Case Study: Anterolateral lumbar discectomy and
arthrodesis via left flank retroperitoneal approach

A patient with a past medical history of coronary artery disease and severe end-stage renal disease on three times weekly dialysis with intractable back pain, who failed nonoperative management.

MRI and CT of his lumbar spine demonstrated severe degenerative disc space breakdown at L3-L4 and L4-L5 and accordingly they were offered a surgery for discogenic pain. The risks and potential benefits of surgery were extensively explained to the patient.

First and foremost, the risk that pain might not improve with a technically successful and complication free surgery, the risk of bleeding, infection, spinal fluid leakage, nerve injury, thecal sac injury, bowel incontinence and the rare potential risk of iliac vessel and intestinal injury were also explained to the patient.

Disc space narrowing at L3-L4 and L4-L5

Disc space narrowing at L3-L4 and L4-L5

Disc bulge and facet arthropathy

Disc bulge and facet arthropathy

They signed informed consent and were brought to the operating room for the aforementioned procedure. The findings of the preoperative lumbar spine x-ray are shown above and the patients also had a preoperative computerized tomography scan (CT scan) shown above.

The operations performed were an Anterolateral lumbar discectomy and arthrodesis via left flank retroperitoneal approach, L4-L5 anterolateral lumbar discectomy and arthrodesis via left flank retroperitoneal approach, placement of intervertebral biomechanical devices (lordotic 3d printed titanium graft) at L3-L4 and L4-L5 levels, and morselized allograft used to augment intervertebral biomechanical fusion.

The patient was identified by two separate name markers and brought into the operating room and general endotracheal anesthesia was induced. All appropriate lines were placed by the Department of Anesthesiology. Short-acting paralytics were used.

Baseline motor evoked and somatosensory evoked potentials were obtained. A twitch test was obtained showing the absence of all paralytics particularly useful for the L4-L5 level. Care was taken to monitor the patient’s femoral and saphenous nerves. The patient was positioned in the right lateral decubitus position with his left flank pointing upwards.

Their iliac crest was placed on the break of the Steris table. They were secured in place with a 3-inch silk tape in the lateral position after all pressure points had been confirmed padded. The table was jackknifed to allow his iliac crest to fall away from the L4-L5 disc space.

Intraoperative X-ray

Intraoperative X-ray

AP and lateral radiographs were used to position him in a true lateral and AP position with his spinous processes equidistant from the pedicles and with his residual endplates crisp on lateral fluoroscopy. The left flank position was then carefully scrubbed, prepped and draped after two separate transverse flank incisions were marked out overlying the L3-L4 and L4-L5 disc spaces under fluoroscopy.

Gram-positive and gram-negative prophylaxis was administered. The patient was then draped in a standard neurosurgical sterile fashion. Members of the operating team went to wash their hands.

Following draping, a final time-out was carried out identifying the patient and the nature of surgery to be performed, the level of the spine to be operated on, and expected roles and responsibilities of all associated team members. Following completion
of the successful time-out, the left flank incision was infiltrated with 0.25% Marcaine with epinephrine and opened with a #10 blade to commence the case.

The case was begun at the L4-L5 level. Dissection was carried down with monopolar electrocautery to the abdominal fascia, which was opened with monopolar electrocautery in line with the skin incision. Self-retaining Weitlaner retractors were placed.

The fibers of the external and internal oblique musculature were bluntly penetrated with bimanual tonsil clamp dissection. The transversalis fascia was bluntly penetrated. A transversalis dilatation maneuver was carried out using the NuVasive MaXcess
dilatation assembly.

Stimulation was carried out and found to have no neural elements whatsoever in proximity through a transversalis dilatation. The MaXcess dilator was docked at the posterior third of L4-L5 disc space under lateral fluoroscopy and affixed in place with a K-wire.

Serial dilatation was then carried out utilizing the NuVasive MaXcess dilators. A MaXcess retractor was assembled with a blade length of 120 mm and passed over a stacked dilatator assembly in transversalis fashion.

After AP and lateral radiographs confirmed excellent positioning at the posterior third of the L4-L5 vertebral body, the MaXcess retractor was affixed in place with the articulating arm and the interior of the MaXcess retractor was carefully inspected with visual confirmation of no neural elements within the blades.

Stimulation was carried out with an electrophysiologic ball-tip probe. Once we were certain that there were no neural elements within our MaXcess retractor, it was affixed in place at L4-L5 disc space with a shim blade and opened in a craniocaudal and anteroposterior fashion. Time-out was started and the remainder of this case was carried out with care being taken to keep overall retraction time under 15 minutes.

The disc was incised with a bayoneted annulotomy knife and aggressively resected with Cobb elevators. Serial dilatational maneuvers were carried out with bullet type trials so as to fully indirectly decompress the L4-L5 disc space and the exiting L4 nerve roots.

No residual disc was found. Some small fragments of cartilage were resected utilizing pituitary rongeurs. This corresponded with the preoperative vacuum disc phenomenon seen on CT scan. The end-plates were meticulously maintained intact and scraped bare with a ring curette.

Once we were certain that the disc space was prepared for arthrodesis, an 8 x 55 x 22 mm lordotic 3D printed titanium cage was selected from the NuVasive tray and impacted into place at the L4-L5 disc space. Excellent indirect decompression and completion of L4 neuroplasty was seen with separation of the L4 and L5 vertebral bodies.

