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Lumbar Spine
Access Surgery
A Comprehensive Guide
to Anterior and Lateral
Approaches
Joseph R. O‘Brien
Jeffrey B. Weinreb
Joseph C. Babrowicz
Editors

123
Lumbar Spine Access Surgery
Joseph R. O'Brien • JeffreyJeffrey B. Weinreb
Joseph C. Babrowicz
Editors

Lumbar Spine Access

Surgery
A Comprehensive Guide to Anterior
and Lateral Approaches
Editors
Joseph R. O'Brien Jeffrey B. Weinreb
Aligned Orthopaedics Department of Orthopedic Surgery
Bethesda, MD, USA The George Washington University
Washington, DC, USA
Joseph C. Babrowicz
Vascular Surgery
Inova Health System
Falls Church, VA, USA

ISBN 978-3-031-48033-1    ISBN 978-3-031-48034-8 (eBook)

https://doi.org/10.1007/978-3-031-48034-8

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
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Acknowledgements

I would like to acknowledge Claire van Ekdom and Gabrielle Heller for their
thoughtful and diligent work on this textbook. I have no doubt that they will make
incredible surgeons one day. I am grateful to my fellow editors: Joe Babrowicz, who
has been my co-captain in many operating rooms, and Jeff Weinreb, who is growing
into a leader in our field. I am grateful to all the authors of this textbook. Through
our collaboration, we have strengthened the bridge between surgical specialties and
made these surgical techniques more accessible to patients. My greatest apprecia-
tion is for my wife, Janet, and my sons, Brad and Alex.
—Joseph R. O’Brien

To my wife Jessie, thank you for supporting me throughout training and for your
indispensable advice.
To my sons Seth and Elias, thank you for making every day exciting and remind-
ing me of the important things in life.
To my family, friends, and mentors, thank you for everything.
—Jeff B. Weinreb

Thank you to my many spine surgery colleagues for the professional relationships
and friendships we have developed over the years. Also, thank you to the many
patients we have had the privilege to care for together. Finally, and most impor-
tantly, thank you to my beautiful supportive wife and amazing, brilliant children.
Surgery as a profession is not easy on the surgeon or those around them. It is by the
unending support of family that we can do this to our best ability.
—Joseph C. Babrowicz

v
Contents

Part I History and Rationale of Lumbar Spine Access Surgery

1 
Overview of Anterior Lumbar Spine Access Surgery��������������������������    3
Emile-Victor Kuyl, Thomas Hong, Tyler Pease, and Jeffrey B. Weinreb
2 History and Evolution of Anterior Lumbar Spine
Access Surgery ����������������������������������������������������������������������������������������   17
Neil Kelly, Francis C. Lovecchio, and Sheeraz A. Qureshi
3 
Rationale for Anterior Lumbar Spine Surgery������������������������������������   29
Lauren E. Matteini

Part II Preoperative Care for Lumbar Spine Access Surgery

4 
Patient Selection for Anterior Lumbar Access Surgery ����������������������   35
Rebecca L. Kelso
5 
Imaging Review for Anterior Lumbar Access Surgery������������������������   43
Devin Zarkowsky, Jonathan E. Schoeff, and Aparna Baheti
6 
Informed Consent for Anterior Lumbar Access Surgery��������������������   49
Steven E. Raper

Part III Intraoperative Care for Lumbar Spine Access Surgery

7 Patient Positioning and Marking for Anterior Lumbar
Access Surgery ����������������������������������������������������������������������������������������   61
Sashi Kilaru and Brian Kuhn
8 Adjunctive Measures: Neuromonitoring, Perfusion
Monitoring, Foley������������������������������������������������������������������������������������   69
David Y. Zhao and Faheem A. Sandhu
9 
Incision Choice for Anterior Lumbar Access Surgery ������������������������   83
Parth K. Patel and Jeffrey B. Weinreb

vii
viii Contents

10 
ALIF Retractor Options for Anterior Lumbar Access Surgery����������   91
Timothy R. Rasmusson

Part IV Operative Technique for Lumbar Spine Access Surgery

11 Mini-Open Anterior Retroperitoneal Approach ����������������������������������   97
Brian A. Kuhn, Joel Hlavaty, and Sashi Kilaru
12 
Anterior Transperitoneal Approach to the Lumbar Spine������������������ 117
Doru I. E. Georgescu and Benjamin C. Dorenkamp
13 Biomechanics of Anterior, Oblique, and Lateral
Approaches to the Lumbosacral Spine�������������������������������������������������� 131
G. Bryan Cornwall, William R. Walsh, Ralph Mobbs,
Claire van Ekdom, and Joseph O’Brien
14 Direct Lateral Transpsoas Approach ���������������������������������������������������� 145
Ryan DenHaese
15 Adjunctive Analgesia Methods �������������������������������������������������������������� 153
Ashley Nguyen and Trevor Myers

Part V Intraoperative Complications for Lumbar Spine

Access Surgery
16 Arterial Complications���������������������������������������������������������������������������� 163
Amanda L. Chin, Jesus G. Ulloa, and Jonathan Schoeff
17 Venous Complications������������������������������������������������������������������������������ 169
Daniel H. Newton, Natalie Wall, Jonathan Schoeff,
Devin Zarkowsky, and Aparna Baheti
18 Ureteral Injury ���������������������������������������������������������������������������������������� 185
Daniel Mecca, Santosh Shanmuga, and Robert Mordkin

Part VI Postoperative Care for Lumbar Spine Access Surgery

19 Pain Management������������������������������������������������������������������������������������ 193
Nirguna Thalla, Andrew Wondra, and Mehul J. Desai
20 Venous Thromboembolic Issues�������������������������������������������������������������� 209
Philip Parel, Bruce Seibold, Matt Walker, Ryan Smith,
and Jeffrey B. Weinreb
21 Wound Complications����������������������������������������������������������������������������� 217
Ama J. Winland and Paul W. White
22 Fluid Collections�������������������������������������������������������������������������������������� 229
Conor P. Lynch, Elliot D. K. Cha, and Jonathan A. Myers
23 
Ileus Prevention and Management�������������������������������������������������������� 237
J. R. Salameh
Contents ix

Part VII Additional Considerations for Lumbar Spine

Access Surgery
24 
Revision Anterior and Lateral Spinal Access Surgery ������������������������ 249
R. Mark Hoyle
25 Anterior Lumbar Spine Access Surgery in Ambulatory
Surgery Centers and Outpatient Settings���������������������������������������������� 259
Harvinder Bhatti, Navraj S. Sagoo, and Willis Wagner
26 Preoperative Considerations for Anterior Lumbar
Interbody Fusion Revision���������������������������������������������������������������������� 271
Philip C. Nelson and Stephen D. Lockey
27 Anterior and Lateral Interbody Techniques for
Revision Lumbar Fusion ������������������������������������������������������������������������ 277
Edward Fakhre, Stephen D. Lockey, Seleem Elkadi,
and S. Babak Kalantar
28 
Understanding Spine Biologics for the Access Surgeon ���������������������� 291
Jay Shah, Naina Rao, and Rahul G. Samtani
29 
Lumbar Access Surgery Performed by a Spine Surgeon �������������������� 301
Jeffrey B. Weinreb and Joseph R. O’Brien
30 
Prone Lateral Interbody Fusion ������������������������������������������������������������ 307
Leland C. McCluskey Jr and Mathew Cyriac
31 Minimally Invasive Thoracolumbar Approaches with
Diaphragm Preservation ������������������������������������������������������������������������ 321
Katriel E. Lee, Robert F. Rudy, and Juan S. Uribe
32 Minimally Invasive Trauma Corpectomy of the
Lumbar Spine������������������������������������������������������������������������������������������ 329
Hao-Hua Wu, Steven Wright, Michael Flores, Kelsey Brown,
Yashar Javidan, and Alekos A. Theologis
33 Access to L1–L2 and L2–L3�������������������������������������������������������������������� 341
Karim A. Shafi, Junho Song, Brooks Martino,
and Sheeraz A. Qureshi
34 
Anterior Approaches to the Cervical Spine ������������������������������������������ 359
Michael Hammer, Claire van Ekdom, Brian Panish,
and Eric Feuchtbaum
Index������������������������������������������������������������������������������������������������������������������ 371
 Part I
History and Rationale of Lumbar Spine
Access Surgery
Chapter 1
Overview of Anterior Lumbar Spine
Access Surgery

Emile-Victor Kuyl, Thomas Hong, Tyler Pease, and Jeffrey B. Weinreb

Introduction

In appropriately selected patients, modern lumbar fusion surgery is considered the

gold standard for treatment of multiple spinal pathologies and can result in a signifi-
cant improvement in pain and disability scores [1–4]. An armamentarium of tech-
niques, approaches, and instrumentation exists to help contemporary surgeons treat
patients effectively and safely. Interbody fusion is a technique that allows direct and
indirect decompression, a favorable biologic fusion environment, and the ability to
correct deformity. Interbody fusions are often classified by the approach taken to
place an interbody device and include anterior lumbar interbody fusion (ALIF),
posterior lumbar interbody fusion, oblique lumbar interbody fusion, transforaminal
lumbar interbody fusion, and lateral lumbar interbody fusion (LLIF) [5]. However,
long before various anatomical approaches to lumbar surgery were extensively
studied, physicians and scientists were puzzled over how to treat diseases of the
spine when conservative or nonsurgical management failed.

