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Mills ES, Wang JC, Richardson MK, Chung BC, Mayer LW, Gallo MC, Alluri RK, Hah RJ, Heckmann ND. The change in lumbar lordosis from the standing to the lateral position: implications for lateral interbody fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08493-2. [PMID: 39313682 DOI: 10.1007/s00586-024-08493-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 08/05/2024] [Accepted: 09/10/2024] [Indexed: 09/25/2024]
Abstract
PURPOSE The purpose of this cross-sectional, observational study was to establish the relationship between standing lumbar lordosis (LL) and lateral decubitus LL. METHODS Forty-nine subjects, 24 male and 25 female, were prospectively enrolled. Patients with pre-existing spinopelvic pathology were excluded. Standing, relaxed-seated, and lateral decubitus lateral radiographs were obtained. Radiographic variables measured included LL and lordosis change at each lumbar level (e.g. L1-L2). The change in LL when going from a standing to a lateral decubitus position (ΔLL), the correlation between standing and sitting LL compared to lateral decubitus LL, and the correlation between ΔLL and standing pelvic incidence (PI), pelvic tilt (PT), PI-LL mismatch, pelvic femoral angle (PFA), and sacral slope (SS) were calculated. RESULTS Subjects had an average age of 25.7 ± 2.3 years and body mass index of 24.1 ± 3.0 kg/m2. On average, 11.9°±8.2° (range - 7° to 29°) of LL was lost when transitioning from a standing to the lateral decubitus position. Lateral decubitus LL had a higher correlation with standing LL (R = 0.725, p < 0.001) than with relaxed-seated LL (R = 0.434, p < 0.001). Standing PT and PI-LL mismatch had moderately negative correlations with ΔLL (R=-0.58 and R=-0.59, respectively, both p < 0.05). Standing PI and standing PFA had a low negative correlation with ΔLL (R=-0.31 and R=-0.44, respectively, both p < 0.05) Standing SS and LL had no correlation with ΔLL. CONCLUSIONS Standing LL was strongly correlated to lateral decubitus LL, although subjects lost an average of 11.9° from the standing to the lateral decubitus position. This has important implications for fusion in the lateral position.
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Affiliation(s)
- Emily S Mills
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Jennifer C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Brian C Chung
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Lucas W Mayer
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Matthew C Gallo
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Ram K Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Raymond J Hah
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA.
- Department of Orthopaedic Surgery, Keck Medical Center of USC, 1520 San Pablo St, Ste 2000, Los Angeles, CA, 90033, USA.
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Gerling MC, Baker M, Stanton E, Chaladoff E, Buser Z. Nerve root retraction time during lumbar endoscopic discectomy: association with new onset radiculitis, a post-operative neurologic complication. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:126-132. [PMID: 37747545 DOI: 10.1007/s00586-023-07952-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE To evaluate the relationship between nerve root retraction time, post-operative radiculitis and patient reported outcomes. METHODS Patients who underwent single- or multi-level lumbar discectomy between 2020 and 2022 for lumbar disk herniations were prospectively followed with pre-operative, interoperative and post-operative variables including radiculitis and patient reported outcomes including VAS, ODI and CAT domains Pain interference, Pain intensity and Physical function. Intraoperative nerve root retraction time was recorded. Paired sample two-tailed t-test and multivariate regression were utilized with p < 0.05 being significant. RESULTS A total of 157 patients who underwent single- or multi-level endoscopic lumbar discectomy. Average patient age was 44 years, and 64% were male patients. Nerve retraction time ranged from 4 to 15 min. Eighteen percent reported new radiculitis at 2-weeks post-operatively. In patients with new-onset radiculitis 79.2% reported significantly worse VAS leg at 2 weeks post-operative (4.2 vs. 8.3, p < 0.001) compared to 12.5% who had improved VAS leg (9.3 vs. 7, p = 0.1181). Patients with radiculitis and worse VAS scores had substantially longer nerve retraction time (13.8 ± 7.5 min) than patients with improved VAS leg (6.7 ± 1.2 min). At 6 months, patients with longer nerve retraction time had no significant improvement in the ODI or CAT compared to the baseline. CONCLUSIONS This is the first study in discectomy literature to show that new onset radiculitis and poorer outcomes in VAS leg correlate with longer nerve retraction time at early and later time points.
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Affiliation(s)
- Michael C Gerling
- Gerling Institute, Brooklyn, NY, USA
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, 94 9th Street, Unit 1-222, Brooklyn, NY, 11215, USA
| | | | - Eloise Stanton
- Keck School of Medicine, University of Southern California, Los Angeles, USA
| | | | - Zorica Buser
- Gerling Institute, Brooklyn, NY, USA.
- Department of Orthopedic Surgery, NYU Grossman School of Medicine, 94 9th Street, Unit 1-222, Brooklyn, NY, 11215, USA.
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Buckland AJ, Huynh NV, Menezes CM, Cheng I, Kwon B, Protopsaltis T, Braly BA, Thomas JA. Lateral lumbar interbody fusion at L4-L5 has a low rate of complications in appropriately selected patients when using a standardized surgical technique. Bone Joint J 2024; 106-B:53-61. [PMID: 38164083 DOI: 10.1302/0301-620x.106b1.bjj-2023-0693.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Aims The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique. Methods This was a multicentre retrospective study involving consecutively enrolled patients who underwent L4-L5 LLIF by seven surgeons at seven institutions in three countries over a five-year period. The demographic details of the patients and the details of the surgery, reoperations and complications, including femoral and non-femoral neuropraxia, thigh pain, weakness of hip flexion, and abdominal complications, were analyzed. Neurological and psoas-related complications attributed to LLIF or posterior instrumentation and persistent symptoms were recorded at one year postoperatively. Results A total of 517 patients were included in the study. Their mean age was 65.0 years (SD 10.3) and their mean BMI was 29.2 kg/m2 (SD 5.5). A mean of 1.2 levels (SD 0.6) were fused with LLIF, and a mean of 1.6 (SD 0.9) posterior levels were fused. Femoral neuropraxia occurred in six patients (1.2%), of which four (0.8%) were LLIF-related and two (0.4%) had persistent symptoms one year postoperatively. Non-femoral neuropraxia occurred in nine patients (1.8%), one (0.2%) was LLIF-related and five (1.0%) were persistent at one year. All LLIF-related neuropraxias resolved by one year. A total of 32 patients (6.2%) had thigh pain, 31 (6.0%) were LLIF-related and three (0.6%) were persistent at one year. Weakness of hip flexion occurred in 14 patients (2.7%), of which eight (1.6%) were LLIF-related and three (0.6%) were persistent at one year. No patients had bowel injury, three (0.6%) had an intraoperative vascular injury (not LLIF-related), and five (1.0%) had ileus. Reoperations occurred in five patients (1.0%) within 30 days, 37 (7.2%) within 90 days, and 41 (7.9%) within one year postoperatively. Conclusion LLIF involving the L4-L5 disc level has a low rate of persistent neurological, psoas-related, and abdominal complications in patients with the appropriate indications and using a standardized surgical technique.
