Endopelvic Approach for Iliac Crest Bone Harvesting

Accepted Manuscript Endopelvic approach for iliac crest bone harvesting: Technical Note S. Le Pape, MD, R. Gauthe, MD, L. Du Pouget, MD, O. Gille, MD-PhD., J.-M. Vital, MD-PhD., M. Ould-Slimane, MD PII:

S1878-8750(17)31191-9

DOI:

10.1016/j.wneu.2017.07.091

Reference:

WNEU 6153

To appear in:

World Neurosurgery

Received Date: 19 March 2017 Revised Date:

14 July 2017

Accepted Date: 15 July 2017

Please cite this article as: Le Pape S, Gauthe R, Du Pouget L, Gille O, Vital J-M, Ould-Slimane M, Endopelvic approach for iliac crest bone harvesting: Technical Note, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.07.091. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT ENDOPELVIC APPROACH FOR ILIAC CREST BONE HARVESTING: TECHNICAL NOTE S. LE PAPE1 MD., R. GAUTHE1 MD., L. DU POUGET2 MD., O. GILLE3 MDPHD., J-M. VITAL3 MD-PHD., M. OULD-SLIMANE MD1 1

Regional Spine Institute, University hospital of Rouen, F-76000, France Urology department, University hospital of Rouen, F-76000, France 3 Spine Unit 1, University hospital Pellegrin, Bordeaux, F-33000, France

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Corresponding author: Sébastien LE PAPE Regional Spine Institute University hospital of Rouen Rue de Germont 76000 ROUEN +33647696826 [email protected]

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Keywords Bone graft; Endopelvic approach; iliac crest; Anterior Lumbar Interbody Fusion; Lumbar spine surgery

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Abbreviations list Anterior lumbar interbody fusion (ALIF), Recombinant human bone morphogenetic protein 2 (rhBMP-2), Visual analog scale (VAS), Lateral femoral cutaneous nerve (LFCN), Magnetic resonance imaging (MRI)

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Abstract Background The anterior approach to lumbar spine surgery has grown in popularity in the past few years; spinal fusion of the last two lumbar levels is often required. While there are alternatives to bone grafting available, including recombinant human bone morphogenetic protein 2 or bone substitutes, only cancellous autologous bone has all the required factors for bone growth. To avoid the use of bone substitutes, remote iliac crest bone harvesting remains the gold standard. However, this technique may lead to some unfavorable outcomes. Case description A 46-year-old patient suffered from severe back and left leg pain. The magnetic resonance imaging showed an inflammatory discopathy of L5-S1 associated with a left poster lateral herniated disc. Conservative treatment failed, and surgical treatment of the lumbar disk disease and the herniated disc was scheduled. A novel iliac crest bone harvesting method was performed during the retroperitoneal approach to the anterior lumbar interbody fusion (ALIF). The patient’s postoperative course was uneventful. There were no adverse outcomes related to the bone donor site. CONCLUSION: This paper represents the first in vivo report of endopelvic iliac crest bone harvesting. This technique allows performing bone graft harvesting with the same retroperitoneal approach used for ALIF. It avoids many common complications associated with the remote approach to the iliac crest.

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Anterior lumbar interbody fusion (ALIF) has grown in popularity among spine surgeons in the past few years. This procedure is used to treat several pathologies such as lumbar spondylosis or lumbar disk disease. The most treated levels are L4-L5 and L5-S1 1. Cancellous bone remains the gold standard for spinal fusion, but iliac crest bone harvesting may lead to donor-site complications 2,3. Using bone substitutes such as recombinant human bone morphogenetic protein 2 (rhBMP2) can also promote fusion. rhBMP2 is associated with a high rate of fusion, but serious complications have been reported 4. In the present case, a new endopelvic iliac crest bone harvesting method is performed using the same retroperitoneal approach as the ALIF procedure.

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Case presentation:

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The reported case is that of a 46-year-old man with no medical or surgical history. For 2 years prior to surgery, the patient complained of low back pain accompanying left S1 radicular pain. Although he received conservative treatment including rehabilitation, physiotherapy and pain medications, the symptoms gradually worsened. Magnetic resonance imaging showed a L5-S1 discopathy associated with Modic type I 5 signal and a left posterolateral herniated disc (Fig. 1). A standard retroperitoneal approach for anterior lumbar interbody fusion of L5-S1 was performed. When the extraperitoneal plane was identified, the muscles were mobilized laterally. Dissection was then performed to identify the psoas and the iliacus muscles. Blunt dissection was used to expose the iliac fascia, and the lateral femoral cutaneous nerve (LFCN) was identified. The site of the iliac crest bone harvesting was located between the LFCN and the psoas muscle (Fig. 2). The fascia was incised according to the orientation of the iliac muscle. The iliac muscle was spread using blunt dissection on the superior and intermediate part of the ilium (Fig. 3). Once the bony surface of the ilium was reached, a cortical window of 2x2cm was excised using an osteotome (Fig 4). Then the cancellous bone was harvested with a curette (Fig. 5). After harvesting, SURGICEL® FIBRILLAR™ (Ethicon, Somerville, NJ, USA) was applied on the donor site to perform hemostasis. The iliac muscle and fascia were repositioned. The ALIF procedure was followed. An ROI-A lumbar cage (Zimmer Biomet, Troyes, France) was filled entirely with autologous cancellous bone graft and inserted into the L5-S1 interbody space (Fig. 6). At the end of the procedure, the donor site was infused with ropivacaine and a closed suction drain was placed in the retroperitoneal space. The postoperative course had no major outcomes. The patient experienced complete relief from leg pain and an improvement of back pain from 7/10 preoperatively to 2/10 on the visual analog scale (VAS). The drain was removed on day one. The volume of blood loss was 50cc. Pain at the iliac crest donor site was controlled using paracetamol. The patient was

