.1016/j.spinee.2011.10.006</electronic-resource-num><language>eng</language></record></Cite></EndNote>[1], instability  ADDIN EN.CITE <EndNote><Cite><Author>Vibert</Author><Year>2006</Year><RecNum>22</RecNum><DisplayText>[2]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vibert, B. T.</author><author>Sliva, C. D.</author><author>Herkowitz, H. N.</author></authors></contributors><auth-address>William Beaumont Hospital, Department of Orthopaedic Surgery and Division of Spine Surgery, Royal Oak, MI, USA.</auth-address><titles><title>Treatment of instability and spondylolisthesis: surgical versus nonsurgical treatment</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>222-7</pages><volume>443</volume><edition>2006/02/08</edition><keywords><keyword>*Decision Making</keyword><keyword>Glucocorticoids/administration &amp; dosage/*therapeutic use</keyword><keyword>Humans</keyword><keyword>Injections, Epidural</keyword><keyword>*Physical Therapy Modalities</keyword><keyword>Spinal Fusion/*methods</keyword><keyword>Spondylolisthesis/*therapy</keyword></keywords><dates><year>2006</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0009-921X (Print)&#xD;0009-921X (Linking)</isbn><accession-num>16462445</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16462445</url></related-urls></urls><electronic-resource-num>10.1097/01.blo.0000200233.99436.ea&#xD;00003086-200602000-00030 [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>[2], neuroforaminal stenosis  ADDIN EN.CITE  ADDIN EN.CITE.DATA [3, 4] and protection of S1 screws at the end of long fusion constructs to the sacrum  ADDIN EN.CITE  ADDIN EN.CITE.DATA [5-7]. Interbody fusion at L5-S1 may be achieved anteriorly (anterior lumbar interbody fusion, ALIF), posteriorly (posterior lumbar interbody fusion, PLIF) or via the neuroforamen (transforaminal lumbar interbody fusion, TLIF). These techniques have specific advantages and pitfalls, making none of them the ideal approach for lumbosacral fusion. The more recently described axial transsacral lumbar interbody fusion (AxiaLIF) addresses some of the concerns of the previous fusion techniques. Early evidence suggests that the technique may be performed safely to obtain L5-S1 fusion for degenerative disc disease, spondylolisthesis and at the distal end of long posterior fusion constructs. This review will focus on the biomechanical studies, early clinical outcomes and complications of the axial transsacral approach to lumbosacral interbody fusion.

Current approaches to L5-S1 interbody arthrodesis
There are three well-established methods to obtain L5-S1 interbody arthrodesis. ALIF requires a retroperitoneal approach to access the L5-S1 interspace below the bifurcation of the aorta into the left and right common iliac arteries  ADDIN EN.CITE  ADDIN EN.CITE.DATA [8]. This direct access allows for release of the anterior longitudinal ligament and restoration of sagittal alignment using a lordotic graft with large footprint. The anterior approach can help restore sagittal balance, increase neuroforaminal height and allows for high fusion rates  ADDIN EN.CITE  ADDIN EN.CITE.DATA [3, 4, 9]. However, the exposure risks injury to the iliac vessels (especially the thin-walled common iliac vein which is adjacent to the L5-S1 disc space on the left side) and the sympathetic plexus which can cause retrograde ejaculation in males. ADDIN EN.CITE  ADDIN EN.CITE.DATA [8, 10]. The PLIF and TLIF cages are smaller compared to ALIF cages, because of the limited space for entry around the cauda and nerve roots; the smaller size results in a smaller footprint and a potential lower rate of arthrodesis  ADDIN EN.CITE <EndNote><Cite><Author>DiPaola</Author><Year>2008</Year><RecNum>26</RecNum><DisplayText>[11]</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>DiPaola, C. P.</author><author>Molinari, R. W.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, University of Rochester, Rochester, NY 14642, USA.</auth-address><titles><title>Posterior lumbar interbody fusion</title><secondary-title>J Am Acad Orthop Surg</secondary-title></titles><periodical><full-title>J Am Acad Orthop Surg</full-title></periodical><pages>130-9</pages><volume>16</volume><number>3</number><edition>2008/03/05</edition><keywords><keyword>Biomechanics</keyword><keyword>Humans</keyword><keyword>*Lumbar Vertebrae</keyword><keyword>Spinal Fusion/adverse effects/instrumentation/*methods</keyword></keywords><dates><year>2008</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1067-151X (Print)&#xD;1067-151X (Linking)</isbn><accession-num>18316711</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18316711</url></related-urls></urls><electronic-resource-num>16/3/130 [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>[11]. Retraction to place these cages can result in neurologic injury  ADDIN EN.CITE  ADDIN EN.CITE.DATA [11-13]. In the majority of cases, the direct lateral interbody approach (XLIF or DLIF) cannot be used to obtain interbody arthrodesis at L5-S1 because of the overhang of the iliac wing and obstruction by the nerve roots of the lumbosacral plexus  ADDIN EN.CITE <EndNote><Cite><Author>Sharma</Author><Year>2010</Year><RecNum>7</RecNum><DisplayText>[14]</DisplayText><record><rec-number>7</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">7</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sharma, A. K.</author><author>Kepler, C. K.</author><author>Girardi, F. P.</author><author>Cammisa, F. P.</author><author>Huang, R. C.</author><author>Sama, A. A.</author></authors></contributors><auth-address>*Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN daggerDepartment of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.</auth-address><titles><title>Lateral Lumbar Interbody Fusion: Clinical and Radiographic Outcomes at 1 Year: A Preliminary Report</title><secondary-title>J Spinal Disord Tech</secondary-title></titles><periodical><full-title>J Spinal Disord Tech</full-title></periodical><edition>2010/09/17</edition><dates><year>2010</year><pub-dates><date>Sep 14</date></pub-dates></dates><isbn>1539-2465 (Electronic)&#xD;1536-0652 (Linking)</isbn><accession-num>20844451</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=20844451</url></related-urls></urls><electronic-resource-num>10.1097/BSD.0b013e3181ecf995</electronic-resource-num><language>Eng</language></record></Cite></EndNote>[14]