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Affiliation(s)
- Aaron J Buckland
- Melbourne Orthopaedic Group, Melbourne, Australia
- Spine and Scoliosis Research Associates Australia, Melbourne, Australia
- Department of Orthopaedics, NYU Langone Health, New York, New York, USA
| | - Nam V Huynh
- Spine and Scoliosis Research Associates Australia, Melbourne, Australia
| | | | - Ivan Cheng
- Austin Spine Surgery, Austin, Texas, USA
| | - Brian Kwon
- Division of Spine Surgery, New England Baptist Hospital, Boston, Massachusetts, USA
| | | | | | - J A Thomas
- Atlantic Neurosurgical and Spine Specialists, Wilmington, Delaware, USA
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DeLong CA, Bashti M, Di L, Shah SS, Jaman E, Basil GW. Management of Refractory Post-operative Osteomyelitis and Discitis: A Case Report. Cureus 2024; 16:e52620. [PMID: 38374846 PMCID: PMC10875402 DOI: 10.7759/cureus.52620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2024] [Indexed: 02/21/2024] Open
Abstract
Vertebral osteomyelitis/discitis is a relatively rare disease but is a known potential complication of spinal surgical intervention. In general, the first-line treatment for this condition is targeted antibiotic therapy with surgical intervention only utilized in refractory cases with evidence of extensive damage, structural instability, or abscess formation. However, surgical best practices have not been established for osteomyelitis, including indications for anterior lateral interbody fusion (ALIF), posterior lateral interbody fusion (PLIF), or direct lateral interbody fusion (DLIF). This case provides a discussion of the indications that led to a direct lateral approach in the setting of refractory osteomyelitis/discitis, supporting factors that led to its success, and the efficacy of utilizing intraoperative neuromonitoring in cases of infection.
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Affiliation(s)
- Chase A DeLong
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Malek Bashti
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Long Di
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Sumedh S Shah
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Emade Jaman
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
| | - Gregory W Basil
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA
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Feng DP, Liu MQ, Zhang W, Wang JQ, Li ZW. Anterior column realignment via a minimally invasive hybrid approach in adult spinal deformity surgery: a short-term retrospective study. BMC Musculoskelet Disord 2023; 24:979. [PMID: 38114995 PMCID: PMC10729504 DOI: 10.1186/s12891-023-07106-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Anterior column realignment (ACR) is a novel surgical method for correcting spinal sagittal balance. meanwhile, oblique lumbar interbody fusion (OLIF) and anterior lumbar interbody fusion (ALIF) are considered minimally invasive surgical methods through natural anatomical space. This study aimed to explore the corrective effects and clinical outcomes of OLIF or ALIF combined with ACR technology in patients with adult spinal deformity (ASD). METHODS We retrospectively analyzed patients with sagittal imbalance who received OLIF and/or ALIF and ACR treatment from 2018 to 2021. Surgical time and intraoperative bleeding volume are recorded, the corrective effect is determined by the intervertebral space angle (IVA), lumbar lordosis (LL), the sagittal vertical axis (SVA), clinical outcome is evaluated by preoperative and final follow-up visual analog pain score (VAS), Japanese orthopedic association scores (JOA) and complications. RESULTS Sixty-four patients were enrolled in the study, average age of 65.1(range, 47-82) years. All patients completed 173 fusion segments, for 150 segments of ACR surgery. The operation time of ALIF-ACR was 50.4 ± 22.1 min; The intraoperative bleeding volume was 50.2 ± 23.6 ml. The operation time and intraoperative bleeding volume of single-segment OLIF-ACR was 66.2 ± 19.4 min and 70.2 ± 31.6 ml. At the follow-up of 6 months after surgery, the intervertebral space angle correction for OLIF-ACR and ALIF-ACR is 9.2° and 12.2°, the preoperative and postoperative lumbar lordosis were 16.7° ± 6.4°and 47.1° ± 3.6° (p < 0.001), VAS and JOA scores were improved from 6.8 to 1.8 and 7.8 to 22.1 respectively, statistically significant differences were observed in these parameters. The incidence of surgical related complications is 29.69%, but without serious complications. CONCLUSION ACR via a minimally invasive hybrid approach for ASD has significant advantages in restoring local intervertebral space angulation and correcting the overall sagittal balance. Simultaneously, it can achieve good clinical outcomes and fewer surgical complications.
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Affiliation(s)
- Da Peng Feng
- The Second Affiliated Hospital of Dalian Medical University, Liaoning, People's Republic of China
| | - Ming Quan Liu
- Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wei Zhang
- The Second Affiliated Hospital of Dalian Medical University, Liaoning, People's Republic of China
| | - Jia Qi Wang
- The Second Affiliated Hospital of Dalian Medical University, Liaoning, People's Republic of China
| | - Zheng Wei Li
- The Second Affiliated Hospital of Dalian Medical University, Liaoning, People's Republic of China.