E.-V. Kuyl · T. Hong

School of Medicine and Health Sciences,
The George Washington University, Washington, DC, USA
T. Pease (*)
Department of Orthopedic Surgery, University of Maryland School of Medicine,
Baltimore, MD, USA
J. B. Weinreb
Department of Orthopedic Surgery, University of Maryland School of Medicine,
Baltimore, MD, USA
Department of Orthopedic Surgery, The George Washington University, Washington, DC, USA

© The Author(s), under exclusive license to Springer Nature 3

Switzerland AG 2023
J. R. O’Brien et al. (eds.), Lumbar Spine Access Surgery,
https://doi.org/10.1007/978-3-031-48034-8_1
Visit https://textbookfull.com
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4 E.-V. Kuyl et al.

A History of the Anterior Approach to the Lumbar Spine

In 1779, a surgeon by the name of Percivall Pott described a complication of

Mycobacterium tuberculosis infection as spastic paralysis of the lower limbs associ-
ated with abnormal curvature and deformity of the spine (later to be termed Pott
disease) [6, 7]. Failing to resolve with conservative treatment or medical therapy, he
recommended draining paraspinal tuberculous abscesses via a surgical incision to
drain pus and decompress the spinal canal [7]. When direct surgery of the spine
could finally be considered in 1828 after the completion of the first successful lami-
nectomy, only posterior approaches existed, but Pott disease abscesses were largely
located on the anterior surface of the spine. In 1906, Müller performed the first suc-
cessful anterior approach to the lumbar spine but failed to achieve good outcomes—
resulting in the abandonment of the procedure altogether [8]. A definitive ventral
approach would finally be described by the Japanese orthopedic surgeon Hiromu Ito
in 1934 [9]. By accessing the abscess cavity with an extraperitoneal approach, Ito
was able to perform a fusion to stabilize the spine after the abscess was resected [9].
As antituberculosis drugs became more efficient in treating Pott disease, the indica-
tion for anterior/lateral lumbar surgery became less prevalent for this infectious
disease [6].
From 1930 to 1960, surgeons continued to adapt and perfect the anterior approach
for various pathologies of the lumbar spine including spondylolisthesis and discec-
tomy [6, 10–13]. As posterior approaches began to be utilized for fusion of spondy-
lolisthesis, Norman Capener described a theoretical anterior operation in 1932
where bilateral grafts were placed in the anterior-posterior direction into L5 and S1
to fuse spondylolisthesis. Notably, Capener advised against his own approach given
the theoretical risks [14]. In 1933, Burns developed and performed an anterior L5–
S1 fusion using bone drilling and grafting on a 14-year-old boy with traumatic
spondylolisthesis, not unlike a modern-day reverse-Bohlman technique [10]. A few
years later in 1936, Mercer would perform and modify the Burns technique to
include transperitoneal discectomy, graft, and screw placement that closely approxi-
mates a modern ALIF technique (Fig. 1.1) [11]. Due to difficulties with posterior
visualization of lumbar disc herniations, Lane and Moore described a transperito-
neal multilevel ALIF for disc herniations with good results [12]. In 1957, Southwick
and Robinson described a retroperitoneal anterolateral approach that was a modifi-
cation of the general surgery approach generally used for sympathectomy but was
also noted to provide excellent exposure of L4 and L5 [13]. Their modification
required a 12th rib resection for visualization of L1–L5 and was noted to provide
excellent access for psoas abscess debridement and bone grafting [13]. A few years
later in 1960, Harmon described his experience with an anterior extraperitoneal
lumbar approach for disc herniation with fusion using autologous, allogeneic, and
xenogenic bone grafting with a 98% fusion rate with autologous grafting [15]. From
the 1960s onwards, improvements in ALIF involved newer instrumentation and
techniques that made the procedure less traumatic and more minimally invasive
including Fraser’s muscle-splitting approaches in 1992 (which limited disruption of
1 Overview of Anterior Lumbar Spine Access Surgery 5

Fig. 1.1 The original description of the Mercer technique for transperitoneal discectomy and bone
grafting (open domain under CC BY 4.0) [11]
6 E.-V. Kuyl et al.

the abdominal wall) [6, 16–19]. The mini-open approach (a modified version of
Fraser’s muscle splitting approach) was proposed by Mayer in 1997 and eventually
outperformed laparoscopic approaches—eventually leading to the development of
lateral extraperitoneal approaches which are often utilized today [20, 21].

Relevant Anatomy of the Lateral and Anterior Lumbar Spine

A detailed understanding of the relevant osseous, vascular, urological, and neural

anatomy for anterior or lateral spine surgery is essential for optimal outcomes and
intraoperative patient safety. The lumbar spine consists of five vertebrae (L1–L5)
situated caudal to the thoracic vertebrae and cranial to the sacrum. Between each
vertebral body lies an intervertebral disc that serves to mitigate compression forces.
Posterior elements of each vertebra consist of pedicles, lamina, spinous processes,
and facet joints—all of which are not typically visualized during anterior approaches
to the spine. Depending on the specific approach, the entire lumbar spine can be
visualized anteriorly, while the location of the diaphragm proximally and the lum-
bar plexus and iliac crest distally may limit a lateral approach without modifications
like rib resection or a transthoracic component. During the anterior approach, the
muscle layers of the abdominal wall are separated and therefore are not violated.
Lateral approaches require passing anterior to or through the psoas muscle, which
originates from the transverse processes and lateral vertebral bodies (L1–L5) and
inserts into the femur after passing under the posterior inguinal ligament [22].
The aorta and inferior vena cava (IVC) lie anterior to the vertebral bodies and
split into the common iliac arteries and veins, respectively. This bifurcation typi-
cally happens at the L4 level. When patients lay supine, the left common iliac ves-
sels can be at increased risk of damage [23]. Placing patients in the lateral decubitus
position instead can cause the abdominal contents and vessels to shift out of the
operative field due to gravity and help mitigate some of the risks [24–26]. The aorta
tends to lie ventrally to the IVC and slightly to the left. For approaches that require
dissection at L4–L5, surgeons should be aware of one or more branches of the ilio-
lumbar vein that crosses the psoas muscle from the IVC. Lumbar arteries originat-
ing from the aorta run below the inferior endplate of each superior intervertebral
disc space. Segmental and spinal branches pass around each vertebral body and
enter the dura near the dorsal root ganglia. The venous system of the lumbar spine
runs parallel to the arterial system. Drainage of the spine occurs through a large
valveless venous plexus (Batson’s). Intradural venous drainage passes from radicu-
lomedullary veins into anterior and posterior spinal veins [22].
During lateral and anterior approaches to the lumbar spine, careful attention
must be paid to the kidneys and ureters, which lie close to the spine in the retroperi-
toneal space. The left kidney aligns itself slightly more caudal from T11–12 to
L2–L3, whereas the right kidney typically rests between T12–L1 and L3–L4. From
the right kidney, the right ureter travels anteromedially along the right aspect of the
1 Overview of Anterior Lumbar Spine Access Surgery 7

IVC and crosses the external iliac artery before entering the pelvis. The left kidney
ureter crosses instead over the common iliac artery [22].
The spinal cord terminates as the conus medullaris at the L1 or L2 level and
continues as the lumbar and sacral nerve roots, known as the cauda equina. In the
lumbar spine, nerve roots exit below their corresponding pedicle and form the lum-
bar plexus. From L1, the ilioinguinal and iliohypogastric nerves pass laterally and
anteriorly into the abdomen. From L1 and L2, the genitofemoral nerve exits the
ventral psoas and divides into the femoral and genital branches, lateral to the com-
mon and iliac arteries. The obturator and femoral nerves arise from L2–L3 and
L4–L5, respectively, and comprise the largest branches of the lumbar plexus. Since
the obturator nerve lies medially to the psoas, it is not considered to be at much risk
compared to the femoral nerve during lateral transpsoas approaches [22].