The axial transsacral approach to L5-S1 interbody arthrodesis
	 The axial transsacral approach to interbody fusion at L5-S1 allows for placement of a cylindrical cage (AxiaLIF, TranS1, Wilmington DE) through the presacral corridor. The AxiaLIF implant has a reverse thread pitch to provide interspace distraction during implantation (Figure 1A, B). This technique has several advantages including a muscle-sparing approach and complete preservation of the annulus  ADDIN EN.CITE  ADDIN EN.CITE.DATA [13, 15].  The minimally vascular presacral corridor allows for safe implant placement with little risk for vascular injury ADDIN EN.CITE <EndNote><Cite><Author>Marotta</Author><Year>2006</Year><RecNum>5</RecNum><DisplayText>[15]</DisplayText><record><rec-number>5</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">5</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Marotta, N.</author><author>Cosar, M.</author><author>Pimenta, L.</author><author>Khoo, L. T.</author></authors></contributors><auth-address>Division of Neurosurgery, University of California at Los Angeles, California, USA.</auth-address><titles><title>A novel minimally invasive presacral approach and instrumentation technique for anterior L5-S1 intervertebral discectomy and fusion: technical description and case presentations</title><secondary-title>Neurosurg Focus</secondary-title></titles><periodical><full-title>Neurosurg Focus</full-title></periodical><pages>E9</pages><volume>20</volume><number>1</number><edition>2006/02/08</edition><keywords><keyword>Adult</keyword><keyword>Diskectomy/*instrumentation/*methods</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Intervertebral Disk/surgery</keyword><keyword>Intervertebral Disk Displacement/complications/*surgery</keyword><keyword>Lumbar Vertebrae/surgery</keyword><keyword>Middle Aged</keyword><keyword>Neurodegenerative Diseases/etiology/*surgery</keyword><keyword>Spinal Fusion/instrumentation/*methods</keyword></keywords><dates><year>2006</year></dates><isbn>1092-0684 (Electronic)&#xD;1092-0684 (Linking)</isbn><accession-num>16459999</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16459999</url></related-urls></urls><electronic-resource-num>200109 [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>[15]. However, the trajectory must be very precise as the implant is navigated posterior to the rectum and rectal injury has been reported with this technique  ADDIN EN.CITE  ADDIN EN.CITE.DATA [16, 17]. Biomechanical and preliminary clinical data suggest good short term outcomes for axial lumbar interbody fusion for degenerative disc disease, spondylolisthesis and as anterior support caudal to long fusion constructs  ADDIN EN.CITE  ADDIN EN.CITE.DATA [18-21].

