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Objective: The main goal is bilateral microsurgical decompression of the cauda equina using a unilateral over the top approach. The challenge is to achieve decompression with minimal iatrogenic trauma to anatomical structures in the approach region and in the target area., Indications: Degenerative spinal disorders including lumbar central stenosis, lumbar lateral recess spinal stenosis, and foraminal narrowing. This technique is performed in patients presenting primarily with neurogenic claudication, leg or buttock symptoms, heaviness in the legs with or without radicular symptoms, with or without neurological deficits, and comparable MRI findings. There are no limitations regarding number of affected segments or the extent of narrowing., Contraindications: All available conservative treatment modalities not exhausted. Lack of serious neurological deficit., Surgical Technique: Minimally invasive, muscle-sparing and facet-joint-sparing bilateral enlargement of the lumbar spinal canal through a unilateral microsurgical cross-over approach., Postoperative Management: Patients are mobilized early 4-6 h postoperatively. Light sports activities (e.g., ergometer cycling, swimming) are allowed after 2 weeks. The same is true for the return to normal daily or work activities except for heavy physical work (usually 4 weeks out of work). Soft lumbar brace for 4 weeks (optional)., Results: The clinical outcomes are good to excellent. Meta-analyses and large case series report success rates for microsurgical decompression procedures of 73.5-95%. The reoperation rates are low (0.5-10%).

Purpose: The purpose of this study was to assess the mid-term clinical and radiological results as well as patient safety in terms of complication and reoperation rates in patients treated with a novel anterior stand-alone fusion (ASAF) device (Synfix-LR, DePuy Synthes, West Chester, PA, USA) in a cohort of patients with predominant and intractable low back pain originating from monosegmental degenerative disc disease at the lumbosacral junction., Methods: Clinical outcome scores visual analog scale (VAS), Oswestry disability index (ODI) and patient satisfaction rates were acquired within the framework of an ongoing single-center prospective clinical trial. Evaluation of radiological data included segmental and global lumbar lordosis, neuroforaminal height and width. Interbody fusion was assessed from post-operative CT scans. The minimum follow-up (FU) was 12 months., Results: 71 out of an initial 77 patients were available for final FU (92.2 % FU rate) after a mean FU of 35.1 months (range 12.0-85.5 months). The overall results revealed a highly significant improvement from baseline VAS and ODI levels (p < 0.0001). 77.5 % (n = 55/71) of all patients reported a 'highly satisfactory' (n = 37/71; 52.1 %) or a 'satisfactory' (n = 18/71; 25.4 %) outcome; 22.5 % of patients were not satisfied. The overall complication rate was 12.7 % (n = 9/71). Two cases required post-operative revision surgery (2.8 %). Radiographical analysis demonstrated a highly significant increase of segmental lordosis from 16.1° to 26.7° (p < 0.0001). A high rate of solid interbody fusion was confirmed in 97.3 % of all cases (n = 36/37)., Conclusion: The current study delineates satisfactory clinical results following ASAF at the lumbosacral junction. Patient safety was demonstrated with acceptable complication and low reoperation rates. Radiological data demonstrated a significant reconstruction of lordosis at the lumbosacral junction. Solid interbody fusion was achieved in 97.3 % of all cases in a highly selected cohort with optimal predisposition for fusion. ASAF may serve to avoid a variety of negative side effects for a considerable number of patients which, otherwise, would have been candidates for posterior instrumented fusion techniques.

Unlabelled: SURGICAL GOAL: Surgical treatment of dynamic lumbar spinal stenosis and discogenic/arthrogenic low back pain with a new percutaneous interspinous spacer as a therapeutic alternative to more invasive standard procedures., Indications: Central, lateral and foraminal dynamic lumbar spinal stenosis. Discogenic and arthrogenic (facet osteoarthritis) low back pain. Symptomatic, segmental hyperlordosis. Disc degeneration with dynamic (reducible) retrolisthesis. Interspinous pain ('Kissing-Spines')., Contraindications: Osteoporosis. Conus-/Cauda-syndrome. Structural spinal stenosis. Spondylolisthesis (degenerative and/or isthmic). Deformities. Previous posterior operation in index segment., Surgical Technique: Percutaneous, minimally invasive implantation of an interspinous spacer (InSpace ™, Synthes, Oberdorf, Switzerland)., Postoperative Management: Early unrestricted mobilization., Results: Good early results (after 2 year follow-up) in 42 patients with 76% subjective patient satisfaction rate. No approach related complications. Avoidance of the more invasive alternative procedure (decompression, fusion, total disc replacement) in 76.2% of the patients.