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Morton MB, Wang YY, Buckland AJ, Oehme DA, Malham GM. Lateral lumbar interbody fusion - clinical outcomes, fusion rates and complications with recombinant human bone morphogenetic protein-2. Br J Neurosurg 2023:1-7. [PMID: 37029604 DOI: 10.1080/02688697.2023.2197503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/03/2023] [Accepted: 03/28/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND The authors report an Australian experience of lateral lumbar interbody fusion (LLIF) with respect to clinical outcomes, fusion rates, and complications, with recombinant human bone morphogenetic protein-2 (rhBMP-2) and other graft materials. METHODS Retrospective cohort study of LLIF patients 2011-2021. LLIFs performed lateral decubitus by four experienced surgeons past their learning curve. Graft materials classified rhBMP-2 or non-rhBMP-2. Patient-reported outcomes assessed by VAS, ODI, and SF-12 preoperatively and postoperatively. Fusion rates assessed by CT postoperatively at 6 and 12 months. Complications classified minor or major. Clinical outcomes and complications analysed and compared between rhBMP-2 and non-rhBMP-2 groups. RESULTS A cohort of 343 patients underwent 437 levels of LLIF. Mean age 67 ± 11 years (range 29-89) with a female preponderance (65%). Mean BMI 29kg/m2 (18-56). Most common operated levels L3/4 (36%) and L4/5 (35%). VAS, ODI and SF-12 improved significantly from baseline. Total complication rate 15% (53/343) with minor 11% (39/343) and major 4% (14/343). Ten patients returned to OR (2-wound infection, 8-further instrumentation and decompression). Most patients (264, 77%) received rhBMP-2, the remainder a non-rhBMP-2 graft material. No significant differences between groups at baseline. No increase in minor or major complications in the rhBMP-2 group compared to the non-rhBMP-2 group respectively; (10.6% vs 13.9% [p = 0.42], 2.7% vs 8.9% [p < 0.01]). Fusion rates significantly higher in the rhBMP-2 group at 6 and 12 months (63% vs 40%, [p < 0.01], 92% vs 80%, [p < 0.02]). CONCLUSION LLIF is a safe and efficacious procedure. rhBMP-2 in LLIF produced earlier and higher fusion rates compared to available non-rhBMP-2 graft substitutes.
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Affiliation(s)
- Matthew B Morton
- Epworth Hospital, Richmond, Australia
- Faculty of Medicine, Monash University, Clayton, Australia
| | - Yi Yuen Wang
- St Vincent's Hospital, Fitzroy, Australia
- Department of Surgery, The University of Melbourne, Parkville, Australia
| | - Aaron J Buckland
- Epworth Hospital, Richmond, Australia
- Melbourne Orthopaedic Group, Windsor, Australia
- Spine and Scoliosis Research Associates Australia, Windsor, Australia
- NYU Langone Health, New York, NY, USA
| | - David A Oehme
- Epworth Hospital, Richmond, Australia
- St Vincent's Hospital, Fitzroy, Australia
| | - Gregory M Malham
- Epworth Hospital, Richmond, Australia
- Swinburne University of Technology, Hawthorn, Australia
- University of Melbourne, Parkville, Australia
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Yang H, Liu J, Hai Y, Han B. What Are the Benefits of Lateral Lumbar Interbody Fusion on the Treatment of Adult Spinal Deformity: A Systematic Review and Meta-Analysis Deformity. Global Spine J 2023; 13:172-187. [PMID: 35442824 PMCID: PMC9837508 DOI: 10.1177/21925682221089876] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
STUDY DESIGN A systematic review and meta-analysis. OBJECTIVE The purpose of this systematic review and meta-analysis was to compare the efficacy of lateral lumbar interbody fusion (LLIF) combined with posterior spinal fusion (PSF) with that of conventional PSF in the treatment of adult spinal deformity (ASD). METHODS A comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, and the Cochrane Library. Spinopelvic parameters, surgical data, complications, and clinical outcomes at the last follow-up were compared between patients with ASD who underwent LLIF combined with PSF (LLIF+PSF group) and those who underwent conventional PSF (only-PSF group). RESULTS Ten studies, comprising 621 patients with ASD (313 in the LLIF+PSF group and 308 in the only-PSF group), were included. The level of evidence was III for 7 studies and IV for 3 studies. There was no significant difference in the improvement in the visual analog scale score, systemic complication rate, and revision rate between groups. In the LLIF+PSF group, we noted a superior restoration of lumbar lordosis (weighted mean difference [WMD], 9.77; 95% confidence interval [CI] 7.10 to 12.44, P < .001), pelvic tilt (WMD, -2.50; 95% CI -4.25 to -.75, P = .005), sagittal vertical axis (WMD, -21.92; 95% CI -30.73 to -13.11, P < .001), and C7 plumb line-center sacral vertical line (WMD, -4.03; 95% CI -7.52 to -.54, P = .024); a lower estimated blood loss (WMD, -719.99; 95% CI -1105.02 to -334.96, P < .001) while a prolonged operating time (WMD, 104.89; 95% CI 49.36 to 160.43, P < .001); lower incidence of pseudarthrosis (risk ratio [RR], .26; 95% CI .08 to .79, P = .017) while higher incidence of neurologic deficits (RR, 2.04; 95% CI 1.27 to 3.25, P = .003); and a better improvement in Oswestry Disability Index score (WMD, -7.04; 95% CI -10.155 to -3.93, P < .001) and Scoliosis Research Society-22 total score (WMD, .27; 95% CI .11 to .42, P = .001). The level of evidence in this systematic review and meta-analysis was II. CONCLUSION Compared with conventional PSF, LLIF combined with PSF was associated with superior restoration of sagittal and coronal alignment, lower incidence of pseudarthrosis, better improvement in quality of life, and less surgical invasiveness in the treatment of ASD, albeit at the cost of prolonged surgical times and substantially high incidence of lower extremity symptoms. Surgeons should weigh the advantages and disadvantages of this procedure, and inform patients about its side effects.
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Affiliation(s)
- Honghao Yang
- Department of Orthopedic Surgery, Beijing Chao-Yang
Hospital, Beijing, China
| | - Jingwei Liu
- Department of Orthopedic Surgery, Beijing Chao-Yang
Hospital, Beijing, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chao-Yang
Hospital, Beijing, China,*Yong Hai, Department of Orthopedic
Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Gongti South
Rd, No. 8, Beijing 100020, China.