Biomechanical Evaluation
Biomechanical studies have shown that the axial transsacral introduction of a fusion cage is technically feasible and has fixation properties comparable to existing implants for lumbosacral arthrodesis   ADDIN EN.CITE  ADDIN EN.CITE.DATA [18-21]. Ledet and colleagues mechanically tested 24 bovine lumbar motion segments in sagittal and lateral bending, torsion and axial compression after drilling an axial canal and implanting a fixation rod within the drilled canal. Drilling had little effect on stiffness and range of motion of the specimens. However specimens implanted with the axial rod demonstrated significant decreases in range of motion and increases in stiffness relative to the intact state. When compared to results reported for existing anterior, posterior, and interbody instrumentation, specifically femoral ring allograft, BAK cages, Brantigan ALIF and TLIF implants, Harms cages, and Kaneda, Isola, and University plating systems, lateral and sagittal bending stiffness of the axial rod was greater than that of the other interbody devices, while stiffness in extension and axial compression was similar to plate and rod constructs. Torsional stiffness was similar to interbody constructs and lower than plate and rod constructs. Thus the stiffness of the  axial rod is comparable to or greater than existing fixation  devices suggesting that it biomechanically is a good implant for obtaining lumbosacral interbody fusion  ADDIN EN.CITE <EndNote><Cite><Author>Ledet</Author><Year>2005</Year><RecNum>3</RecNum><DisplayText>[20]</DisplayText><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ledet, E. H.</author><author>Tymeson, M. P.</author><author>Salerno, S.</author><author>Carl, A. L.</author><author>Cragg, A.</author></authors></contributors><auth-address>Division of Orthopaedic Surgery, Albany Medical College, Albany, NY 12208, USA.</auth-address><titles><title>Biomechanical evaluation of a novel lumbosacral axial fixation device</title><secondary-title>J Biomech Eng</secondary-title></titles><pages>929-33</pages><volume>127</volume><number>6</number><edition>2006/01/28</edition><keywords><keyword>Animals</keyword><keyword>Arthrodesis/*instrumentation/methods</keyword><keyword>Biomechanics/instrumentation/methods</keyword><keyword>*Bone Plates</keyword><keyword>Cattle</keyword><keyword>Compressive Strength</keyword><keyword>Equipment Failure Analysis</keyword><keyword>Joint Instability/diagnosis/*physiopathology/*prevention &amp; control</keyword><keyword>Lumbosacral Region/*physiopathology/*surgery</keyword><keyword>Prosthesis Design</keyword><keyword>Range of Motion, Articular</keyword><keyword>Spinal Fusion/*instrumentation/methods</keyword><keyword>Stress, Mechanical</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2005</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0148-0731 (Print)&#xD;0148-0731 (Linking)</isbn><accession-num>16438229</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16438229</url></related-urls></urls><language>eng</language></record></Cite></EndNote>[20]
	Erkan and colleagues have tested two-level fusion (L4-S1) using the axial rod technique. Six  human cadaveric L4 to S1 motion segments were tested in axial torsion, lateral bending, and flexion extension following intact, stand alone AxiaLIF (2-level rod) , and AxiaLIF with posterior fixation with either facet screws or pedicle screws. At L4-L5 level in axial torsion and flexion extension, none of the surgical treatments showed any statistically significance. In lateral bending, the posterior fixation devices had significantly higher construct stability compared to the stand alone AxiaLIF.  At L5-S1 level in axial torsion and lateral bending, none of the surgical treatments were statistically significant. However, in flexion extension, the stand alone AxiaLIF had significantly greater range of motion compared with the posterior fixation techniques suggesting that AxiaLIF should be performed in conjunction with posterior fixation to obtain greater stability for a successful arthrodesis  ADDIN EN.CITE  ADDIN EN.CITE.DATA [19].

Surgical Procedure
The patient undergoes a standard bowel preparation 24 hours prior to surgery. The procedure is performed with the patient prone with a pillow elevating the pelvis. Preoperative antibiotics are administered. The sacrococcygeal region is prepped and draped in the standard sterile fashion. If a prior posterior spinal fusion had been performed at the same operative setting, the posterior wound is closed and the patient is reprepped and draped for the axial interbody procedure. This reprepping minimize infection risk and allows for optimal patient positioning in lumbosacral lordosis to help with implant targeting into the vertebral body of L5. A 3 cm transverse incision is made at the right side of the coccyx and carried through the subcutaneous tissue to the fascia.  The anterior surface of the coccyx is located with a curved Kelly clamp. Using biplanar fluoroscopy, a blunt dissecting tool (TranS1) then advanced along the anterior face of the sacrum to the S1-S2 level and docked (Figure 2A). The inner blunt stylet is exchanged for a guide pin which is introduced into the S1 vertebral body, across the L5-S1 disc space under fluoroscopic visualization (Figure 2B). A series of dilators open the osseous path allowing for placement of a working cannula; through this cannula, a path is drilled from the anterior sacrum through S1 into the L5-S1 disc space. Radial cutting instruments are used to perform the discectomy and prepare the endplates for fusion (Figure 2C).  Cutting instruments should not be turned 360 degrees as they may invade the spinal canal.  After discectomy, the disc space is bone grafted with local bone removed from the vertebral body and demineralized bone matrix. The appropriate length AxiaLIF implant is inserted over a guide pin through a protective cannula transfixing the L5-S1 level (Figure 2D). The wound is irrigated and closed after removal of guide wires and cannulas  ADDIN EN.CITE <EndNote><Cite><Author>Issack</Author><Year>2011</Year><RecNum>36</RecNum><DisplayText>[22]</DisplayText><record><rec-number>36</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">36</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Issack, P.S.</author><author>Boachie-Adjei, O.</author></authors></contributors><titles><title>Axial lumbosacral interbody fusion appears safe as a method to obtain lumbosacral arthrodesis distal to long fusion constructs </title><secondary-title>HSS J</secondary-title></titles><periodical><full-title>HSS J</full-title></periodical><volume>Online</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>[22].
Li and colleagues, in human cadaveric study, dissected the presacral space in 16 pelvic specimens and observed the position of the entry guide pin for AxiaLIF in relation to the pelvic splanchnic nerves. The pelvic splanchnic nerves limited the dissection of the lower rectum and the minimum distance from the guide pin to the pelvic splanchnic nerves was as small as 4 mm. Clearly the margin of error is small and the accurate placement of the blunt stylet through which the guide pin is passes is the most critical step in the operation.  ADDIN EN.CITE <EndNote><Cite><Author>Li</Author><Year>2011</Year><RecNum>30</RecNum><DisplayText>[23]</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Li, X. M.</author><author>Zhang, Y. S.</author><author>Hou, Z. D.</author><author>Wu, T.</author><author>Ding, Z. H.</author></authors></contributors><auth-address>*Institute of Clinical Anatomy, Southern Medical University, Guangzhou, China.</auth-address><titles><title>The relevant anatomy of the approach for axial lumbar interbody fusion</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><edition>2011/04/16</edition><dates><year>2011</year><pub-dates><date>Apr 7</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>21494190</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=21494190</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e31821b8f6d</electronic-resource-num><language>Eng</language></record></Cite></EndNote>[23]