Common Pathologies

Intervertebral discs are composed of an outer annulus fibrosus and an inner nucleus
pulposus [27]. The annulus fibrosus is made up of type 1 collagen fibers that pass
obliquely between vertebral bodies, while the nucleus pulposus is a gel-like sub-
stance made of proteoglycan, water, type II collagen, and elastin fibers [28].
Degeneration of intervertebral discs in the lumbar spine can be a causative factor for
lower back pain and contribute to motion segment instability, and compression of
the neural elements.
Degenerative disc disease (DDD) is a common condition that increases with age
and is most commonly seen in the lower lumbar spine [29]. The main cause of disc
degeneration is thought to be excessive mechanical loading [30], which can disrupt
the structure of the disc and trigger a series of irreversible cell-mediated responses
that cause further damage [31]. Injured discs show increased levels of catabolic
cytokines and matrix metalloproteinases (MMPs), which lead to scar formation and
renewed matrix turnover [32]. With aging, the overall proteoglycan and water con-
tent of the disc decrease, leading to a relative increase in collagen content [33].
Genetics also play a major role in the development of DDD, accounting for 74% of
the variability in twin studies [34], and several individual genes have been associ-
ated with disc degeneration, including those for type IX collagen, aggrecan, vitamin
D receptor, MMP3, and cartilage intermediate layer protein [28, 35–39]. Isolated
disc resorption is a subtype of DDD that is characterized by the breakdown of the
nucleus pulposus. This can cause the disc to lose its height and ability to absorb
shock, leading to pain and other symptoms [40, 41]. Spondylosis refers to the
degeneration of spinal structures, including the intervertebral discs, facet joints, and
ligaments. It can result in the development of osteophytes and a reduction in the
disc’s height, which can put pressure on the spinal nerves and cause pain, numbness,
and weakness [42, 43].
Motion segment instability, or lumbar instability, is abnormal mobility in the
lumbar motion segment, a reference to two adjacent vertebrae in the lumbar spine
8 E.-V. Kuyl et al.

connected by three joints—the left and right zygapophyseal (facet) joints and the
intervertebral discs [44, 45]. Motion segments in the spinal column are made stable
by the interactions between the spinal column and its ligaments, the central nervous
system, and the various muscles supporting the spine, including the multifidus,
transverse abdominis, erector spinae, and quadratus lumborum muscles [46–48].
Motion segment instability can involve conditions such as spondylolisthesis, where
one vertebra slips forward or backward in relation to the adjacent vertebra, and
scoliosis, a multidimensional spinal curvature [49–51].

Indications

Indications for an anterior approach to the lumbar spine include DDD, deformity,
trauma, infection, tumor, pseudarthrosis, and motion segment instability [52–54].
The decision may depend on patient characteristics such as age, comorbidities, and
spinal pathology.
Placement of an interbody device can help restore disc height, decompress nerve
roots, and stabilize the affected segment, making it a safe and effective surgical
option for DDD [5]. ALIF can also be an effective treatment for motion segment
instability and patients with spondylolisthesis have demonstrated good outcomes
with ALIF [55–58].
Regarding other pathologies, ALIF can also be a viable option for patients with
adjacent segment disease, which is the development of symptoms at levels adjacent
to a previous spinal fusion [59, 60]. Pseudarthrosis, which is the failure of a previ-
ous fusion, may also be treated with ALIF [61–63]. Recurrent lumbar disc hernia-
tion and post-discectomy collapse can be treated with ALIF but may also require
additional surgical intervention [52, 64]. Instability after laminectomy or posterior
decompression, spinal osteotomy, and kyphosis may also be addressed with ALIF
[52, 65, 66].
Contraindications for ALIF may include osteoporosis, infection, and unfavorable
anatomy [52]. Osteoporosis can increase the risk of implant failure and may make
it difficult to obtain adequate fixation. Infection can lead to implant failure, and
existing posterior instrumentation may need to be removed or revised to accommo-
date the procedure to allow for anterior mobilization. Consultation with the vascular
or general surgery team is critical in the context of relative contraindications includ-
ing previous abdominal surgery with adhesions, unfavorable vascular anatomy, and
severe peripheral vascular disease [67]. It is also essential to evaluate other spinal
areas to determine if they require surgical intervention and if an anterior approach
is the best option.
1 Overview of Anterior Lumbar Spine Access Surgery 9

Risks of Anterior and Lateral Lumbar Surgery

During an anterior approach there is limited direct visualization of the neural ele-
ments and the risk of dural laceration is minimal [68, 69]. However, major concerns
remain for serious complications such as vascular injury and retrograde ejaculation
[70–78]. Other complications include infection, wound dehiscence, hernia, seroma,
ileus, bleeding, thrombosis/embolism, and injury to the bowel, nervous, and genito-
urinary structures [79–81].
Vascular complications are a potentially devastating risk of the anterior approach.
Although in some cases the spine surgeon may feel comfortable addressing vascular
injuries, these complications often require the assistance of a vascular approach
surgeon and consideration must be paid to the local medicolegal environment [74,
79, 82]. The rate of vascular injury has been reported as greater than 10% in some
studies and is a major risk factor for deep vein thrombosis [80, 83, 84]. Intraoperative
vascular injury greatly increases procedure time, length of stay (LOS), and readmis-
sion rate, placing patients at risk of additional complications and longer recovery
time [84, 85].
Retrograde ejaculation (RE) in the context of an anterior approach is poorly
described in the literature, making it difficult for approach surgeons to counsel their
male patients [86–88]. As surgeons have shifted towards retroperitoneal approaches
and away from a transperitoneal approach, damage to intraperitoneal structures has
decreased, but injury to major vasculature and the hypogastric plexus remains a
major risk [89, 90]. RE typically occurs secondary to damage of the hypogastric
plexus which crosses the prevertebral space near L5–S1. The consequent decrease
in sympathetic function permits relaxation of the internal bladder sphincter during
ejaculation, allowing retrograde flow of ejaculate into the bladder [86]. Some stud-
ies have also implicated the use of bone morphogenetic protein 2 (BMP2) during
ALIF with the development of RE [72, 82, 86, 87, 91]. Surgeons should be prepared
to discuss this potential complication with their male patients, including preopera-
tive sperm banking, as well as the potential for possible self-resolution.

 ontemporary Utilization of Anterior Approach

C
and Future Directions

The anterior approach to lumbar spine surgery has undergone significant changes in
utilization over the last few decades. Over the past 10–15 years, there has been a
significant increase in ALIF/LLIF utilization in older patients with more comorbidi-
ties and higher American Society of Anesthesiologists classifications [92]. Within
the same time frame, the utilization of ALIF/LLIF in the smoking population has
dropped [92]. Despite the increased use of the approach in higher-risk patients,
morbidity has significantly decreased [92, 93]. This may be due to a rise in the use
of tranexamic acid, granting spine surgeons greater degrees of hemostatic control
10 E.-V. Kuyl et al.

[94–96]. The decrease in LOS over the past decade is likely greatly influenced by
new applications of enhanced recovery pathways, multimodal anesthesia, and
opioid-­sparing/regional analgesic techniques [97–101]. Additionally, there has been
increased adoption of BMP to enhance osseointegration and improve fusion rates in
ALIF since its approval in 2002 by the U.S. Food and Drug Association [102].
The anterior approach has also evolved to offer a range of surgical techniques,
including more traditional retroperitoneal or transperitoneal approaches and newer
oblique and lateral approaches. In the anterior retroperitoneal or transperitoneal
approaches, an incision is made on either the right or left side between the rectus
abdominis muscle and the peritoneum while the patient lies supine [103]. The
oblique and lateral approaches place the patient in a lateral decubitus or prone posi-
tion, and the spine is accessed retroperitoneally. It is possible that an anterolateral
approach is preferred for surgeons as it may avoid mandatory involvement of access
surgeons [24, 67, 103]. In recent times, LLIF in the prone position has gained popu-
larity because it allows for simultaneous posterior instrumentation, decompression
procedures, and corrective osteotomies in a more familiar position [104].

Conclusion

Anterior access via an anterior or lateral approach is commonly utilized in modern

spine surgery. Initially described for treating Pott disease, anterior approaches have
since been adapted for the treatment of spondylolisthesis, lumbar disc herniations,
malignancy, degenerative conditions, trauma, and deformity. Safe and effective sur-
gery through anterior exposure requires a multidisciplinary team of providers who
should be aware of the unique anatomy, pathophysiology, indications, and associ-
ated risks. With the further development of variant approaches, enhanced recovery
pathways, biologics, and instrumentation technologies, the anterior approach may
continue to reshape surgical treatment for spinal pathologies.

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1 Overview of Anterior Lumbar Spine Access Surgery 15

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Chapter 2
History and Evolution of Anterior Lumbar
Spine Access Surgery

Neil Kelly, Francis C. Lovecchio, and Sheeraz A. Qureshi

Introduction

From the earliest reports of nonoperative management of spine disorders in the

Edwin Smith papyrus to the first successful spine surgery performed in 1829 by
Alban Smith, there has long been a culture of forward thinking in spine care [1, 2].
Spine surgery has advanced tremendously in a relatively short period of time and
has revolutionized the care for a myriad of spine conditions. This revolution in care
is due in part to expanding modes of access to the spine. Over time, the field has
evolved to include anterior, lateral, and oblique approaches to surgical treatments of
the spine. With each approach now recognized for distinct advantages and indica-
tions, the purpose of this chapter is to highlight the history and evolution from
posterior to anterolateral surgical approaches of the spine (Fig. 2.1).

