A Discussion of the Trans1 AxiaLIF

With this novel paracoccygeal, transsacral approach to the L5-S1 interspace, surgeons can now perform a near-total discectomy without violating the annulus or surrounding ligaments, thereby significantly increasing the immediate postoperative stiffness of the motion segment with distraction. In addition, this leaves the area around the disc, great vessels, and neural elements untouched and therefore free of surgical scarring. This makes the technique more attractive for future cases requiring revision or adjacent level surgery.

The AxiaLIF® system was approved by the FDA in January 2005 with market launch also that same month. Its indications include:

• Degenerative disc disease, with or without radicular symptoms
  
• Pseudoarthrosis (unsuccessful previous fusion) and
  
• Grades 1 or 2 spondylolisthesis

Dr Larry Khoo, of the UCLA Medical Center, has been involved in clinical trials of the AxiaLIF® system and is a coauthor of a technical note and 2 case presentations on the system* and has presented their long-term clinical experience with the technique at several national meetings. Here we ask him to provide further insight to this new procedure.

Dr Khoo, what role does patient selection play in using the AxiaLIF®?
Like any spinal surgical procedure, patient selection is critical to ensure the best possible outcomes. Essentially, patients who have mechanical back pain arising from the L5-S1 disc that could otherwise be treated via an anterior lumbar interbody or posterior lumbar interbody fusion are potentially excellent candidates for the AxiaLIF® procedure.

Is there any additional instruction (eg certification from the company, etc.) needed prior to use of the AxiaLIF®? Is there anything you feel should be added, such as length of experience, viewing X number of surgeries by someone previously trained, etc?
Although straightforward and minimally invasive, the AxiaLIF® approach involves anatomy that is often unfamiliar to most spinal surgeons. As such, I would recommend that surgeons wishing to perform the procedure review the local anatomy and study the potential structures at risk. Additionally, it is prudent for surgeons to attend a fluoroscopically-based training course to understand the key steps and nuances of the procedure. If possible, observation of a procedure with an experienced surgeon can also provide further insight and preparation prior to ones first procedure.

Do you have any surgical pearls related to this surgery? (Perhaps especially related to measurement/preciseness of the presacral space?)
Obtaining a wide view lateral lumbar X-ray or CT reconstruction to fully visualize the relationship of the L5 vertebral body and the sacrum is important to be able to anticipate anatomic configurations that would prohibit the AxiaLIF® technique. Furthermore, in cases of spondylolisthesis, it will often be necessary to reduce the spondylolisthesis somewhat to allow for proper placement of the AxiaLIF® cage.

*Marotta N, Cosar M, Pimenta L, Khoo LT. A novel minimally invasive presacral approach and instrumentation technique for anterior L5-S1 intervertebral discectomy and fusion. Technical note and case presentations.