The general procedure is:

1. Surgical approach
• A three-inch to five-inch incision is made on the left side of the abdomen or alternatively in the midline. The abdominal muscles are retracted to the side.
• Since the anterior abdominal muscle in the midline (rectus abdominis) runs vertically, it does not need to be cut and easily retracts to the side. The abdominal contents lay inside a large sack (peritoneum) that can also be retracted, thus allowing the surgeon access to the front of the spine.
• Alternatively, the peritoneum can be cut and the abdominal contents retracted to approach the spine. This is performed most commonly at L5-S1.
• The large blood vessels that continue to the legs (aorta and vena cava) are gently retracted off of the anterior spine. This part of the procedure is often performed by a general or vascular surgeon.
  
  
2. Disc removal
• A needle is then inserted into the disc space and an x-ray is done to confirm that the surgeon is at the correct level of the spine
• After the correct disc space has been identified on x-ray, the disc is then removed by first cutting the outer annulus fibrosis (fibrous ring around the disc) and removing the nucleus pulposus (the soft inner core of the disc)
• Dissection is carried out from the front to back of the disc.
  
  
3. Preparation of the disc space
• After the disc is removed, a space remains between the vertebral bodies.
• Disc space shavers and spacers may be used to template the height, width, and depth of implant that is needed.
• The surfaces of the vertebral bodies are meticulously prepared by burring any irregularities. This allows surface area for the contact of the implant, and maintenance of structural integrity of the bone to support the implant.
• The appropriate sized spacer is placed, making sure to place it in the midline of the disc, with good fill of the disc space from anterior to posterior and from side to side.