N. Kelly · F. C. Lovecchio
Weill Cornell Medical College, New York, NY, USA
S. A. Qureshi (*)
Weill Cornell Medical College, New York, NY, USA
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA

© The Author(s), under exclusive license to Springer Nature 17

Switzerland AG 2023
J. R. O’Brien et al. (eds.), Lumbar Spine Access Surgery,
https://doi.org/10.1007/978-3-031-48034-8_2
 18

Fig. 2.1 Timeline of significant events in the history of anterolateral lumbar spine access
N. Kelly et al.
2 History and Evolution of Anterior Lumbar Spine Access Surgery 19

History of Anterior Lumbar Spine Access

Spine surgery has been performed for nearly two centuries, the first third of which
was spent exclusively using a posterior surgical approach. The first alternatives to a
posterior approach were developed in the early twentieth century to improve the
treatment of Pott’s disease. In the following decades, the use of anterior lumbar
spine access would continue to expand to include new indications, instrumentation,
and minimally invasive techniques. Now, modern anterior approach techniques are
recognized for advantages which include direct access and wide exposure to the
anterior spinal column, ease of insertion of large implants, avoidance of paraspinal
muscle dissection and denervation, enhanced indirect decompression of interverte-
bral neural foramen, and improved fusion rates and sagittal profile [3]. Additionally,
rates of complications associated with the anterior approach, such as vascular injury,
ileus, and retrograde ejaculation, are relatively low when performed by experienced
surgeons [4].