| | - Bo Han
- Department of Orthopedic Surgery, Beijing Chao-Yang
Hospital, Beijing, China
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Pan B, Yu W, Lou C, Gao J, Huang W, He D. Comparison of mini-open, anteroinferior psoas approach and mini-open, direct lateral transpsoas approach for lumbar burst fractures: A retrospective cohort study. Front Surg 2022; 9:995410. [PMID: 36311940 PMCID: PMC9614075 DOI: 10.3389/fsurg.2022.995410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/26/2022] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE We evaluated the effect of a novel modified OLIF technique (anteroinferior psoas approach, AIPA) for anterior decompression reconstruction in lumbar burst fractures, and compared the clinical, radiological outcomes and approach-related complications with the mini-open, lateral transpsoas approach (LTPA). METHODS From March 2016 to November 2019, 68 patients with lumbar burst fractures underwent one-stage monosegmental posterior/anterior surgery from L1-L4 segments. 35 patients included in AIPA and 33 patients in LTPA group underwent anterior decompression reconstruction. The clinical, radiological and functional evaluation outcomes were recorded during the 16-60 months follow-up period. RESULTS At the latest follow up, neurological state of one or more ASIA grades were achieved in AIPA (90.9%) and LTPA group (94.9%). No significant differences were noted between the two groups regarding preoperative and postoperative Cobbs angle. The surgery time (192.29 vs. 230.47 min, P = 0.02) in AIPA group was better compared with LTPA. The AIPA showed better improvement on Oswestry Disability Index (43.4% vs. 60.8%, P < 0.05) and Mental Component Score (49.0% vs. 43.7%, P < 0.05) one month after surgery, but no difference at the latest follow-up. 10 patients (9 in LTPA and 1 in AIPA) experienced temporary motor deficits in hip flexor and groin or thigh numbness, which disappeared six months after surgery. CONCLUSIONS Compared with lateral transpsoas approach, anterior decompression reconstruction via mini-open, anteroinferior psoas approach was a safe and less invasive approach, with fewer approach-related complications in the treatment for unstable lumbar burst fractures.
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Rates of Postoperative Complications and Approach-related Neurological Symptoms After L4-L5 Lateral Transpsoas Lumbar Interbody Fusion Compared With Upper Lumbar Levels. Clin Spine Surg 2022:01933606-990000000-00058. [PMID: 35945666 DOI: 10.1097/bsd.0000000000001367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective comparative study. OBJECTIVE To compare the likelihood of approach-related complications for patients undergoing single-level lateral lumbar interbody fusion (LLIF) at L4-L5 to those undergoing the procedure at upper lumbar levels. SUMMARY OF BACKGROUND DATA LLIF has been associated with a number of advantages when compared with traditional interbody fusion techniques. However, potential risks with the approach include vascular or visceral injury, thigh dysesthesias, and lumbar plexus injury. There are concerns of a higher risk of these complications at the L4-L5 level compared with upper lumbar levels. MATERIALS AND METHODS A retrospective cohort review was completed for consecutive patients undergoing single-level LLIF between 2004 and 2019 by a single surgeon. Indication for surgery was symptomatic degenerative lumbar stenosis and/or spondylolisthesis. Patients were divided into 2 cohorts: LLIF at L4-L5 versus a single level between L1 and L4. Baseline characteristics, intraoperative complications, postoperative approach-related neurological symptoms, and patient-reported outcomes were compared and analyzed between the cohorts. RESULTS A total of 122 were included in analysis, of which 58 underwent LLIF at L4-L5 and 64 underwent LLIF between L1 and L4. There were no visceral or vascular injuries or lumbar plexus injuries in either cohort. There was no significant difference in the rate of postoperative hip pain, anterior thigh dysesthesias, and/or hip flexor weakness between the cohorts (53.5% L4-L5 vs. 37.5% L1-L4; P=0.102). All patients reported complete resolution of these symptoms by 6-month postoperative follow-up. DISCUSSION LLIF surgery at the L4-L5 level is associated with a similar infrequent likelihood of approach-related complications and postoperative hip pain, thigh dysesthesias, and hip flexor weakness when compared with upper lumbar level LLIF. Careful patient selection, meticulous use of real-time neuromonitoring, and an understanding of the anatomic location of the lumbar plexus to the working corridor are critical to success.
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10
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Li Y, Wang MY. Safe Electromyography Stimulation Thresholds Within Kambin's Triangle During Endoscopic Transforaminal Lumbar Interbody Fusion. Neurosurgery 2022; 91:150-158. [PMID: 35383716 DOI: 10.1227/neu.0000000000001959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Transforaminal endoscopic approaches through Kambin's triangle traditionally require surgery to be performed without general anesthesia to allow live patient feedback. No reliable intraoperative neuromonitoring method specific to the dorsal root ganglion (DRG), the structure most at risk during this approach, currently exists. OBJECTIVE To correlate evoked electromyography (EMG) thresholds within Kambin's triangle with new postoperative pain or sensorimotor symptoms potentially resulting from DRG irritation. METHODS Data were prospectively collected for all patients undergoing endoscopic transforaminal lumbar interbody fusion (TLIF) under general anesthesia at a single institution. A stimulation probe was inserted into Kambin's triangle under fluoroscopic and robotic guidance, before passage of endoscopic instruments. EMG thresholds required to elicit corresponding myotomal responses were measured. Postoperatively, any potential manifestations of DRG irritation were recorded. RESULTS Twenty-four patients underwent a total of 34 transforaminal lumbar interbody fusion levels during the study period, with symptoms of potential DRG irritation occurring in 5. The incidence of new onset symptoms increased with lower stimulation thresholds. Sensitivities for EMG thresholds of ≤4, ≤8, and ≤11 mA were 0.6, 0.8, and 1, respectively. Corresponding specificities were 0.90, 0.69, and 0.55, respectively. CONCLUSION We demonstrated for the first time the feasibility of direct intraoperative neuromonitoring within Kambin's triangle in transforaminal endoscopic surgery. Eight milliampere seems to be a reasonable compromise between sensitivity and specificity for this monitoring technique. In the future, larger-scale studies are required to refine safe stimulation thresholds.