Treating degenerative disc disease and spondylolisthesis with AxiaLIF
The majority of clinical studies on the axial interbody technique are to treat degenerative disc disease and spondylolisthesis  ADDIN EN.CITE  ADDIN EN.CITE.DATA [1, 5, 15, 24-26]. Aryan and colleagues reviewed 35 patients with back pain secondary to lumbar degenerative disc disease, degenerative scoliosis, or isthmic spondylolisthesis treated with AxiaLIF and recombinant human BMP.  Twenty-three patients underwent supplemental posterior pedicle screw fixation. Thirty-two patients (91%) had clinical and radiographic evidence of L5-S1 interbody fusion at a mean follow-up of 17.5 months  ADDIN EN.CITE  ADDIN EN.CITE.DATA [5]. Tobler and Ferrara prospectively followed 26 patients who underwent AxiaLIF with posterior pedicle screw fixation for 2 years for degenerative disc disease. The fusion was at one-level (L5-S1) in 17 patients and two-level at (L4-S1) in 9 patients. Twenty two achieved interbody fusion at 1 year and 23 achieved fusion at 2 years. One patient with a pseudarthrosis underwent successful revision posterolateral fusion  ADDIN EN.CITE  ADDIN EN.CITE.DATA [25]. In a larger retrospective study, Tobler and colleagues evaluated 156 patients who underwent an L5-S1 interbody fusion using the AxiaLIF (Figure 3A,B).  There were significant improvements in pain and mean Oswestry Disability Index scores at 2 years follow-up. Radiographic evidence of interbody fusion was observed in 94% of the patients (145 of 155)  ADDIN EN.CITE <EndNote><Cite><Author>Tobler</Author><Year>2011</Year><RecNum>35</RecNum><DisplayText>[26]</DisplayText><record><rec-number>35</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">35</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tobler, W. D.</author><author>Gerszten, P. C.</author><author>Bradley, W. D.</author><author>Raley, T. J.</author><author>Nasca, R. J.</author><author>Block, J. E.</author></authors></contributors><auth-address>The Christ Hospital Medical Office Building, Cincinnati, OH, USA.</auth-address><titles><title>Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>E1296-301</pages><volume>36</volume><number>20</number><edition>2011/04/16</edition><dates><year>2011</year><pub-dates><date>Sep 15</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>21494201</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=21494201</url></related-urls></urls><electronic-resource-num>10.1097/BRS.0b013e31821b3e37</electronic-resource-num><language>eng</language></record></Cite></EndNote>[26].
	Gerszten and colleagues reported on 26 patients with grade 1 or grade 2 symptomatic L5-S1 isthmic spondylolisthesis who underwent L5-S1 AxiaLIF and posterior pedicle screw fixation. Approximately half the patients showed a reduction of at least 1 grade. Axial pain improved after axial lumbar interbody fusion with a 66% reduction from baseline. Fusion rate at 2 years was 100% with 81% of patients deemed excellent or good using Odom criteria  ADDIN EN.CITE <EndNote><Cite><Author>Gerszten</Author><Year>2011</Year><RecNum>27</RecNum><DisplayText>[24]</DisplayText><record><rec-number>27</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">27</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gerszten, P. C.</author><author>Tobler, W.</author><author>Raley, T. J.</author><author>Miller, L. E.</author><author>Block, J. E.</author><author>Nasca, R. J.</author></authors></contributors><auth-address>*Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA daggerThe Christ Hospital Medical Office Building, Cincinnati, OH double daggerMinimally Invasive Spine Institute, Arlington, VA section signMiller Scientific Consulting, Inc., Biltmore Lake, NC paragraph signJon E. Block, PhD, Inc., San Francisco, CA paragraph signOrthopaedic &amp; Spine Surgery, Wilmington, NC.</auth-address><titles><title>Axial Presacral Lumbar Interbody Fusion and Percutaneous Posterior Fixation for Stabilization of Lumbosacral Isthmic Spondylolisthesis</title><secondary-title>J Spinal Disord Tech</secondary-title></titles><periodical><full-title>J Spinal Disord Tech</full-title></periodical><edition>2011/10/04</edition><dates><year>2011</year><pub-dates><date>Sep 29</date></pub-dates></dates><isbn>1539-2465 (Electronic)&#xD;1536-0652 (Linking)</isbn><accession-num>21964453</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=21964453</url></related-urls></urls><electronic-resource-num>10.1097/BSD.0b013e318233725e</electronic-resource-num><language>Eng</language></record></Cite></EndNote>[24]. 