A Need for Anterior Access to the Lumbar Spine

Although the posterior approach has been the mainstay since the inception of spine
surgery, it has several key limitations which spurred initial interest in an alternative
anatomical access route. For example, posterior lumbar dissection leads to damage,
detachment, and denervation of the paraspinal musculature, while access to the disc
space is limited by the retraction of the neural elements [5]. Pott’s disease was the
original impetus for finding a new approach to the spine.
First referenced in ancient medical texts between 3200 and 1800 BCE and later
formally described by Percival Pott in 1779 CE, Pott’s disease (i.e., tuberculous
spondylitis) is osteomyelitis of the spine which develops from a Mycobacterium
tuberculosis infection [6]. Infection spread also commonly affects the nearby para-
spinal and psoas muscles, resulting in tubercular abscesses. In fact, Pott’s observa-
tion that drainage of superficial paraspinal abscesses led to neurologic improvement
spurred interest in developing a strategy to drain deeper, anterior abscesses, which
were difficult to access surgically via a posterior approach [7]. Among the first alter-
natives to a posterior approach was costotransversectomy reported in 1894 by
Menard and the anterior transperitoneal approach reported in 1906 by Müller [8, 9].
Shortly thereafter, posterior fusion techniques to prevent postinfectious kyphosis
were developed independently by Albee and Hibbs in 1911 [10, 11]. In 1934, Ito
combined and expanded the work of Müller, Albee, and Hibbs [12]. By performing
an anterior extraperitoneal approach through which deep and anterior abscesses
could be removed and fusion of the affected segments could be performed, Ito
developed the first definitive anterior surgical treatment for Pott’s disease [12].
Surgical improvements and alternative approaches to treat Pott’s disease were pur-
sued through 1960 when Hodgson et al. employed the use of anterior, lateral, and
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something very rude as he passed and put his tongue out at me. But
what did that boy matter? What did the whole world matter now? I
stood as if I was dazed, and might have stood there longer if my
little brother had not begun to cry. That made me conscious of a
terrible shame and of a sharp pain in my arm, and I felt that the
child was heavy. I noticed also that it was nearly dinnertime and
knew that my mother was waiting for me. I called my little sister,
who had been ceaselessly picking up stones from the ground, and,
avoiding the crowded streets as much as I could, I made for home.
My mother was standing in front of our gate, and looking searchingly
up and down the street. Having caught sight of us she came to meet
me and took the boy from my arms.
"Where have you been?" she asked; "you look hot."
"I am terribly hungry," I said, and slipped into the house while my
mother followed slowly with the children. Soon afterwards we sat
down to dinner, and my mother was busily preparing the food for the
little ones. I helped her a little, handing her a fork, a spoon, or
anything that was beyond her reach. After a pause of some length
my mother said: "Did you see any of your friends?"
"No," I replied without hesitation, hastily swallowing a large
mouthful. I could feel how the blood rushed back into my cheeks,
not because I had told a lie (I often told lies), but because I heard
the cruel words hum in my head again.
"You are getting quite a big girl now," my mother continued after a
pause, "and you could make yourself very useful at home, if it were
not that you have to go to school again."
A silly, incomprehensible fear immediately gripped me. Until that
moment I had not thought of having to go to school again. "Mother,"
I said, and lifted up my arms imploringly, "pray do not send me to
school again."
"You are getting more and more lazy; you ought to be ashamed of
yourself."
"So I am," I answered rudely.
My mother got up from the chair suddenly, and I thought that she
was going to beat me for such an impudent answer. But she did not
beat me; she bent down to one of the little ones and, with her face
turned away, told me to clear the things from the table.
During our stay at Hohenburg I had scarcely learnt anything, and
when my mother took me to school the next day, the headmaster
found that out at once. He declared that I was not by any means
able to join the fourth class, but must take up the third class once
more. My mother never understood why I looked so exceedingly
happy when the headmaster told me that.... I was now at least
spared the company of those "two." The mere thought of them
became unbearable to me. I decided never to go near them again,
and to avoid everything that could bring me into touch with them.
But if it happened now and then that we met during the recreation,
which we had all to spend out in the garden, I quickly looked in
another direction. Hilda and Leopoldine were together almost
constantly, and it was only sometimes that I met Hilda by herself.
She passed me then with eyes cast down, but inwardly I felt that
she loved me still and only did not speak because she was forbidden
to do so. At such moments I loved her more than I had ever done
before; I even thought of walking up to her and speaking to her
again. But whenever I wanted to put that thought into action, my
feet refused to move; I stood like one rooted to the ground, and all
that I was able to do was to look after her and watch how she went
away slowly, sometimes very slowly.
One day I heard from a schoolfellow that Hilda had been sent to
Krems in order to join a seminary for school-teachers. After that I
felt as lonely and wretched as a child has ever felt. It is true that she
had never spoken to me again, but her figure was the most vivid
picture in my mind, and to watch her secretly from behind a quiet
corner had filled my heart with a happiness strangely sweet and
sad.... "Why," I thought angrily—"why was Hilda sent away? why not
Leopoldine?" Whenever we met, her face wore a malicious smile, the
very smile it had worn when she had said those terrible words to
me. I began to hate her, and prayed every night to God that He
might cause her mother (she had no father) to be locked up too. But
her mother never got locked up. One day when I accidentally passed
their house I saw a lot of labourers busying themselves over it, and
when I, driven by curiosity, stole by in the dusk another evening, the
house looked more beautiful than ever. Henceforth Leopoldine was
dressed in very pretty clothes, and the smile on her face grew more
and more malicious.
I had no pretty clothes, and my parents had no pretty house. My
father's business went from bad to worse, and he himself grew to be
taciturn and did not speak to us children for weeks. Another little
brother had arrived too, and my mother worked incessantly. I
assisted her by minding the children and carrying about the baby,
but I did not like doing it and felt utterly unhappy.
My brother had been sent to the High School at Krems because my
mother had set her heart upon it. My father used to point out to her
that he was hardly able to afford the expense, but my mother
responded that Charlie was the cleverest boy that could be found,
and that it would be an everlasting pity to bring him up otherwise.
After these explanations my father was silent, but I am perfectly
convinced that he would have much preferred to apprentice my
brother to some trade. Charlie came home every Sunday and left
again on the Monday. On these visits he treated us all in a most
conceited manner, and even declared one day that country-folk were
fools. In spite of that I used to see him off each time he went away,
and felt like crying when the train had steamed out of the little
station.
 Chapter IV
Without being able to give a satisfactory explanation of my feelings I
grew unhappier from day to day, and at times when I was most sad
I became conscious of a story in my head, and wrote it down, but
tore the paper up again without ever showing it to anybody. My
dearest wish was to be sent to Krems, so that I also might join the
seminary for school-teachers, and I wondered in my heart of hearts
whether Hilda would speak to me then. As a matter of course that
secret longing was in vain.
The time when I was to leave school approached at last, and I
hailed that event with great delight, for I rejoiced at the thought that
in the future I should not be compelled to meet Leopoldine. I had
time to spare now, but I did not help my mother with her housework
any more than before. I did not like staying at home, and wanted to
go away. But whenever I mentioned the subject my mother declared
that she could not spare me yet, and that in any case I was too
young to face the world alone. I felt exceedingly impatient, grew
very discontented, silent towards my mother and my two bigger
sisters, and spent, in spite of the noisy company around me, a very
lonely life. My poems were the only joy I had; they used to come
again and again, but I kept them as secret as before.
During the course of these events I had entered on my fifteenth
year, and into my discontent and restlessness there began to twine
themselves the thoughts, the dreams, and the wishes of a girl of my
age. I knew that all the girls who had left school with me were
already associating with young men, and I wondered which of the
young men of the village I could love. But I soon discovered that
there were none at all who pleased me, because they were all very
rude, and constantly alluding to things which made me blush.
Contempt and disgust were the only feelings they aroused within
me, and it was clear to me that Langenau did not hold the hero of
my dreams.
The young men themselves hated me. Whenever they spoke to me I
responded shortly and tartly, and if any of them tried to pinch my
arm or stroke my cheek, I stepped back and uttered an angry
exclamation. After that they used to say that I had better not be so
affected, if they were good enough to look at me despite the fact
that my people were deeply in debt. I was perfectly used to such
words, and knew that those who spoke them were speaking the
truth, since the same thing was said at home without anyone
contradicting it.
Owing to the fact that my father could afford the fees no longer, my
brother had been compelled to leave the High School, and was
serving his time in a business.
I suffered under these conditions more than I can ever say. My only
wish was to go away from Langenau and to live in some place where
nobody knew me and where nobody could reproach me. But my
mother would not hear of such a thing. Whenever I spoke about it
she comforted me with the idea of getting away later, and I gave in,
simply because I could do nothing else.
It was one of my daily occupations to chop up wood in a little shed.
The shed was situated at the back of the house, and close to the
wine-cellar that belonged to the landlord. Wealthy people from
Vienna or the surroundings used to buy wine from our landlord, and
not infrequently a gentleman went down into the cellar, and with the
landlord sampled the different wines. One afternoon I was chopping
wood again—I loved doing it merely because I was all alone in the
shed, and my thoughts could come and go undisturbed. I stood with
my back against the door, and was both chopping and thinking
diligently when a shadow fell suddenly across the wooden sides of
the shed; and turning round I saw one of the gentlemen who used
to visit the wine-cellar. He smiled at me and started a conversation—
whether the rough work pleased me, and so forth. First I felt
ashamed of having been observed, but his winning, open manner
soon banished my shyness. While he was speaking he smiled and
entered the shed. But in spite of his friendliness I felt all at once
terribly afraid. I lifted the chopper as if to protect myself, and said:
"Will you please go out?" He smiled with even more friendliness, and
I saw that his teeth were white and even.
"How shy you are, little one! all I should like to have is a kiss."
I pressed myself hard against the wooden wall, set my lips tightly,
and raised the chopper higher still. He must have read in my face
something of my determination, because he started to whistle
suddenly, and went out of the shed, going backwards as he left. I
would have killed him had he dared to touch me.
A young man visited our village sometimes in order to collect sums
of money due to a life insurance company. My parents were in no
way insured, but every month the people next door received a call
from him. One day, instead of the young fellow, a smartly-dressed
man appeared who told our neighbours that he was the manager of
the company, and that he himself was collecting on this occasion,
because frauds had been discovered in connection with the young
fellow who had collected previously. After he had left them he
knocked at our door, and entered in the politest fashion possible. He
looked so very smart that my mother wiped a chair with her apron