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Affiliation(s)
- Yingda Li
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope LIFE Centre, Miami, Florida, USA
- Department of Neurosurgery, Westmead Hospital, Westmead, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope LIFE Centre, Miami, Florida, USA
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11
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Morgan CD, Katsevman GA, Godzik J, Catapano JS, Hemphill C, Turner JD, Uribe JS. Outpatient outcomes of patients with femoral nerve neurapraxia after prone lateral lumbar interbody fusion at L4-5. J Neurosurg Spine 2022; 37:92-95. [PMID: 35120313 DOI: 10.3171/2021.11.spine211289] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Single-position prone lateral lumbar interbody fusion (LLIF) improves the efficiency of staged minimally invasive lumbar spine surgery. However, laterally approaching the lumbar spine, especially L4-5 with the patient in the prone position, could increase the risk of complications and presents unique challenges, including difficult ergonomics, psoas migration, and management of the nearby lumbar plexus. The authors sought to identify postoperative femoral neurapraxia after single-position prone LLIF at L4-5 to better understand how symptoms evolve over time. METHODS This retrospective analysis examined a prospectively maintained database of LLIF patients who were treated by two surgeons (J.S.U. and J.D.T.). Patients who underwent single-position prone LLIF at L4-5 and percutaneous pedicle screw fixation for lumbar stenosis or spondylolisthesis were included if they had at least 6 weeks of follow-up. Outpatient postoperative neurological symptoms were analyzed at 6-week, 3-month, and 6-month follow-up evaluations. RESULTS Twenty-nine patients (16 women [55%]; overall mean ± SD age 62 ± 11 years) met the inclusion criteria. Five patients (17%) experienced complications, including 1 (3%) who had a femoral nerve injury with resultant motor weakness. The mean ± SD transpsoas retractor time was 14.6 ± 6.1 minutes, the directional anterior electromyography (EMG) threshold before retractor placement was 20.1 ± 10.2 mA, and the directional posterior EMG threshold was 10.4 ± 9.1 mA. All patients had 6-week clinical follow-up evaluations. Ten patients (34%) reported thigh pain or weakness at their 6-week follow-up appointment, compared with 3/27 (11%) at 3 months and 1/20 (5%) at 6 months. No association was found between directional EMG threshold and neurapraxia, but longer transpsoas retractor time at L4-5 was significantly associated with femoral neurapraxia at 6-week follow-up (p = 0.02). The only case of femoral nerve injury with motor weakness developed in a patient with a retractor time that was nearly twice as long as the mean time (27.0 vs 14.6 minutes); however, this patient fully recovered by the 3-month follow-up evaluation. CONCLUSIONS To our knowledge, this is the largest study with the longest follow-up duration to date after single-position prone LLIF at L4-5 with percutaneous pedicle screw fixation. Although 34% of patients reported ipsilateral sensory symptoms in the thigh at the 6-week follow-up evaluation, only 1 patient sustained a nerve injury; this resulted in temporary weakness that resolved by the 3-month follow-up evaluation. Thus, longer transpsoas retractor time at L4-5 during prone LLIF is associated with increased ipsilateral thigh symptoms at 6-week follow-up that may resolve over time.
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Alan N, Kanter JJ, Puccio L, Anand SK, Kanter AS. Transitioning from lateral to the prone transpsoas approach: flatten the learning curve by knowing the nuances. NEUROSURGICAL FOCUS: VIDEO 2022; 7:V8. [PMID: 36284730 PMCID: PMC9558910 DOI: 10.3171/2022.3.focvid2224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/29/2022] [Indexed: 11/06/2022]
Abstract
Prone transpsoas lateral lumbar interbody fusion is the newest frontier in surgical approach to the lumbar spine. Prone positioning facilitates segmental lordosis and facile posterior segmental fixation. However, even in experienced hands, transitioning from a lateral decubitus to prone position necessitates alterations to the traditional technique. In this video, the authors highlight the nuances of adopting the prone transpsoas lateral lumbar interbody fusion technique and strategies to overcome them. The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2224
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Affiliation(s)
- Nima Alan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Jared J. Kanter
- Department of Communications–Media, University of Alabama, Tuscaloosa, Alabama
| | - Lauren Puccio
- Department of Communications–Media, University of Alabama, Tuscaloosa, Alabama
| | - Sharath Kumar Anand
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Adam S. Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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13
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Tohmeh A, Somers C, Howell K. Saphenous somatosensory-evoked potentials monitoring of femoral nerve health during prone transpsoas lateral lumbar interbody fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1658-1666. [PMID: 35532816 DOI: 10.1007/s00586-022-07224-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 12/30/2021] [Accepted: 04/12/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess whether saphenous somatosensory-evoked potentials (saphSSEP) monitoring may provide predictive information of femoral nerve health during prone lateral interbody fusion (LIF) procedures. METHODS Intraoperative details were captured prospectively in consecutive prone LIF surgeries at a single institution. Triggered electromyography was used during the approach; saphSSEP was monitored throughout using a novel system that enables acquisition of difficult signals and real-time actionable feedback facilitating intraoperative intervention. Postoperative neural function was correlated with intraoperative findings. RESULTS Fifty-nine patients (58% female, mean age 64, mean BMI 32) underwent LIF at 95 total levels, inclusive of L4-5 in 76%, fixated via percutaneous pedicle screws (81%) or lateral plate, with direct decompression in 39%. Total operative time averaged 149 min. Psoas retraction time averaged 16 min/level. Baseline SSEPs were unreliable in 3 due to comorbidities in 2 and anesthesia in 1; one of those resulted in transient quadriceps weakness, fully recovered at 6 weeks. In 25/56, no saphSSEP changes occurred, and none had postoperative femoral nerve deficits. In 24/31 with saphSSEP changes, responses recovered intraoperatively following intervention, with normal postoperative function in all but one with delayed quadriceps weakness, improved at 4 months and recovered at 9 months, and a second with transient isolated anterior thigh numbness. In the remaining 7/31, saphSSEP changes persisted to close, and resulted in 2 transient isolated anterior thigh numbness and 2 combined sensory and motor femoral nerve deficits, both resolved at between 4 and 8 months. CONCLUSIONS SaphSSEP was reliably monitored in most cases and provided actionable feedback that was highly predictive of neurological events during LIF. LEVEL OF EVIDENCE Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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Affiliation(s)
- Antoine Tohmeh
- MultiCare Neurosurgery and Spine, 605 E. Holland, Suite 202, Spokane, WA, 99218, USA.
| | - Cheri Somers
- MultiCare Neurosurgery and Spine, 605 E. Holland, Suite 202, Spokane, WA, 99218, USA
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Alluri R, Mok JK, Vaishnav A, Shelby T, Sivaganesan A, Hah R, Qureshi SA. Intraoperative Neuromonitoring During Lateral Lumbar Interbody Fusion. Neurospine 2021; 18:430-436. [PMID: 34610671 PMCID: PMC8497239 DOI: 10.14245/ns.2142440.220] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To review the evidence for the use of electromyography (EMG), motor-evoked potentials (MEPs), and somatosensory-evoked potentials (SSEPs) intraoperative neuromonitoring (IONM) strategies during lateral lumbar interbody fusion (LLIF), as well as discuss the limitations associated with each technique.
Methods A comprehensive review of the literature and compilation of findings relating to clinical studies investigating the efficacy of EMG, MEP, SSEP, or combined IONM strategies during LLIF.
Results The evidence for the use of EMG is mixed with some studies demonstrating the efficacy of EMG in preventing postoperative neurologic injuries and other studies demonstrating a high rate of postoperative neurologic deficits with EMG monitoring. Multimodal IONM strategies utilizing MEPs or saphenous SSEPs to monitor the lumbar plexus may be promising strategies based on results from a limited number of studies.