AxiaLIF caudal to long fusion constructs 
In adult deformity surgery, long posterior fusion constructs must often be extended to include L5-S1 in situations where there is lumbosacral disc degeneration, spondylosis, degenerative spondylolisthesis or a fractional lumbosacral curve greater than 15 degrees in magnitude. ADDIN EN.CITE  ADDIN EN.CITE.DATA [27-29]  To protect distal fixation, particularly S1 screws, the addition of iliac screws and anterior interbody support at L5-S1 is recommended to offset load on distal fixation. ADDIN EN.CITE  ADDIN EN.CITE.DATA [5-7]  While interbody fusion at L5-S1 caudal to long fusion constructs has traditionally been achieved by ALIF, PLIF or TLIF, the axial interbody approach has recently been demonstrated to provide anterior support distal to long posterior fusions at short term follow-up (Figure 4). 
	Anand and colleagues prospectively evaluated 12 patients undergoing circumferential fusion for lumbar degenerative scoliosis, of which 5 patients had fusions to L5-S1 performed using the axial technique. There were no complications. Blood loss was less than 200 ml. Fusions extended as proximal as T12 in these 5 AxiaLIF cases  ADDIN EN.CITE <EndNote><Cite><Author>Anand</Author><Year>2008</Year><RecNum>6</RecNum><DisplayText>[27]</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Anand, N.</author><author>Baron, E. M.</author><author>Thaiyananthan, G.</author><author>Khalsa, K.</author><author>Goldstein, T. B.</author></authors></contributors><auth-address>Department of Surgery, Institute for Spinal Disorders, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA. neel.anand@cshs.org</auth-address><titles><title>Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study</title><secondary-title>J Spinal Disord Tech</secondary-title></titles><periodical><full-title>J Spinal Disord Tech</full-title></periodical><pages>459-67</pages><volume>21</volume><number>7</number><edition>2008/10/07</edition><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Feasibility Studies</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Intervertebral Disk Displacement/*surgery</keyword><keyword>Lumbar Vertebrae/*surgery</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Scoliosis/*surgery</keyword><keyword>Spinal Fusion/*methods</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2008</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1539-2465 (Electronic)&#xD;1536-0652 (Linking)</isbn><accession-num>18836355</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18836355</url></related-urls></urls><electronic-resource-num>10.1097/BSD.0b013e318167b06b&#xD;00024720-200810000-00001 [pii]</electronic-resource-num><language>eng</language></record></Cite></EndNote>[27].  In a retrospective study of 28 patients who underwent minimally invasive correction and fusion over 3 or more levels for adult scoliosis, 13 1-level (L5-S1) and 4 two level (L4-S1) axial interbody fusions were performed. At a mean follow-up time of 22 months, all patients achieved fusion  ADDIN EN.CITE  ADDIN EN.CITE.DATA [30]. There were no complications related to the AxiaLIF procedure. Blood loss was 231 ml (including posterior instrumentation). These results suggest good outcomes using the axial transsacral technique to fuse L5-S1 below posterior fusion constructs extending up to T12  ADDIN EN.CITE  ADDIN EN.CITE.DATA [27, 30].
	Issack and Boachie-Adjei retrospectively examined 9 patients who underwent axial interbody fixation and fusion caudal to long fusion constructs for adult scoliosis. There were four 1-level and 5 two-level procedures. Fusions in this series were longer than those described above with 6 patients having fusions extending proximally to T10 or higher (up to T3). There were 2 pseudoarthroses and no major complications occurred. There were significant  improvements in the pain, self-image and satisfaction with management domains of the SRS-22  ADDIN EN.CITE <EndNote><Cite><Author>Issack</Author><Year>2011</Year><RecNum>36</RecNum><DisplayText>[22]</DisplayText><record><rec-number>36</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">36</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Issack, P.S.</author><author>Boachie-Adjei, O.</author></authors></contributors><titles><title>Axial lumbosacral interbody fusion appears safe as a method to obtain lumbosacral arthrodesis distal to long fusion constructs </title><secondary-title>HSS J</secondary-title></titles><periodical><full-title>HSS J</full-title></periodical><volume>Online</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>[22].