ACCEPTED MANUSCRIPT discharged on day 3. At 6 weeks, the patient was no longer taking pain medication. Fusion was achieved 6 months after surgery (Fig. 7). Discussion

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The anterior approach used for lumbar spine procedures has many advantages. The retroperitoneal exposure of the lumbar spine allows for increasing the intervertebral space and lordosis, minimizing the risk of neural injury and avoiding damage to the back muscles 1 . Decreasing excessive muscle lesions increases oxygen and nutrient factors for bone growth. To obtain good fusion rates, the lumbar interbody cage should be filled with materials that promote bone growth. Autologous bone remains the gold standard for spinal arthrodesis 6. Three categories of autologous bones exist: cortical, vascularized cortical and cancellous. Cancellous bone has the most potential for osteogenesis, osteoconduction and osteoinduction, which lead to good fusion rates 2,7,8. Iliac crest bone harvesting techniques may result in complications at a rate of 2.5% to as much as 39% 9. Major complications have been reported ranging from 0.7% to 25% including deep wound infection, arterial injury, peritoneal perforation, hernia or ilium fracture9,10. Minor complications range from 4 to 49% and include gait disturbance, chronic donor site pain, hematomas and superficial wound infection 9. These outcomes of autogenous bone grafts led to the use of bone graft substitutes. The most common bone graft substitutes are allografts, demineralized bone matrix, ceramic-based substitutes and bone morphogenetic protein (BMP) 6. Studies comparing different bone graft substitutes did not show statistical differences regarding outcomes 7,11. However, bone morphogenetic proteins like rhBMP-2 result in a high rate of fusion due to the high potential of osteoinductivity 8. But since 2008, studies have shown that the use of rhBMP-2 can lead to serious complications, such as higher rates of retrograde ejaculation, heterotopic ossification, radiculopathies or carcinogenesis 12. In this report, endopelvic iliac crest bone graft harvesting resulted in fewer complications than remote iliac crest harvesting. A cadaveric study of this endopelvic approach for iliac crest harvesting showed its feasibility 13. To decrease the risk of nerve damage during the approach, surgeons must have a good knowledge of nerve anatomy. The bony window of the iliac crest is situated between the psoas and the LFCN (3cm down from the anterior superior iliac spine) 14. The femoral nerve is located directly beneath the body of the psoas muscle but could emerge on its lateral border. The genitofemoral nerve is found on the superficial surface of the psoas muscle 15,16. To prevent iatrogenic nerve injury, surgeons should use blunt dissection during the approach and carefully manipulate the osteotome.

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To decrease the risk of hematoma, the cortical window should be unicortical. The widest segments of the iliac crest are located on the anterior and intermediate part. 17 After harvesting the iliac crest, performing hemostasis of the donor site is very important. Hematoma of the iliacus muscle could lead to a femoral nerve palsy and increased pain in the donor site 18. A hemostatic agent like bone wax, absorbable hemostats or hemostatic matrix might be used. Considering hemostatic agents, human gelatin-thrombin matrix sealant showed improvements over other hemostatic agents in reducing the time to achieve hemostasis and reducing blood loss 19. At the end of the procedure a closed suction drain is placed next to the iliacus muscle to decrease the risk of iliacus muscle hematoma.

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Conclusion Fusion in anterior lumbar spine surgery is always challenging. When the choice is made to use cancellous bone, endopelvic iliac bone crest harvesting may be used. Using autologous cancellous bone avoids complications associated with the use of bone substitutes like bone morphogenetic protein. The retroperitoneal approach avoids the usual complications of remote iliac crest harvesting. Paying attention to the neurological anatomy and achieving a good hemostasis might avoid complications of this procedure. This is the first report of in vivo retroperitoneal iliac crest bone harvesting, but more studies are required to determine outcomes of the procedure.

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ACCEPTED MANUSCRIPT 17. Mahato NK. Characterization of cortico-cancellous bone along the iliac crest: focus on graft harvesting. Surg Radiol Anat. 2011;33(5):433-437. doi:10.1007/s00276-010-0752-z. 18. Murray IR, Perks FJ, Beggs I, Moran M. Femoral nerve palsy secondary to traumatic iliacus haematoma--a young athlete’s injury. BMJ Case Rep. 2010;2010. doi:10.1136/bcr.05.2010.3045.

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Figure 1: Magnetic Resonance Imaging showing degenerative disc disease of L5S1 associated with a left posterolateral herniated disc: (left) T2-weighted image (center) T1-weighted image, (right) STIR-weighted image. Figure 2: Retroperitoneal anatomy sketch: (a) lateral femoral cutaneous nerve, (b) Femoral nerve, (Green circle) zone of iliac crest bone harvesting.

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Figure 3: Perioperative view of the harvesting zone: (1) lateral femoral cutaneous nerve, (2) iliac muscle fascia, (3) psoas muscle.

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Figure 4: Perioperative view after dissection of the iliac muscle fascia: (1) lateral femoral cutaneous nerve, (2) inner cortical of the iliac crest, (3) psoas muscle. Figure 5: Perioperative view of the iliac crest cortical window: (1) zone of harvesting, (2) lateral femoral cutaneous nerve, (3) psoas muscle. Figure 6: Interbody cage filled with iliac crest bone graft.

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Figure 7: Postoperative radiograph of L5-S1 at 6 months: (left) front view, (right) lateral view.

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ACCEPTED MANUSCRIPT Highlights

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Anterior lumbar interbody fusion has gained popularity among spine surgeons in the past few years Bone Fusion is always a challenge Autologous cancellous bone graft remains the gold standard Remote iliac crest bone graft harvesting presents some complications Endopelvic iliac crest bone graft harvesting can prevent donor site complications

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