Conclusion The use of traditional EMG during LLIF remains without consensus. There is a growing body of evidence utilizing multimodal IONM with MEPs or saphenous SSEPs demonstrating a possible decrease in postoperative neurologic injuries after LLIF. Future prospective studies, with clear definitions of neurologic injury, that evaluate different multimodal IONM strategies are needed to better assess the efficacy of IONM during LLIF.
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Affiliation(s)
- Ram Alluri
- Hospital for Special Surgery, New York, NY, USA
| | | | | | - Tara Shelby
- Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | | | - Raymond Hah
- Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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15
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Batheja D, Dhamija B, Ghodke A, Anand SS, Balain BS. Lateral lumbar interbody fusion in adult spine deformity - A review of literature. J Clin Orthop Trauma 2021; 22:101597. [PMID: 34722145 PMCID: PMC8531858 DOI: 10.1016/j.jcot.2021.101597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Surgery for adult spine deformity presents a challenging issue for spinal surgeons with high morbidity rates reported in the literature. The minimally invasive lateral approach aims at reducing these complications while maintaining similar outcomes as associated with open spinal surgeries. The aim of this paper is to review the literature on the use of lateral lumbar interbody fusion in the cases of adult spinal deformity. METHODS A literature review was done using the healthcare database Advanced Research on NICE and NHS website using Medline. Search terms were "XLIF" or "LLIF" or "DLIF" or "lateral lumbar interbody fusion" or "minimal invasive lateral fusion" and "adult spinal deformity" or "spinal deformity". RESULTS A total of 417 studies were considered for the review and 44 studies were shortlisted after going through the selection criteria. The data of 1722 patients and 4057 fusion levels were analysed for this review. The mean age of the patients was 65.18 years with L4/5 being the most common level fused in this review. We found significant improvement in the radiological parameters (lordosis, scoliosis, and disk height) in the pooled data. Transient neurological symptoms and cage subsidence were the two most common complications reported. CONCLUSION LLIF is a safe and effective approach in managing adult spinal deformity with low morbidity and acceptable complication rates. It can be used alone for lower grades of deformity and as an adjuvant procedure to decrease the magnitude of open surgeries in high-grade deformities.
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Affiliation(s)
- Dheeraj Batheja
- Corresponding author. Spinal Disorders, Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Gobowen, Oswestry, SY10 7AG, UK.,
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Pennicooke B, Guinn J, Chou D. Symptomatic contralateral osteophyte fracture with migration causing lumbar plexopathy during oblique lumbar interbody fusion: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21210. [PMID: 35854959 PMCID: PMC9272363 DOI: 10.3171/case21210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/15/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND While performing lateral lumbar interbody fusion surgery, one of the surgical goals is to release the contralateral side with a Cobb elevator, allowing distraction of the interbody space. Many times, there are large osteophytes on the contralateral side, and the osteophytes can be split open with the Cobb or blunt instrument. It is extremely rare for the actual osteophyte to break off from the vertebral body into the contralateral psoas muscle and lumbar plexus. OBSERVATIONS The authors report a case of symptomatic lumbar plexopathy caused by an osteophyte fracture after an oblique lumbar interbody fusion requiring a right-sided anterior approach to excise the bony fragment. They illustrate the case with imaging that the radiologist did not comment on, and they also show a video of the surgical excision of the osteophyte through a right-sided anterior lumbar retroperitoneal approach. The authors also show how the patient had spontaneous right-sided electromyography (EMG) firing before excision of the osteophyte and how the EMG firing resolved after excision. LESSONS Although the literature is plentiful with regard to ipsilateral approach–related complications, the authors discuss the literature with regard to contralateral complications after minimally invasive lateral lumbar interbody fusion.
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Affiliation(s)
- Brenton Pennicooke
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Jeremy Guinn
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Lim S, Chang V. Commentary: Single-Position Surgery: Prone Lateral Lumbar Interbody Fusion: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E373-E375. [PMID: 33646295 DOI: 10.1093/ons/opab055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Seokchun Lim
- Department of Neurological Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202, USA
| | - Victor Chang
- Department of Neurological Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202, USA
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18
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Hiyama A, Katoh H, Nomura S, Sakai D, Sato M, Watanabe M. Radiographs assessment of changes in the psoas muscle at L4-L5 level after single-level lateral lumbar interbody fusion in patients with postoperative motor weakness. J Clin Neurosci 2021; 90:165-170. [PMID: 34275544 DOI: 10.1016/j.jocn.2021.05.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 12/01/2022]
Abstract
The purposes of this study were (1) to investigate postoperative changes in cross-sectional area (CSA) and signal intensity (SI) of the psoas muscle (PS) using magnetic resonance imaging (MRI) and (2) to compare the CSA and SI of the PS between patients with and without motor weakness after single-level lateral lumbar interbody fusion (LLIF) at level L4-L5. Sixty patients were divided into two groups-those with postoperative motor weakness and those without-and the two groups were compared. Baseline demographics and clinical characteristics, such as operation time and blood loss, length of hospital stay, and postoperative complications, were recorded. The CSA and SI of the PS were obtained from the MRI regions of interest defined by manual tracing. Patients who developed motor weakness after surgery were significantly older (p = 0.040). The operation time (p = 0.868), LLIF operative time (p = 0.476), and estimated bleeding loss (p = 0.168) did not differ significantly between groups. In both groups, the CSA and SI of the left and right PS increased after surgery. The change in the CSA of the left PS was significantly higher in patients with weakness (247.6 ± 155.2 mm2) than without weakness (152.2 ± 133.1 mm2) (p = 0.036). The change in SI of the left PS did not differ between the two groups (p = 0.530). To prevent postoperative motor weakness regardless of the operation time, surgeons should be aware of the potential for surgical invasive of the PS during LLIF in older people.