Complications
Rectal perforation has been reported following the AxiaLIF procedure  ADDIN EN.CITE  ADDIN EN.CITE.DATA [16, 17]. Botolin and colleagues reported the case of a 44 year old female patient with a history of previous anterior and posterior spinal surgeries, pelvic inflammatory disease and previous diverticulitis who underwent L5-S1 axial interbody fusion. After surgery, the patient presented with abdominal pain, nausea, vomiting and melena. An abdominal CT scan with IV and oral contrast demonstrated soft tissue fluid density with fat stranding in the presacral space. There was extraluminal rectal contrast and gas consistent with rectal perforation (Figure 5). The patient required a diverting ileostomy with intravenous antibiotics. The authors suggested that a preoperative pelvic CT with rectal contrast be performed in patients at risk for adhesion formation  ADDIN EN.CITE  ADDIN EN.CITE.DATA [17].
	Issack and Boachie-Adjei had two pseudoarthroses in their series, one at L4-5 and one at L5-S1. One of these patients had a near 10 cm positive sagittal balance after AxiaLIF. Though the numbers are too small in this series to draw statistically significant conclusions, restoration of sagittal balance is likely to be important for interbody fusion  ADDIN EN.CITE <EndNote><Cite><Author>Issack</Author><Year>2011</Year><RecNum>36</RecNum><DisplayText>[22]</DisplayText><record><rec-number>36</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">36</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Issack, P.S.</author><author>Boachie-Adjei, O.</author></authors></contributors><titles><title>Axial lumbosacral interbody fusion appears safe as a method to obtain lumbosacral arthrodesis distal to long fusion constructs </title><secondary-title>HSS J</secondary-title></titles><periodical><full-title>HSS J</full-title></periodical><volume>Online</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>[22].  Furthermore, thorough and meticulous discectomy and endplate preparation followed by robust bone grafting are likely essential components (as in ALIF, TLIF and PLIF) of successful arthrodesis.
	Lindley and colleagues retrospectively reviewed complications in 68 patients who underwent AxiaLIF surgery. Sixteen patients (23.5%) suffered complications including rectal perforation (2 patients), pseudarthrosis (6 patients), superficial infection (4 patients), pelvic hematoma (2 patients) and sacral fracture (2 patients). With regard to superficial infection, we found that making a transverse incision, instead of a longitudinal incision, reduced this risk. To prevent pelvic hematoma, we recommend that all patients have a preoperative MRI performed to demonstrate a clear fat plane separating the visceral peritoneum and rectum from the anterior sacral wall. If extensive vasculature is seen in this plane, AxiaLIF is contraindicated, as instruments cannot be safely passed through the presacral space. To prevent sacral fracture, the trajectory of the guide pin is critical. Too anterior a path may result in fracture of the anterior sacral cortex when either instruments or the implant is inserted. A trajectory that is too posterior may result in posterior vertebral cortical penetration with possible neural element injury.

Conclusions
The axial transsacral approach to L5-S1 provides a minimally invasive approach to interbody arthrodesis at L5-S1. Biomechanical studies on the AxiaLIF implant suggest stiffness comparable to existing interbody fixation devices. Early clinical studies on the AxiaLIF demonstrate good to excellent results in terms of pain relief and fusion rates when performing L5-S1 arthrodesis to treat degenerative disc disease and spondylolisthesis. Short term follow-up studies on the use of the axial interbody fusion caudal to long fusion constructs demonstrates good pain relief, fusion rates and minimal blood loss. The technique however is exacting and complications, while rare, can be major. Long term follow-up studies to assess clinical outcome, fusion and complications are required before the axial approach can be recommended as a standard, routine approach to achieve L5-S1 interbody arthrodesis in adult scoliosis. 
	









Figure Legends

Figure 1. A. The AxiaLIF implant with reverse thread pitch to provide interspace distraction during implantation B.  AxiaLIF rod implanted in the L5�S1 disc space. Reproduced with permission from: Tobler WD, Gerszten PC, Bradley WD, Raley TJ, Nasca RJ, Block JE:Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes. Spine (Phila Pa 1976) 2011;36(20): E1296-301.

Figure 2. AxiaLIF surgical technique. A. Guide pin is introduced into the presacral space over a blunt, walked on the anterior face of the sacrum and docked. B. Dilator and guide pin introduced into the L5�S1 disc space. C. Radial cutters to perform discectomy and prepare endplates for fusion D. Implantation of AxiaLIF rod and bone grafting. Reproduced with permission from: Tobler WD, Gerszten PC, Bradley WD, Raley TJ, Nasca RJ, Block JE:Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes. Spine (Phila Pa 1976) 2011;36(20): E1296-301.


Figure 3. A. Anteroposterior and lateral radiographs demonstrating L5�S1 interbody fusion with the AxiaLIF rod and pedicle screw fixation. B. Coronal and sagittal CT images demonstrating L5-S1 arthrodesis. Reproduced with permission from: Tobler WD, Gerszten PC, Bradley WD, Raley TJ, Nasca RJ, Block JE:Minimally invasive axial presacral L5-S1 interbody fusion: two-year clinical and radiographic outcomes. Spine (Phila Pa 1976) 2011;36(20): E1296-301.

Figure 4. Anteroposterior and lateral radiographs demonstrating a 2-level (L4-S1) AxiaLIF implanted caudal to a long posterior fusion construct.

Figure 5. Abdominal CT scan with IV and oral contrast demonstrates soft tissue fluid density with fat stranding in the presacral space. There is extraluminal rectal contrast and gas present consistent with high rectal perforation (black arrow). Reproduced with permission from: Botolin S, Agudelo J, Dwyer A, Patel V, Burger E:High rectal injury during trans-1 axial lumbar interbody fusion L5-S1 fixation: a case report. Spine (Phila Pa 1976) 2010;35(4): E144-8.