Once the cage had been inserted to the appropriate depth spanning the entirety of the L4-L5 disc space, it was released from the cage inserter. The area was inspected one final time, copiously irrigated with antibiotic impregnated saline, and the MaXcess retractor blade was then collapsed. The shim was removed and the retractor was removed to allow the fibers of the psoas musculature to fall inwards.

Postoperative X-ray

Postoperative X-ray

Attention was then turned to the L3-L4 disc space. Exactly the same procedures that had been carried out at L4-L5 was carried out at L3-L4 beginning with an incision overlying L3-L4 through the epidermis using a #10 blade, followed by dissection down to level of the abdominal fascia using monopolar electrocautery for hemostasis.

A self-retaining Weitlaner retractor was placed. The fibers of the abdominal fascia were divided with monopolar electrocautery. Bimanual tonsil clamp dissection was utilized to separate the fibers of the external and internal oblique down to the level of the transversalis fascia. Transversalis fascia was bluntly penetrated with tonsil clamps and an identical transversalis dilatation at L4-L5 was carried out with the MaXcess retractor.

Once the dilators had been affixed to the L3-L4 disc space at the posterior aspect with the K-wire and stimulation was carried out ensuring no neural element surrounding this, the MaXcess retractor with the blade length maintained at 120 mm was passed over a stacked dilator assembly and following identical inspection of the L3-L4 disc space with visualization.

The retractor was affixed in place with a shim blade following electrophysiologic stimulation ensuring no neural elements were within our field of view and was opened in a craniocaudal and anteroposterior fashion.

The disc was incised with an annulotomy knife at L3-L4 and then aggressively resected using Cobb elevators to separate the cartilaginous endplates followed by pituitary rongeurs. Once again, the majority of the disc was found to be completely degenerated and collapsed. Some small fragments were sent to Pathology.

Serial bullet trials were impacted into the L3-L4 disc space to complete an indirect decompression and neuroplasty of the exiting L3 nerve roots. The bony endplates were then aggressively prepared with a ring curette following withdrawal of the bullet paddles. An 8 x 50 x 22 mm lordotic CoRoent titanium cage from the NuVasive tray was then directly impacted into L3-L4 disc space to complete the arthrodesis.

Intraoperative X-ray

Intraoperative X-ray

AP and lateral radiographs indicated excellent cage positioning, restoration of lordosis, and indirect decompression throughout. Accordingly, the L3-L4 cage was released from the cage inserter. The area was copiously irrigated with antibiotic impregnated saline and packed with Surgiflo hemostatic matrix product.

The shim blade was then removed. The MaXcess retractor blades were collapsed and the retractor was withdrawn with direct visual inspection of the psoas musculature. No suggestion of psoas hematoma was seen whatsoever.

Accordingly, the case was felt completed with a two-level anterolateral interbody fusion being performed very efficiently at the L3-L4 and L4-L5 levels. The abdominal fascia was reapproximated with interrupted figure-of-eight #0 Vicryl sutures followed
by layered subcutaneous skin closure with inverted interrupted #2-0 Vicryl sutures followed by a running subcuticular #4-0 Monocryl suture to reapproximate both skin edges.

At the close of the case, the patient’s bed was taken out of jackknife position and the patient was positioned supine. No changes in motor evoked and somatosensory evoked potentials were noted throughout. The patient was then extubated uneventfully following reversal of general endotracheal anesthesia.

They were found to be in the same condition in which they entered the operating room, which is to say awake, alert, following commands briskly with full motor powers in his upper and lower extremities. They had no complaints of radicular pain at rest.

The patient followed up in two weeks after the surgery and showed signs of improvement. The patient also then continued to follow up in 4, 6, 8, 12, 24 weeks. In their last office visit the patient stated they were able to do their usual activities.

Postoperative X-ray Saggital View

Postoperative X-ray Sagittal View

Postoperative X-ray

Postoperative X-ray

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Based on 116 reviews
I had an extremely friendly and personalized medical consult with Dr Karkare. Dr Karkare was very knowledgeable and very professional. His communication skills was extremely good and explained my medical condition in very simple words. The office visit was very helpful in understanding my medical condition. Thank you Dr Karkare
Padmanabhan Nagaraj
20:49 25 Sep 23
Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
Anna Acker
22:46 07 Sep 23
Dr Vedant Vaksha had done emergency surgery in 2020 after a traumatic injury.His office at Complete Orthopedics handled the continued care thereafter.Dr V and his staff had been Professional and friendly throughout the process, taking the time to explain all the questions on how to proceed and what to expect.Whenever I needed to speak with Dr V or the office they were a phone call away, without waiting or calling several numbers like in so many other medical offices.The office was accommodating to scheduling to my needs at all times. Dr Vedant Vaksha earned the following5 out of 5 stars, highly recommended.
John Kuey
20:58 05 Sep 23
Dr. Vaksha helped me recover from an injury. I am very thankful that he took the time to explain the best treatment for my injury. Also thankful for the wonderful office staff!
Joseph Castelli
22:30 02 Aug 23
The office is wonderful!… Dr Paresh was very helpful and attentive and made my sister in laws recovery so much better.. Thank you for everything
Jazz Lorenzo
17:48 14 Jul 23
The ladies are very welcoming, the service is great, the doctor is very professional and caring and the building is super clean. I really like to come here, the atmosphere is very friendly... Come and you will love it too.
Joan Carasco
14:41 30 Jun 23
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

You can see my full CV at my profile page.