Objective: Mono- or bisegmental atraumatic microsurgical approach to the anterior cervical spine between C3 and C7 for total disc replacement., Indications: 'Soft' disc herniations C3-C7 with radicular symptoms. Ossified 'hard' disc herniations with preserved segmental motion. Erosive osteochondrosis with signs of activation (MRI: Modic I changes) and neck pain. Relative Indication: Adjacent segment degeneration following fusion., Contraindications: Thyromegalie. Multiple previous cervical operations. Other implant-specific contraindications: Anterior osteophytes. Range of Motion (ROM) less than 5° (flexion/extension). Segmental collapse. Endplate anomalies (e.g. excessive concavity of cranial endplate). Endplate defects (e.g. Schmorl's nodes). Cervical myelopathy (limited postop evaluation of the spinal canal and spinal cord if implant is made out of ferromagentic materials)., Surgical Technique: Through a 2.5-3 cm skin incision, exposure and splitting of the platysma muscle. Blunt dissection between carotis sheath and esophageus/trachea with preservation of the thyroid blood vessels and the strap muscles (especially m. omohyoideus) and the recurrent laryngeal nerve. Exposure of the anterior disc space between the longus colli muscles after splitting of the prevertebral fascia., Postoperative Management: Mobilisation the same day after 6-8 hrs. Functional postop treatment. Implant-dependent postop soft collar for max. 14 days., Results: Safe and reliable anterior approach with low peri- and postoperative morbidity. In large series (> 900,000 operations) complication rate range between 2-2.9% [20]. Approach related complications are rare: postop Hematoma 0.39%, vascular Injuries (carotid artery, vertebral artery) (0.06%). Vocal cord palsy 0.14%, dysphagia 0.75%. Older age and cervical myelopathy have been identified as significant risk factors. Both situations don't play a significant role in total disc replacement since this type of operation is usually performed in young patients. Moreover, cervical myelopathy is still considered as a relative contraindication for total disc replacement.

Objective: Indirect decompression of the spinal canal and the neuroforamina by means of interspinous process distraction and limitation of extension movements. Reduction of forces acting on the posterior joint structures of a functional spinal unit (posterior anulus, facet joints, intervertebral discs)., Indications: Primary indication: Spinal claudication with improvement of the clinical symptomatology upon taking an inclined position. Secondary indication: Low back pain in the presence of accompanying retrolisthesis. Hyperlordosis Facet joint complaints Annulus lesions with high intensity zones (HIZ) M. Baastrup ("kissing spine"). Adjacent segment preservation (e.g. prophylaxis of recurrent disc herniation after discectomy or topping-off following previous fusion)., Contraindications: Spinal instabilities which prohibit a solid fixation of the implant (e.g. spondylolysis, isthmus fractures, condition following previous (hemi-) laminectomy) Degenerative spondylolisthesis ffl 1st degree. Severe structural narrowing of the spinal canal. Absent dynamic aspect without improvement upon inclination, segmental ankylosis., Surgical Technique: Positioning of the patient in an inclined position. Approximately 4 cm median skin incision, bilateral access with preservation of the supraspinous ligament. Perforation of the interspinous ligament. Following interspinous distraction the adequate size implant is established. Insertion of the interspinous process distraction device (IPD) unit and fixation of the mobile wing unit from the contralateral side. Medial positioning and solid fixation of the implant by connecting the two implant units., Postoperative Management: Lumbar orthosis (optional), otherwise no further support required. Daily living activities immediately after the operation. Physiotherapeutic exercises (optional). Low impact sporting activities from 2nd week after operation, intense/ high impact sporting activities from 6 months postoperatively., Results: Previous studies have reported satisfactory results for interspinous distraction devices for the treatment of dynamic spinal canal stenosis. However, the majority of these previously published studies are based on data with only shortterm follow-up or small patient numbers. In particular, the results of interspinous spacers for the treatment of different indications have not been evaluated separately. Complications and long-term results still need to be established.