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Affiliation(s)
- Akihiko Hiyama
- Department of Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
| | - Satoshi Nomura
- Department of Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
| | - Masato Sato
- Department of Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
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Hofler RC, Fessler RG. Intraoperative Neuromonitoring and Lumbar Spinal Instrumentation: Indications and Utility. Neurodiagn J 2021; 61:2-10. [PMID: 33945449 DOI: 10.1080/21646821.2021.1874207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Multimodal intraoperative neurophysiologic monitoring (IONM) can be utilized as an adjunct to lumbar spinal instrumentation in order to aid with avoidance of neurologic complications. The most commonly utilized modalities include somatosensory-evoked potentials, motor-evoked potentials, and electromyography. Somatosensory-evoked potentials (SSEPs) allow for continuous assessment of the dorsal columns of the spinal cord and are therefore most useful during procedures with a posterior approach to the cervical and thoracic spine. Motor-evoked potentials (MEPs) and electromyography (EMG) can be applied intermittently to assess motor nerve function. The utility of each individual modality can be largely dependent on the surgical approach. Approaches to lumbar spinal instrumentation can be generally categorized as anterior, lateral, and posterior. For lateral approaches, electromyography can be helpful in identifying neural structures crossing the surgical field to prevent injury. In posterior and anterior approaches, somatosensory-evoked potentials and motor-evoked potentials can be used to assess nerve injury during and after maneuvers for decompression and instrumentation. Additionally, during the placement of pedicle screws, direct stimulation with triggered electromyography can be used to detect the pedicle cortex's breach. The efficacy of intraoperative neuromonitoring is dependent on prompt and accurate recognition of changes in signals. This is then followed by accurate recognition of the cause for these changes and appropriate responses by the surgeon, anesthesiologist, and monitoring personnel to correct the change.
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Affiliation(s)
- Ryan C Hofler
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Richard G Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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Segawa T, Koga H, Oshina M, Ishibashi K, Takano Y, Iwai H, Inanami H. Clinical Evaluation of Microendoscopy-Assisted Oblique Lateral Interbody Fusion. ACTA ACUST UNITED AC 2021; 57:medicina57020135. [PMID: 33546404 PMCID: PMC7913526 DOI: 10.3390/medicina57020135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022]
Abstract
Background and objectives: Oblique Lateral Interbody Fusion (OLIF) is a widely performed, minimally invasive technique to achieve lumbar lateral interbody fusion. However, some complications can arise due to constraints posed by the limited surgical space and visual field. The purpose of this study was to assess the short-term postoperative clinical outcomes of microendoscopy-assisted OLIF (ME-OLIF) compared to conventional OLIF. Materials and Methods: We retrospectively investigated 75 consecutive patients who underwent OLIF or ME-OLIF. The age, sex, diagnosis, and number of fused levels were obtained from medical records. Operation time, estimated blood loss (EBL), and intraoperative complications were also collected. Operation time and EBL were only measured per level required for the lateral procedure, excluding the posterior fixation surgery. The primary outcome measure was assessed using the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ). The secondary outcome measure was assessed using the Oswestry Disability Index (ODI) and the European Quality of Life–5 Dimensions (EQ-5D), measured preoperatively and 1-year postoperatively. Results: This case series consisted of 14 patients in the OLIF group and 61 patients in the ME-OLIF group. There was no significant difference between the two groups in terms of the mean operative time and EBL (p = 0.90 and p = 0.50, respectively). The perioperative complication rate was 21.4% in the OLIF group and 21.3% in the ME-OLIF group (p = 0.99). In both groups, the postoperative JOABPEQ, EQ-5D, and ODI scores improved significantly (p < 0.001). Conclusions: Although there was no significant difference in clinical results between the two surgical methods, the results suggest that both are safe surgical methods and that microendoscopy-assisted OLIF could serve as a potential alternative to the conventional OLIF procedure.
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Affiliation(s)
- Tomohide Segawa
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
- Correspondence: ; Tel.: +81-03-3450-1773
| | - Hisashi Koga
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
- Department of Neurosurgery, Iwai FESS Clinic, Suite 101, 8-18-4 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan
| | - Masahito Oshina
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
| | - Katsuhiko Ishibashi
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
- Department of Neurosurgery, Iwai FESS Clinic, Suite 101, 8-18-4 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan
| | - Yuichi Takano
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
| | - Hiroki Iwai
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
- Department of Neurosurgery, Iwai FESS Clinic, Suite 101, 8-18-4 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan
| | - Hirohiko Inanami
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
- Department of Neurosurgery, Iwai FESS Clinic, Suite 101, 8-18-4 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan
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Ohiorhenuan IE, Martirosyan NL, Wewel JT, Sagar S, Uribe JS. Lateral Interbody Fusion at L4/5: Management of the Transitional Psoas. World Neurosurg 2020; 148:e192-e196. [PMID: 33385599 DOI: 10.1016/j.wneu.2020.12.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Managing retraction of the lumbar plexus is critical to safely perform lateral lumbar interbody fusion (LLIF) via the transpsoas approach. Occasionally, a transitional psoas is encountered at L4/5 and has been postulated to be a contraindication to transpsoas LLIF. A case series of patients with transitional psoas who underwent L4/5 LLIFs is presented. METHODS This retrospective review assessed 79 consecutive patients who underwent L4/5 LLIF during a 24-month period. Preoperative imaging was reviewed, and patients were classified into 2 groups: normal psoas or transitional psoas. Intraoperative features and outcomes were compared between groups. RESULTS Seventy-nine patients underwent L4/5 LLIFs, of whom 23 had transitional psoas anatomy and 56 had normal psoas anatomy. Among patients with transitional psoas, the center of the psoas was a mean (range) of 11.2 (5.2-26.6) mm in front of the center of the vertebral body compared with 2.0 (0-4) mm in the normal psoas group. The mean (range) retraction time was similar between groups (10.8 [6.7-14.9] minutes in the transitional psoas group vs. 11.0 [7.8-15.0] minutes in the normal psoas group). No permanent motor injuries occurred in either group, and no differences in length of stay or preoperative or postoperative Oswestry Disability Index scores were found between the groups. The protocol for L4/5 LLIF in patients with transitional psoas anatomy is described. CONCLUSIONS Transitional psoas anatomy is frequently encountered in surgical candidates for L4/5 LLIF. Through careful identification of the lumbar plexus and judicious retraction, the transpsoas LLIF can safely be performed in these patients.
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Affiliation(s)
- Ifije E Ohiorhenuan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua T Wewel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Soumya Sagar
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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22
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Pimenta L, Taylor WR, Stone LE, Wali AR, Santiago-Dieppa DR. Prone Transpsoas Technique for Simultaneous Single-Position Access to the Anterior and Posterior Lumbar Spine. Oper Neurosurg (Hagerstown) 2020; 20:E5-E12. [DOI: 10.1093/ons/opaa328] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 08/10/2020] [Indexed: 12/16/2022] Open
Abstract
Abstract
BACKGROUND
Effective decompression, arthrodesis, and correction of spinal conditions frequently utilize operative approaches that expose both the anterior and posterior spinal column. Until now, circumferential spinal column access often requires the surgeon to reposition and drape the patient multiple times or utilize a posterior only approach that has limited anterior correction capability or to utilize a lateral-only approach that complicates otherwise traditional posterior surgical maneuvers.