and invited him to sit down. It was summer, and very hot. The
manager seemed to be tired, and asked for a glass of water. After
my mother had filled one of her best glasses with clear and cool
well-water, he emptied it at one draught, after which he stretched
his legs and glanced searchingly through our little room, that looked
poor indeed but was kept very clean. My mother, who is but a plain
woman, felt much flattered at the sight of his unmistakable comfort,
and tried in her humble way to draw him into conversation.
"Dear madam," the manager said at last, "do you by any chance
know of a young girl who could help my wife with her housework?"
I sat at the window with a half-knitted stocking in my hands, and
slowly let it sink.
"What I need," continued the grand gentleman, "is a nice girl who
will mind the children and make herself generally useful."
My mother was just going to say that at present she knew of
nobody, but that she could make inquiries if the gentleman wished—
or something of that sort—when I got up and, standing before the
manager, said: "Perhaps I could be of some use to you?"
Scarcely had I uttered these words when I felt terrified at the
courage I had shown, and thought that I must have said something
very silly and rude. The manager, however, did not seem to have the
same idea, because he smiled and nodded his head.
"That would be excellent," and, after a little pause, addressing
himself to my mother, he asked, "When could she come?"
I was quite prepared to hear my mother reply that I could not go at
all, or even to see her bursting into tears, and was therefore greatly
surprised at what she replied: "If you really care to try her, I could
send her next week."
At these words I scarcely managed to suppress a cry of delight. The
gentleman then said that he lived at Krems, and that I could come
home sometimes. The day of my arrival as well as a few other things
having been settled, the manager bowed himself out. As soon as the
door had closed behind him I glanced rather shyly at my mother, but
she looked into my eyes steadily and said: "As you absolutely will
not stay at home, it is best that you should go soon to see for
yourself what the world is like." And after a moment she added:
"Perhaps you will have good luck."
During the rest of the day I tried to do everything I could to please
my mother. I sang the youngest child to sleep, and told the elder
ones stories. In the evening when the children had gone to bed, I
promised my mother that I would work hard and try to save up a
little money. When my father came home and heard of my decision,
all he said was that he hoped I could stand the hardship of service.
The week passed rapidly; my mother washed and ironed the few
pieces of underclothing I possessed, and I mended them as much as
possible. I would have liked very much to buy a little trunk, but my
father said that he had not enough money, so I packed my
belongings into brown paper, and tied up the small parcel with a
thick string.
The manager had arranged to come and fetch me himself. On the
appointed day I stood in my Sunday dress and a faded straw hat,
which I had decorated with a new bright ribbon, awaiting him in our
best room. He arrived very soon; my mother had laid the table, and
brought in the steaming hot coffee and some appetizing white
bread. After the manager had helped himself to enormous portions,
he prepared to depart. I had neither touched the coffee nor the
bread, feeling sick at heart, although nothing could have induced me
to make such a confession. Several times I ran into the kitchen as if
to fetch something, but in reality I wanted to wipe away the tears
quickly and secretly. The parting came at last, a scene that could
only be a simple one to such a simple woman as my mother,
although behind her coloured frock the dear, faithful heart trembled
and ached....
"Be good," she called after me, and I nodded back this time with
tears in my eyes.
 Chapter V
The people to whom I went were Jews. The mistress with her dark
hair and dark eyes seemed beautiful to me. The four children—three
boys and one girl—had all rather reddish hair and freckles, except
one of the boys, who was seven years old and idiotic. I had to take
the three elder children to school and fetch them home again, to tidy
the rooms and to keep the kitchen in order. The lady did the cooking
herself. As the idiotic boy did not go to school, he was constantly
around me and chattered to me all day long in unintelligible
sentences. Often he tore off his clothes and ran about naked. In the
beginning I was afraid of him, but I soon noticed that with the
exception of a few disagreeable things, to which one had to get
used, he was perfectly harmless. Many times during the day he
would come and spit into my face. At first I could hardly bear this,
but by-and-by I got to know his movements, and quickly turned
away when I saw him coming. But worse still than this poor boy was
his brother, a boy of twelve years, who had a horrible way of
speaking to me, and made me feel as much as possible that I had to
obey him. The girl I liked the best.
I had not been in this family for two months when I noticed that the
circumstances of the manager were no better than those of my
parents. People frequently came to the door and asked me if they
could see the manager. But as soon as I announced such a visitor
the manager became furious, and told me to tell the people to go to
hell. I soon got to know that these were all creditors asking for their
money. It had been decided that I should receive eight shillings each
month, and I could scarcely wait the day on which my wages fell
due. When I left home I only possessed one pair of shoes, and these
were almost in shreds. Therefore I thought of getting a new pair of
strong shoes and also a small notebook into which I could copy my
verses, which, although my work was plentiful, I did not stop
writing. But yet I felt as lonely as before. I could easily have made
acquaintances, but I did not wish to. The cook at the next house
often spoke to me, and told me once that every second Sunday she
went out with her sweetheart, who was a corporal; after which she
asked me how many times I went out. I told her that I did not go
out at all, and at this she looked at me with suspicion.
"Well, I never! then madam very likely allows your sweetheart into
her drawing-room to visit you, eh?"
"You impudent person, I have no sweetheart!"
At these words she gave a jeering laugh.
"So it is as far as that already. You are sick of men; I expect one of
them has left you in the lurch."
Without answering I turned my back on her, and afterwards we saw
each other as little as possible.
I began to hate everybody with whom I came in contact: the baker
because he had always some nasty words ready, which made me
cast down my eyes and caused the blood to rush to my head; the
milkman for the same reason; and the family itself because it was
plain that the man was a liar. To my great disappointment I had not
received my wages, and so I wrote my verses, which were even
more frequent now, on paper bags that had previously contained
such things as rice, tea or sugar; and these verses I carefully kept
and put away.
One day I had just come back from a walk with the children, and
after I had put the youngest child into the cot I went into the
kitchen to warm his milk; on entering the kitchen whom should I see
but Madam standing calmly in front of the drawer in which I kept my
belongings. The drawer was open and my mistress held in her hands
one of those paper bags that I knew so well. I was frightened and
furious at the same time, but the respect which, at least outwardly, I
had for that very indiscreet person prevented me from uttering any
angry exclamation. With an amused and astonished face she turned
towards me and held up the bag, "You have never told me about
these things," she said, seeming not at all troubled at being detected
in that mean action. "If you please," I answered, trying to get hold
of the bag, "it would not have been worth the while." She still wore
the amused smile on her face. "No, let me have it, I am going to
show it to my husband."
"For God's sake, no!" I cried in dismay.
"Why not? I like the verses very well."
The whole of my indignation and feelings of revolt immediately
vanished. I felt like kneeling down and kissing the hem of her dress;
her words had made me very happy, and from that day forward I
recognized in her my guardian angel.
The fact that I as yet had not received my wages made me, it is
true, feel very sad; but I told myself that this must be the manager's
fault, for he ought to have provided her with the money to pay her
servant. But she, and of this I was perfectly sure, never even caught
sight of a single penny.
My mistress had shown the manager some of the verses discovered
in the drawer, but he had laughed and responded that she had
better not turn my head altogether since I was a good, hard-working
girl, and that there were a far greater number of good poets than
good servants in existence. The manager had to go away to Vienna
nearly every week. One day when he had gone there as usual and
the children were put to bed, Madam came down into the kitchen
where I was busily washing up, and said: "Anna, I want to speak to
you."
I thought that she was going to pay me my wages at last, and my
heart beat faster. She sat down on a kitchen chair, and watched me
silently for a while. Suddenly she began again:
"Tell me why you have not been truthful with me?"
I was startled and looked at her in surprise, but my conscience was
clear, and so I answered quietly:
"I don't know what you mean, Madam."
She tapped the floor impatiently with her feet, and said:
"No pretences, please. You remember that you told me once that
you had no sweetheart, but that poem"—and oh, horror and dismay!
she held up a paper bag on which I had written only the day before,
and which I had never intended to show to anybody—"that poem
does not say the same. Where is he? What profession is he in? Have
you got his photo?"
I took my hands out of the hot dish-water, and covered my face.
"Don't be so silly," she continued. "I am a married woman, and you
may trust me. Now, come, out with it," and while she said that she
looked at me half commandingly, half lovingly. My hands dropped,
and I noticed how very red and ugly they were. A new shame
overcame me.
"It is true," I said at last.
"That you have got a sweetheart?"
"No; I mean that I have not got one."
"But this poem?" and, greatly puzzled, she looked down at the bag
that was smelling of coffee.
"I don't know who he is, nor where he is;" and with sudden courage:
"all I know is that he does exist."
"But, pray, where have you seen him, then?"
"I have never seen him at all, except in my thoughts."
"Oh" she exclaimed, and rising with a yawn, she began to leave the
kitchen; but at the doorway she turned round once more and said:
"As long as you know him only in your thoughts he can do you no
harm."
Scarcely had the door closed behind her, when I flew at the drawer,
pulled out the bags, and threw them into the fire. I watched until
the flickering flames had destroyed every bit of them, then I leaned
against the grey wall of the kitchen and wept bitterly.
Oh, for those tears in that grey kitchen! Oh, for those dreams in that
grey kitchen! Every moment my heart yearned in incomprehensible
longing for him. When would he come? Oh, when? When would he
come to take me away, like the princes came in the fairy tales to
woo a shepherdess or a kitchen-maid? I felt so sure that we were
destined to meet some day, but it seemed a long, long way off.
Sometimes a doubting fear would overcome me. How if the picture
of my dreams—that picture so proud, so far away—should never
turn into a form of flesh and blood, but ever be a dream! At such
moments I was weak and foolish. I looked down at my hands, which
were so red and ugly from washing-up and scrubbing. If no man
would ever love me because of my red and ugly hands, what then?
At that question my soul trembled, and tears thronged into my eyes.
The next second, however, I smiled at my fears; a line or two out of
my poems had fallen into my thoughts. What did it matter that my
hands were red and ugly? What did hands matter at all? What had
the heart, the mind, the soul of a man or woman in common with
his or her hands? The man of my dreams was not a man who would
love a girl only for her beauty. No; he would love me for the purity of
my thoughts, the chastity of my longing, and for that wonderful part
of my being that made me write my poems and dream all day.
Once on washing-day I was standing at the tub, when the door
opened and my mother came in.
"Mother!" I cried, "why did you not write that you were coming?"
"We have not heard from you for so long, and when no letter arrived
yesterday I became worried, and walked over," she said.
Only then I noticed her tired face and the dust that covered her
rough shoes.
"Do you mean to say you walked all that distance?"
"Yes, I did;" and after a little pause; "we must be very careful with
our pennies, business is so bad now."