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D<EndNote><Cite><Author>Chen</Author><Year>1995</Year><RecNum>24</RecNum><DisplayText>[3, 4]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chen, D.</author><author>Fay, L. A.</author><author>Lok, J.</author><author>Yuan, P.</author><author>Edwards, W. T.</author><author>Yuan, H. 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Vertebrae/*surgery</keyword><keyword>Melena/etiology</keyword><keyword>Nausea/etiology</keyword><keyword>Rectum/*injuries/radiography</keyword><keyword>Sacrum/*surgery</keyword><keyword>Spinal Fusion/*adverse effects</keyword><keyword>Tissue Adhesions/complications</keyword><keyword>Tomography, X-Ray Computed</keyword><keyword>Treatment Outcome</keyword><keyword>Vomiting/etiology</keyword><keyword>Wounds, Penetrating/*etiology/radiography/*therapy</keyword></keywords><dates><year>2010</year><pub-dates><date>Feb 15</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 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C.</author></authors></contributors><auth-address>University of Minnesota, Minneapolis, Minnesota 55424, USA. andrewcragg@hotmail.com</auth-address><titles><title>New percutaneous access method for minimally invasive anterior lumbosacral surgery</title><secondary-title>J Spinal Disord Tech</secondary-title></titles><periodical><full-title>J Spinal Disord Tech</full-title></periodical><pages>21-8</pages><volume>17</volume><number>1</number><edition>2004/01/22</edition><keywords><keyword>Animals</keyword><keyword>Biopsy/instrumentation/methods</keyword><keyword>Cadaver</keyword><keyword>Catheterization/instrumentation/methods</keyword><keyword>Diskectomy, Percutaneous/instrumentation/methods</keyword><keyword>Feasibility Studies</keyword><keyword>Fluoroscopy</keyword><keyword>Humans</keyword><keyword>Intraoperative Complications/prevention &amp; control</keyword><keyword>Lumbar Vertebrae/anatomy &amp; histology/*surgery</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Monitoring, Intraoperative/instrumentation/methods</keyword><keyword>Neurosurgical Procedures/*instrumentation/*methods</keyword><keyword>Pilot Projects</keyword><keyword>Postoperative Complications/pathology/physiopathology/prevention &amp; control</keyword><keyword>Reproducibility of Results</keyword><keyword>Sacrum/anatomy &amp; histology/*surgery</keyword><keyword>Spinal Fusion/instrumentation/methods</keyword><keyword>Sus scrofa</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2004</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1536-0652 (Print)&#xD;1536-0652 (Linking)</isbn><accession-num>14734972</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=14734972</url></related-urls></urls><electronic-resource-num>00024720-200402000-00006 [pii]</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Erkan</Author><Year>2009</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Erkan, S.</author><author>Wu, C.</author><author>Mehbod, A. 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H.</author><author>Tymeson, M. P.</author><author>Salerno, S.</author><author>Carl, A. 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A.</author><author>Hsu, B.</author><author>Pahl, D. W.</author><author>Transfeldt, E. E.</author></authors></contributors><auth-address>Twin Cities Spine Center, 913 East 26th Street, Suite 600, Minneapolis, MN 55404, USA.</auth-address><titles><title>Biomechanical evaluation of a new AxiaLIF technique for two-level lumbar fusion</title><secondary-title>Eur Spine J</secondary-title></titles><pages>807-14</pages><volume>18</volume><number>6</number><edition>2009/04/09</edition><keywords><keyword>Aged</keyword><keyword>Biomechanics/physiology</keyword><keyword>Bone Screws/standards/trends</keyword><keyword>Cadaver</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Image Processing, Computer-Assisted/methods</keyword><keyword>Internal Fixators/standards/*trends</keyword><keyword>Lumbar Vertebrae/anatomy &amp; histology/*physiology/*surgery</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Optics and Photonics/methods</keyword><keyword>Range of Motion, Articular/*physiology</keyword><keyword>Sacrum/anatomy &amp; histology/physiology/surgery</keyword><keyword>Spinal Diseases/surgery</keyword><keyword>Spinal Fusion/*instrumentation/*methods</keyword><keyword>Stress, Mechanical</keyword><keyword>Video Recording/methods</keyword><keyword>Weight-Bearing/physiology</keyword><keyword>Zygapophyseal Joint/anatomy &amp; histology/physiology/surgery</keyword></keywords><dates><year>2009</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1432-0932 (Electronic)&#xD;0940-6719 (Linking)</isbn><accession-num>19352729</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=19352729</url></related-urls></urls><custom2>2899656</custom2><electronic-resource-num>10.1007/s00586-009-0953-5</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Ledet</Author><Year>2005</Year><RecNum>3</RecNum><record><rec-number>3</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">3</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ledet, E. H.</author><author>Tymeson, M. P.</author><author>Salerno, S.</author><author>Carl, A. L.</author><author>Cragg, A.</author></authors></contributors><auth-address>Division of Orthopaedic Surgery, Albany Medical College, Albany, NY 12208, USA.</auth-address><titles><title>Biomechanical evaluation of a novel lumbosacral axial fixation device</title><secondary-title>J Biomech Eng</secondary-title></titles><pages>929-33</pages><volume>127</volume><number>6</number><edition>2006/01/28</edition><keywords><keyword>Animals</keyword><keyword>Arthrodesis/*instrumentation/methods</keyword><keyword>Biomechanics/instrumentation/methods</keyword><keyword>*Bone Plates</keyword><keyword>Cattle</keyword><keyword>Compressive Strength</keyword><keyword>Equipment Failure Analysis</keyword><keyword>Joint Instability/diagnosis/*physiopathology/*prevention &amp; control</keyword><keyword>Lumbosacral Region/*physiopathology/*surgery</keyword><keyword>Prosthesis Design</keyword><keyword>Range of Motion, Articular</keyword><keyword>Spinal Fusion/*instrumentation/methods</keyword><keyword>Stress, Mechanical</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2005</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0148-0731 (Print)&#xD;0148-0731 (Linking)</isbn><accession-num>16438229</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16438229</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>MacMillan</Author><Year>1996</Year><RecNum>4</RecNum><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>MacMillan, M.