Objective: Dynamic intervertebral support of the cervical spine via an anterolateral approach using a modular artificial disk prosthesis with end-plate fixation by central keel fixation., Indications: Cervical median or mediolateral disk herniations, symptomatic cervical disk disease (SCDD) with anterior osseous, ligamentous and/or discogenic narrowing of the spinal canal., Contraindications: Cervical fractures, tumors, osteoporosis, arthrogenic neck pain, severe facet degeneration, increased segmental instability, ossification of posterior longitudinal ligament (OPLL), severe osteopenia, acute and chronic systemic, spinal or local infections, systemic and metabolic diseases, known implant allergy, pregnancy, severe adiposity (body mass index > 36 kg/m2), reduced patient compliance, alcohol abuse, drug abuse and dependency., Surgical Technique: Exposure of the anterior cervical spine using the minimally invasive anterolateral approach. Intervertebral fixation of retainer screws. Intervertebral diskectomy. Segmental distraction with vertebral body retainer and vertebral distractor. Removal of end-plate cartilage. Microscopically assisted decompression of spinal canal. Insertion of trial implant to determine appropriate implant size, height and position. After biplanar image intensifier control, drilling for keel preparation using drill guide and drill bit, keel-cut cleaner to remove bone material from the keel cut, radiologic control of depth of the keel cut using the corresponding position gauge. Implantation of original implant under lateral image intensifier control. Removal of implant inserter., Postoperative Management: Functional postoperative care and mobilization without external support, brace not used routinely, soft brace possible for 14 days due to postoperative pain syndromes., Results: Implantation of 100 cervical Prodisc-C disk prostheses in 78 patients (average age 48 years) at a single center. Clinical and radiologic follow-up 24 months postoperatively. Significant improvement based on visual analog scale and Neck Disability Index. Radiologic improvement of segmental lordosis and mobility in the index segment. Incidence of spontaneous fusion in the index segments 8.75% without significant relation to the clinical outcome.

Objective: The aims of laminoplasty are to expand the spinal canal, to secure spinal stability, and to preserve the protective function of the spine. Preservation of mobility is also a goal of this procedure for multiple-level involvement., Indications: Multisegmental spondylotic myelopathy with a relatively narrow spinal canal (anteroposterior spinal canal diameter<13 mm)., Contraindications: Spinal instability. Kyphotic cervical spine., Surgical Technique: Prone positioning of the patient. Three-point pin fixation device such as Mayfield tongs to secure the head. Midline posterior approach to the spine. Exposure of the laminae and the spinous processes. Opening and expanding of the spinal canal, decompression of the spinal cord. Fixation of the laminae with bone and/or implants., Postoperative Management: Cervical collar for 3-4 weeks., Results: Long-term investigations have shown neurological improvement in 57%, a decrease of range of motion in 36%, and a slight reduction of lordosis without clinical relevance.

Objective: Minimally invasive anterolateral retroperitoneal approach to the lumbar spinal levels L2-L5., Indications: Anterior interbody fusion for the treatment of degenerative disk disease (DDD), degenerative instability, isthmic and degenerative spondylolisthesis, tumors, degenerative scoliosis, fractures, spondylodiscitis, failed back syndrome (pseudarthrosis, post-diskectomy)., Contraindications: No absolute contraindications. Relative contraindications are previous surgeries via a sinistral retroperitoneal approach or a far lateral anatomy of the left iliac common vein covering the lateral annulus of the disk space L4/5., Surgical Technique: A small skin incision over the left abdominal wall is followed by a blunt muscle-splitting approach to the retroperitoneal space and the anterolateral circumference of the lumbar spine. A diskectomy, corporectomy and/or grafting (iliac crest or cage) may be performed for a solid ventral fusion., Postoperative Management: Early mobilization from the 1st postoperative day in all cases of combined ALIF (anterior lumbar interbody fusion)/ posterior instrumentation procedures. Thromboembolic prophylaxis with fractionated heparin. Light meals up until recovery of the first bowel movements. A brace is recommended depending on the type of the intervention for a duration of up to 12 weeks. No limitations for standing, walking or sitting in the immediate postoperative period., Results: Minimally invasive anterior interbody fusion procedures with iliac crest bone graft were performed in 120 patients (average age 56.3 years, range 26-84 years) in combination with a dorsal instrumentation. 16 patients were treated with a double-level procedure. Duration of surgery ranged between 50 and 192 min (mean 102.2 min). The intraoperative blood loss was 67.3 cm(3). At the 6-month follow-up, the fusion rate was 95.6%. No vessel, bowel, kidney or spleen injuries were observed.

Although surgical fusion of the painful degenerating functional spinal unit (FSU) of the lumbar spine has always been a matter of debate, it has become a gold-standard procedure for all cases that lack an alternative treatment. However, a detailed and honest review of the clinical data reveals a considerable number of undesired side effects, complications and poor outcomes. The continuous search for alternative surgical treatment modalities has led to the development of numerous ideas for surgical reconstruction of the anterior and/or posterior column. The term "spine arthroplasty" summarises all procedures that have the goal of restoring function. This article describes the principles of the most current surgical techniques and implants, it points out potential challenges and poses a number of questions that need evidence-based answers before the incorporation of these innovations into surgical routine can be justified.