I tried hard to keep back my tears.
"If I only had some money I would gladly give it to you," I said.
My mother shook her head.
"Don't be silly. You need your money yourself. Have you managed to
save a little?"
"No," I answered very slowly.
"Let me see, you have been here for a year now"—she began to
count by the aid of her fingers—"and your wages are eight shillings
a month." She counted again. "That ought to have left you
something. I am afraid you are careless, my dear."
Seeing that she looked at me with tender but reproachful eyes I
cuddled down beside her.
"No," I said, "I am not careless; but—"
And then I told her that I had never received my real wages; only
just enough to buy some very necessary articles of clothing, or to
have a pair of shoes mended when it was urgently required. I felt
very much ashamed to tell her this, since my own stubbornness was
the cause of it all. My mother sat still, and after a long while she
said:
"I am glad I have come. I have never been quite at my ease, and
wanted to see for myself whether you are happy or not. I have
heard of a very good situation, which would be suitable for you. You
would have to look after three children, and to help the cook with
the scrubbing. The household there is kept on a big scale, and you
would learn a great deal."
I remembered the mad boy, who still managed to spit at me
occasionally, and the sneers of the older boy.
"I would like to take that place," I said at last.
My mother got up from the linen-basket on which she had been
sitting.
"It is easy enough," she replied. "I have arranged for a fortnight's
notice with the manager, and if I give it to-day, you are free to go in
two weeks' time. I have seen the lady of the other post; she is very
kind, and does not mind waiting another three weeks. You might
just as well come home for a week. Does that suit you?"
I nodded in silence, and we parted.
When I went into the kitchen later on, my mistress was sitting near
the fire as if she had been waiting for me.
"I am sorry your mother wants you to leave me, but I have always
said that this was too rough work for you. I hope you will like your
new situation."
After the fortnight had passed I again packed up my things into
brown paper, but the parcel seemed to be smaller than it had been a
year ago. When I took my leave my mistress handed me ten
shillings, and promised to send on the rest of the money due to me.
Although I knew for a certainty that she would never do it, I thanked
her very much for the ten shillings, which seemed to be an
enormous sum.
 Chapter VI
I noticed slight changes when I arrived home. The lodging was the
same, but I missed several pieces of furniture, which I knew had
formerly been there. At first I wanted to ask for them, but a strange
sensation of fear and cowardice closed my lips. There was also a
pipe lying on one of the shelves.
"Who smokes a pipe?" I remarked.
My mother threw a quick glance at it.
"Father, of course; he thinks a pipe comes cheaper."
There were also other things that I thought surprising, but I would
ask no more.
"I dare say you know that Charlie has left his master," said my
mother.
"How should I know? Nobody has told me; where is he?"
"With father; I expect they will come in soon."
Although I felt pleased to see my brother again, of whom I had
heard nothing all the time he had been away, I was not pleased that
he had broken off his apprenticeship and had to begin afresh.
My mother had started to put the children to bed and to lay the
table. When it was dark my father came in with my brother, and
after the simple greetings were exchanged we sat down to supper. I
noticed now how handsome my brother had become. Although he
was only sixteen years of age, he was much taller than my father,
and of such gracefulness that I could hardly take my eyes from him.
His face was very beautiful. His eyes blue and large, and shadowed
by most exquisite lashes. On his upper lip a fair, downy moustache
showed, but his under-lip was, I thought, just a little too full.
"What are you going to do now?" I asked him once during the meal.
"Speaking frankly, you are too big (and too handsome I had almost
added) to be an apprentice."
"You are right, my beloved sister," he answered with a touch of
scorn in his voice; "for that sort of position I have grown too big
and, to tell the truth, too superior."
"Too superior?" I asked in amazement, and noticed how white and
beautiful his hands were. He looked at his well-kept nails
thoughtfully for awhile.
"Yes, too big and too superior to have my ears boxed."
"Did they?" I gasped, not daring to complete my sentence.
"Yes, and that's why I ran away."
"Perhaps you ought to have stayed there, after all," remarked my
mother somewhat timidly. "What will you do now?"
He gave my mother a look that alarmed me. It was an ugly, almost
threatening look, which robbed his face of all its beauty. But as if
conscious of the impression produced upon me, he calmly leant back
on the wooden chair and smiled self-contentedly.
"There is no need for you to lament," he said, addressing my
mother; "I shall not be a burden to you.... I am going to Vienna," he
finished, turning to me.
"To Vienna?" I asked. "What are you going to do there?"
He smiled again, and on this occasion contemptuously.
"I don't know yet; but there is no need to worry about such a fellow
as I am; it is true that I have no money, but here (he pointed at his
forehead) I have got something that is worth more than money,"
and after this introduction he started to picture his future.
"To begin with," he said, "it is undoubtedly a great misfortune to be
born in the country. Think of the vast possibilities that are open to
you in town. There are the well-managed schools, the places of
historic importance, the innumerable means of earning a living, and
the very air of culture and refinement that envelopes everybody.
There is no real work in the country, and there never will be. It is
true that the people get up in the mornings and try to do what there
is to be done; but where is, I ask you, that race of all the different
brain and bodily powers that is so characteristic of life in town,
where the clever man is superseded by the cleverest man, and
everybody tries to reach the top in consequence?... If I were silly
enough to stay at a little country-place, what would become of me?
Nothing but a mere loafer, who drags about quite uselessly the great
gift of intelligence that fortune (my dear, I am above that nonsense
of God and Church) has bestowed upon his cradle or rather upon his
brain. I have therefore decided to throw in my lot with the quickest
and cleverest of my age, and it must be hell itself playing against me
if I do not succeed in getting enough money to enable me to buy a
few hundreds of such dens"—he looked round the room
contemptuously—"in a couple of years."
With my hands folded almost devoutly I sat silent during the whole
of this speech, and did not quite know what to make of it. I greatly
admired the graceful flow of his words, as well as his thoughts which
were entirely new to me. Nevertheless there was something within
me that warned me not to surrender the views and ideas I had so
far held.
"I hope you will have good luck," I said at last when he made a little
pause; "but I should like to know what you are going to be."
"Alas!" he replied, "I can see for myself now that you are not much
better than these folks"—he pointed with his thumb at my parents
—"and that you have never, not even in the least, raised yourself
above the level of your birth. Your way of thinking is the way these
folks think"—he pointed at my parents again—"and they think as
their grandparents did. Progress is to all of you as foreign as China.
How can you be so silly," he continued, somewhat more gently, "to
ask me what I am going to be? How can I tell to-day? At the present
I have not the faintest notion of the conditions and circumstances of
Vienna, and how am I to know which of my capacities is likely to be
the most eminent? Let me have the choice of a profession, the
possibility of a trial, and I will tell you what I am made of."
Greatly ashamed of my ignorance, I was silent again.
"If you possessed brain," my brother continued—"a thing which I am
sorry to say I do not suspect you of after I have had the pleasure of
exchanging these few words"—he bowed ironically—"you might have
perceived by now that I am no ordinary person, but of an artistic
turn of mind. These people"—he pointed again at my parents
—"have, unfortunately, little or no understanding of that, and will in
all probability fail to comprehend the greatness that the future holds
in store for me. That is, however, of little consequence; it is you
whom I expect to escape from your present station in life"—I
admired the delicate way in which he referred to my station—"as
soon as possible. It is true that you will never succeed in reaching
the height destined for me, but you may, nevertheless, go on to
perfect yourself in every way possible, in order to spare me the
distress of blushing for your ignorance and social standing later on."
My father had got up from the table some time before, and with his
hands crossed on his back nervously paced the room. He coughed
now and again, as if something irritated his throat, and it was plain
that he was angry. All at once he stopped in front of my brother.
"Don't you think," he asked, "that it would be best for you to mix
with your own class of people as soon as possible?"
"Why, of course," my brother replied with utter coolness, "I have
already decided to leave for Vienna to-morrow; all that I must ask
you is to let me have the money for the journey, a sum so trivial that
I can repay it to you multiplied a hundred times in a few months."
They looked quite calmly at each other, but it was a calm that
seemed to be loaded with thunder and lightning. My mother must
have felt the same, for she got up rather hastily, and her voice
trembled as she said: "There is plenty of time to settle that to-
morrow. You had better go to bed now."
The thunderstorm, however, broke next day. My brother insisted on
a certain sum of money, which my father thought too great and
refused to let him have the whole of it.
"Do you want me to reach Vienna without a single penny in my
pockets?"
"I will give you as much as I can spare; there are the little ones to
be thought of; I cannot let them starve."
"Then you wish rather that I should starve?"
"I don't think that it would come to that. You are old enough to earn
your living."
"Old enough! Do you really mean to say that a fellow sixteen years
of age is old enough to earn his living?"
"Why not? I myself had to leave home when I was only a child of
eleven, and have worked for my living ever since."
"Worked for your living!" my brother cried scornfully. "Wasting
money and getting into debt to such an extent that no dog will take
the trouble to look at us. Do you call that working for your living?"
The veins showed thickly on my father's forehead.
"You wretch!" he cried, and flew at my brother's throat, "is that what
I get for having taken endless trouble to bring you up?"
It was evident that my brother had not expected so violent an
outburst on the part of my habitually gentle father. He grew deadly
pale and tried to free himself from my father's clutch.
After he had succeeded in doing so, he reached for his hat and
turned to the door. But, before he closed it behind him, he said:
"You will find me in the Kamp, if you should happen to look for me
to-morrow."
What he called the Kamp was a river of considerable depth. After he
had left, the room looked a picture of misery and grief. My mother
was leaning against the wall weeping violently; my father was pacing
the room, his face rigidly set and breathing rapidly; the smallest of
the children, roused by the noise, had started to cry; and I trembled
in every limb with excitement.
It was my brother's last words that worried me beyond expression
—"You will find me in the Kamp, if you should happen to look for me
to-morrow."
I imagined him plunging into the dark green water, sinking slowly
and being found entangled in the tall reeds near the banks.
"Mother," I said, speaking incoherently and almost inaudibly, "do you
think that he will?"
"Don't ask me anything," she replied; "I am the most unfortunate
woman under the sun."
During the whole day I hoped that he might still come back. He did
not return, however, and when evening drew near I dismissed all
hope of ever seeing him again. The next day I could not remain
indoors any longer, so I went out and walked towards the river
without actually knowing or wishing it. Every time I saw a group of
people coming towards me I stopped in terror, for I believed that
they had found him. Nobody, however, seemed to be on so terrible a
mission.
The people looked gaily at me, and passed on to their work in the
vineyards. When I reached the church square, the very sight of
which was enough to arouse such sad and sweet memories that I
felt more wretched, my brother appeared on the scene. Giving a