</author><author>Fessler, R. G.</author><author>Gillespy, M.</author><author>Montgomery, W. J.</author></authors></contributors><auth-address>Department Orthopaedic, University of Florida, Gainesville 32610-0246, USA.</auth-address><titles><title>Percutaneous lumbosacral fixation and fusion: anatomic study and two-year experience with a new method</title><secondary-title>Neurosurg Clin N Am</secondary-title></titles><pages>99-106</pages><volume>7</volume><number>1</number><edition>1996/01/01</edition><keywords><keyword>Adult</keyword><keyword>Bone Screws</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Intraoperative Complications</keyword><keyword>Lumbosacral Region</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Orthopedic Fixation Devices</keyword><keyword>Reoperation</keyword><keyword>Spinal Diseases/radiography/*surgery</keyword><keyword>Spinal Fusion/*methods</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1996</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1042-3680 (Print)&#xD;1042-3680 (Linking)</isbn><accession-num>8835150</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=8835150</url></related-urls></urls><language>eng</language></record></Cite></EndNote>&	D<EndNote><Cite><Author>Erkan</Author><Year>2009</Year><RecNum>19</RecNum><DisplayText>[19]</DisplayText><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Erkan, S.</author><author>Wu, C.</author><author>Mehbod, A. 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P.</author></authors></contributors><auth-address>Department of Neurosurgery, University of California-San Francisco, CA, USA.</auth-address><titles><title>Percutaneous axial lumbar interbody fusion (AxiaLIF) of the L5-S1 segment: initial clinical and radiographic experience</title><secondary-title>Minim Invasive Neurosurg</secondary-title></titles><pages>225-30</pages><volume>51</volume><number>4</number><edition>2008/08/07</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Bone Screws</keyword><keyword>Bone Transplantation</keyword><keyword>Diskectomy/instrumentation/methods</keyword><keyword>Female</keyword><keyword>Fluoroscopy</keyword><keyword>Humans</keyword><keyword>Internal Fixators</keyword><keyword>Intervertebral Disk Displacement/complications/pathology/surgery</keyword><keyword>Low Back Pain/etiology/pathology/*surgery</keyword><keyword>Lumbar Vertebrae/anatomy &amp; histology/*surgery</keyword><keyword>Male</keyword><keyword>Medical Illustration</keyword><keyword>Middle Aged</keyword><keyword>Monitoring, Intraoperative</keyword><keyword>Postoperative Complications/etiology/pathology/physiopathology</keyword><keyword>Retrospective Studies</keyword><keyword>Sacrum/anatomy &amp; histology/*surgery</keyword><keyword>Scoliosis/complications/pathology/surgery</keyword><keyword>Spinal Fusion/instrumentation/*methods</keyword><keyword>Spondylolisthesis/complications/pathology/surgery</keyword><keyword>Time Factors</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2008</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0946-7211 (Print)&#xD;0946-7211 (Linking)</isbn><accession-num>18683115</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18683115</url></related-urls></urls><electronic-resource-num>10.1055/s-2008-1080915</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Gerszten</Author><Year>2011</Year><RecNum>27</RecNum><record><rec-number>27</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">27</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gerszten, P. 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S.</author></authors></contributors><auth-address>University of California, San Francisco, USA.</auth-address><titles><title>Outcome and complications of long fusions to the sacrum in adult spine deformity: luque-galveston, combined iliac and sacral screws, and sacral fixation</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>776-86</pages><volume>27</volume><number>7</number><edition>2002/03/30</edition><keywords><keyword>Adult</keyword><keyword>Bone Nails</keyword><keyword>Bone Screws</keyword><keyword>Bone Wires</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Ilium/*surgery</keyword><keyword>Lumbar Vertebrae/surgery</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Sacrum/*surgery</keyword><keyword>Spinal Curvatures/radiography/*surgery</keyword><keyword>*Spinal Fusion/*adverse effects</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2002</year><pub-dates><date>Apr 1</date></pub-dates></dates><isbn>1528-1159 (Electronic)&#xD;0362-2436 (Linking)</isbn><accession-num>11923673</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=11923673</url></related-urls></urls><electronic-resource-num>00007632-200204010-00017 [pii]</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Weistroffer</Author><Year>2008</Year><RecNum>18</RecNum><record><rec-number>18</rec-number><foreign-keys><key app="EN" db-id="rxv2wv2x1azvprefewr5zvsq0x9twfzdvxpa">18</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Weistroffer, J. 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M.</author></authors></contributors><auth-address>Departments of Surgery, Cedars Sinai Spine Center, Cedars Sinai Medical Center, Los Angeles, California 90048, USA. 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M.</author></authors></contributors><auth-address>Departments of Surgery, Cedars Sinai Spine Center, Cedars Sinai Medical Center, Los Angeles, California 90048, USA. 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