joyous exclamation, I hastened towards him.
"Where did you spend the night, Charlie?"
But this question did not seem to please him.
"I certainly expected more tact on your part," he replied, stepping
over to my side, "than even to allude to that distressing scene at
which you were unfortunate enough to be present."
I did not dare to ask another question, and walked along in silence.
Secretly I was surprised at his composure.
"I am extremely sorry for your misfortune," my brother said after a
pause. According to my opinion it was he who was the more
unfortunate of the two.
"Why are you sorry for me?" I asked him, and regretted the question
the next moment, because his face flushed with anger.
"How can you ask why, when you yourself were present at this
miserable occurrence, which must have taught you of what low
descent you are."
"I?"
"Well, of course I mean we, but as I have ceased to belong to these
folks any longer, I cannot help feeling extremely sorry at the thought
that you will have to spend the whole of your life amongst these
narrow-minded people, who are little better than savages. Ever since
yesterday I have thought how I could help you."
According to my opinion he needed help far more than I did; but he
did not seem to think so.
"What I have decided to do is this: I will take you down to Vienna,
where I shall watch over you, cultivate any abilities that you may
show—in short, educate you. As soon as I have shaken my boots
free from the dust of this place and reached Vienna, I am going to
work day and night in order to save enough money to enable me to
write for you, and to let you learn all the important branches of art
and science, such as languages, music, etc. Do you agree to it?"
I felt mightily touched at his generosity and could not speak for a
while.
"As a matter of course," he continued hurriedly, "that cannot be
done right away; you will have to wait a little, and in the meantime
there is nothing to prevent you from accepting the place that mother
has found for you. Your leisure time, however, I want you to fill up
usefully, so that I shall not be ashamed of you when I introduce you
to my friends. I strongly advise you to read Schiller. There is
everything in his dramas that you may need to appear clever and
witty in whatever situation you find yourself. It would be an excellent
thing if you could quote from his works at every possible
opportunity. I also advise you to read Goethe's works. Be careful,
however, not to quote from them, as your mind is not yet ready to
fathom the profound depth of his thoughts, and you might fall into
the evil habit of quoting passages at quite inappropriate moments.
Perhaps it is better for you to refrain altogether from reading his
deeper works, until I myself shall be able to expound them to you.
But," and a very winning smile parted his lips, "it is now time for me
to say good-bye."
"Good-bye!" I exclaimed; "where do you want to go to?"
"I am travelling down to Vienna."
"But you have got no money!"
His lips closed, and the winning smile vanished.
"I can see," he retorted, "that you are backward in every way. The
thing you most lack, and that you need to acquire first, is
tactfulness. Because, alas! one of our family happens to have no
feeling at all, do you really expect everybody to be in the same
miserable state? Always be careful, I tell you, about mentioning
anything that might recall occurrences or situations of a distressing
character. A certain pride exists, which is alive even within the most
pitiable wretch ... take care never to rouse that," and holding out his
hand, he said good-bye.
I did not take his hand, but stared at his beautiful fingers.
"I don't mean to hurt your feelings," I said almost crying, "but how
can you get to Vienna without a single penny?"
He frowned, and his handsome face darkened.
"It seems that I cannot expect from you that delicacy of feeling
which you must possess if you are ever to deserve my affection. But
since you are my sister, and really not to blame for your
imperfections—because it is the duty of parents to attend to their
children's education, and yours, I mean ours, have neglected that
important thing entirely—I will answer your question about the
money. You are perfectly right in suspecting that I have not a single
penny, but let me tell you that I would much rather walk all the
distance from here to Vienna than bring myself to accept another
sou from the man who, on account of a strange accident, is entitled
to call himself my father. I have tried to find out when the goods-
train leaves for Vienna, and have decided to hide myself in it."
I shook my head in horror.
"No, never!" I cried; "you must not do that. I have got some
money," and I pressed the rest of my ten shillings, which I had
carefully wrapped up in a piece of white paper, into his hand;
whereupon I detected signs of both anger and pity on his face.
"Surely," he said, "I should be a scoundrel of the meanest order if I
touched this small sum of yours. Far be it from me to do such a
thing;" and he put the money back into my hand. "It is true," he
added, "that you have shown great tactlessness again, but I will
forgive you this time."
Almost immediately he was gone, and although I was standing in
the street, I began to cry most piteously, regretting my poverty, my
lack of nobleness, even my very existence. I felt convinced that my
brother was not only an artist, but also a hero and a martyr.
 Chapter VII
The situation in which I started soon after these events differed
somewhat from my first one. There were only three children, a
second maid—the cook—and instead of eight shillings I was
promised ten shillings a month. My duties were the same as before.
I had to wash up the dishes, to scrub the floor, and to take out the
children as soon as I had finished the housework. My new charges
behaved much better than the children of the manager, and I liked
them all very much. The cook, too, was nice. Neither in speech nor
in manner was she objectionable, and sometimes I used to read out
my poems to her. She seemed to be very fond of the verses, and
often asked to hear them again. That made me very happy.
But after some months had passed away, and I became used to the
change, I was conscious again of the old well-known feeling of
dissatisfaction and loneliness. Frequently I used to sit down in a
corner and sob without knowing what was the matter. I was careful
not to let the mistress see my tears, but could not always hide them
from the cook, who was nearly always with me. She had asked me
already what I was crying for, but I could give no explanation.
One Saturday afternoon, when we were busily scrubbing the floor
and all the different meat-boards in the kitchen, the cook noticed my
swollen eyelids again.
"What is the matter with you, I should like to know," she said. "You
are home-sick perhaps."
I shook my head slowly and thoughtfully.
"I don't think I am home-sick, but I believe I am unhappy because I
can't go and learn anything."
"Can't go and learn anything!" she repeated. "What on earth do you
want to learn?"
I hesitated a little.
"I am sure I don't know. All I know is that I am frightfully silly."
"Well, I shouldn't say that," she replied good-naturedly. "I quite like
the way you help me in the kitchen."
"Oh well, yes; but I mean that I don't know how to play the piano,
nor how to speak French."
"But you do not need such things in service."
"Quite so; but I don't want to be in service."
"Oh!" she exclaimed, and then there was a long silence.
After we had done our work we took off our wet overalls, and put on
clean pinafores. The cook reached down one of the shining
saucepans hanging on the walls, and began to make the coffee,
while I went into the dining-room to lay the table. After I had taken
in the tray with the hot milk, the steaming coffee, and the cups of
white porcelain, the cook and I sat down in the kitchen to take our
coffee also. The cook poured out the coffee, and I noticed that her
hands trembled a little. She did not speak, and I was silent too, but I
could feel that our previous conversation occupied her thoughts.
When her cup was empty she put her head into her hands, and
looked me straight in the face.
"Then you want to know French?" she asked abruptly.
"Well, it need not be exactly French."
"What else, then?"
"I don't know."
"That's silly. You must know your own mind, to be sure."
"I believe that I should like to learn English," I confessed, much
embarrassed and ashamed.
"I have never heard of a person learning English. Why would you
not rather learn French?"
"No," I said slowly but decisively, "I would much rather learn
English."
"I have thought of everything," she continued after a pause; "the
mistress must not know about it. She herself has never learnt
anything of that sort, and would consider it to be nothing but pride
on your part. But it might be managed, nevertheless, if you would
learn only in the evening after you have put the children to bed."
"Of course," I cried delightedly; "I would not dream of doing it
during the daytime. There is only one thing," I added thoughtfully:
"where shall I be able to find a teacher in the evening?"
"A teacher!" cook exclaimed in utter surprise; "do you mean to say
that you want a teacher?"
I lost heart considerably at her question.
"Of course, I am sure it is impossible without a teacher."
"But won't that be too expensive?"
I assumed great indifference at her remark.
"I don't think that it could cost much," I said.
"How much do you think he would charge you?"
"I don't know exactly, but it won't be above a shilling or two."
"But, my dear, you can't afford that."
"Well, let me see. My wages are ten shillings a month, and I do not
need all the money."
"Of course not But you have to think of the future."
"Well, that's just what I am doing."
The cook did not understand what I meant by these words, and as
the bell rang to show that I was wanted, we dropped the subject,
and I did not dare to touch upon it again in spite of the growing
impatience and longing within me.
A few days later, however, it happened that the cook spoke of it
again quite abruptly.
"Do you think that you would get some benefit from it?"
"From what?" I asked, and looked as if I had no notion of her
thoughts.
"From the English language, of course."
"Well, if I knew how to speak it correctly I am certain that I could
make a lot of money with it."
"Where?"
"Not here, of course," I replied, and turned my head guiltily away
from her gaze. We had to do the scrubbing again, and the cook
devoted herself to the work almost savagely; but when the kitchen
glittered and shone, and we were once more sitting down to drink
our coffee, she continued:
"You must try to take your lessons on a Friday evening. The mistress
as well as the master are at the club, and won't be back before
eleven. Do you think you could be back before then?"
I was happy beyond expression, and would have liked to put my
arms round the neck of that dear simple creature.
"What do you think!" I exclaimed, wild with joy, and with my hands
folded as if in prayer; "I shall be in much earlier than that." But in a
moment I grew worried again. "Are you sure that the porter won't
tell about it?"
"Never mind about the porter. I will have a talk with him."
After that we decided that I should look out for a teacher, and the
matter was settled. On the following days when I took out the
children, I looked up and down the houses most carefully, and found
at last what I was searching for. "Languages and Music taught here,"
stood out clearly from a black board of granite, and the black board
was fastened on to a stately house. In spite of the shyness caused
by the grandeur of the house I longed to go in right away, but the
presence of the children kept me from carrying out my wish. They
were old enough to understand everything, and there was not the
slightest doubt that they would go and repeat my conversation with
a teacher of "languages and music" to their mother. It is true that
my mistress was always most kind to me, but, as cook remarked,
she would never have understood.
When I arrived home I told my friend about my success, and asked
her how I could manage to go there without letting anybody know.
"The only thing you can do," she said, "is to peep in when you go to
fetch the milk."
I thought how very ridiculous it would look for me to go into a room
with a large milk-can in my hands, and did not like her proposal.
There was, however, no other way if I did not want to arouse
suspicion, so next day I pulled the bell of the imposing house. I
could hear it ring from within, and the sound made me still more
uncomfortable. I wished the milk-can at the bottom of the sea, and
while I stood there waiting I thought for a moment of hiding that
disgraceful thing. I looked round for a suitable corner, but then I was
afraid that it might be stolen, so I kept it in my hand, and only tried
to hide it as much as possible behind me when the door opened and
a maid asked what I wanted. Colouring deeply, I told her why I had
come, and she begged me to step in. She led the way into a room,