OBJECTIVE
To describe a technique utilizing a single surgical position that enables minimally disruptive anterior column correction with simultaneous access to the posterior spinal column.
METHODS
The operative technique for accessing the lateral lumbar interbody space from a prone transpsoas (PTP) approach is described. The rationale for this approach and a representative case example are reviewed.
RESULTS
The PTP approach was used to perform an L3-4 and L4-5 interbody fusion in a 71-yr-old female with spondylolisthesis, severe stenosis, and locked facets. The PTP approach enabled efficient completion of an anterior column correction, direct posterior decompression, multi-segment pedicle fixation, and maintenance of alignment, all while in a single prone position. There were no intraoperative or postoperative complications.
CONCLUSION
The authors’ early experience with the described PTP technique suggests it is not only feasible but offers some advantages, as it allows for single-position surgery maximizing both anterior and posterior column access and corrective techniques. Further follow-up studies of this technique are ongoing.
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Affiliation(s)
- Luiz Pimenta
- Instituto de Patologia da Coluna, São Paulo, Brazil
| | - William R Taylor
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Lauren E Stone
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Arvin Raj Wali
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
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Saigal R, Akbarnia BA, Eastlack RK, Bagheri A, Tran S, Brown D, Bagheri R, Mundis GM. Anterior Column Realignment: Analysis of Neurological Risk and Radiographic Outcomes. Neurosurgery 2020; 87:E347-E354. [PMID: 32297951 DOI: 10.1093/neuros/nyaa064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 01/30/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anterior column realignment (ACR) is a less invasive alternative to 3-column osteotomy for the correction of sagittal imbalance. We hypothesized that ACR would correct sagittal imbalance with an acceptable neurological risk. OBJECTIVE To assess long-term neurological and radiographic outcomes after ACR. METHODS Patients ≥18 yr who underwent ACR from 2005 to 2013 were eligible. Standing scoliosis radiographs were studied at preoperation, postoperation (≤6 wk), and at minimum 2 yr of follow-up. Clinical/radiographic data were collected through a retrospective chart review, with thoracic 1 spino-pelvic inclination (T1SPi) used as the angular surrogate for sagittal vertical axis. RESULTS A total of 26 patients had complete data, with a mean follow-up of 2.8 yr (1.8-7.4). Preoperative, sagittal parameters were lumbar lordosis (LL) of -16.1°, pelvic incidence (PI)-LL of 41.7°, T1SPi of 3.6°, and pelvis tilt (PT) of 32.4°. LL improved by 30.6° (P < .001) postoperation. Mean changes in PT (-8.3), sacral slope (8.9), T1SPi (-4.9), and PI-LL (-33.5) were all significant. The motion segment angle improved by 26.6°, from 5.2° to -21.4° (P < .001). Neurological complications occurred in 32% patients postoperation (n = 8; 1 patient with both sensory and motor). New thigh numbness/paresthesia developed in 3 (13%) patients postoperation; only 1 (4%) persisted at latest follow-up. A total of 6 (24%) patients developed a new lower extremity motor deficit postoperation, with 4 (8%) having persistent new weakness at last follow-up. Out of 8 patients with preoperative motor deficit, half saw improvement postoperation and 75% improved by last follow-up. CONCLUSION There was net motor improvement, with 24% of patients improving and 16% having persistent new weakness at latest follow-up; 60% were unchanged. Radiographic results demonstrate that ACR is a useful tool to treat severe sagittal plane deformity.
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Affiliation(s)
- Rajiv Saigal
- Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Behrooz A Akbarnia
- Department of Research, San Diego Spine Foundation, San Diego, California
| | - Robert K Eastlack
- Department of Research, San Diego Spine Foundation, San Diego, California.,Department of Orthopaedics, Scripps Clinic, La Jolla, California
| | - Ali Bagheri
- Department of Research, San Diego Spine Foundation, San Diego, California
| | - Stacie Tran
- Department of Research, San Diego Spine Foundation, San Diego, California
| | - Drew Brown
- Department of Research, San Diego Spine Foundation, San Diego, California
| | - Ramin Bagheri
- Department of Research, San Diego Spine Foundation, San Diego, California.,Department of Orthopaedics, Scripps Clinic, La Jolla, California
| | - Gregory M Mundis
- Department of Research, San Diego Spine Foundation, San Diego, California.,Department of Orthopaedics, Scripps Clinic, La Jolla, California
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Godzik J, Pereira BDA, Hemphill C, Walker CT, Wewel JT, Turner JD, Uribe JS. Minimally Invasive Anterior Longitudinal Ligament Release for Anterior Column Realignment. Global Spine J 2020; 10:101S-110S. [PMID: 32528793 PMCID: PMC7263342 DOI: 10.1177/2192568219880178] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
STUDY DESIGN Review of the literature. OBJECTIVES Anterior column realignment (ACR) is a powerful but relatively new minimally invasive technique for deformity correction. The purpose of this study is to provide a literature review of the ACR surgical technique, reported outcomes, and future directions. METHODS A review of the literature was performed regarding the ACR technique. A review of patients at our single center who underwent ACR was performed, with illustrative cases selected to demonstrate basic and nuanced aspects of the technique. RESULTS Clinical and cadaveric studies report increases in segmental lordosis in the lumbar spine by 73%, approximately 10° to 33°, depending on the degree of posterior osteotomy and lordosis of the hyperlordosis interbody spacer. These corrections have been found to be associated with a similar risk profile compared with traditional surgical options, including a 30% to 43% risk of proximal junctional kyphosis in early studies. CONCLUSIONS ACR represents a powerful technique in the minimally invasive spinal surgeon's toolbox for treatment of complex adult spinal deformity. The technique is capable of significant sagittal plane correction; however, future research is necessary to ascertain the safety profile and long-term durability of ACR.
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Affiliation(s)
- Jakub Godzik
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Courtney Hemphill
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Corey T. Walker
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Joshua T. Wewel
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Jay D. Turner
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Juan S. Uribe
- Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
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25
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Minimally Invasive Lateral Lumbar Interbody Fusion for Clinical Adjacent Segment Pathology: A Comparative Study With Conventional Posterior Lumbar Interbody Fusion. Clin Spine Surg 2019; 32:E426-E433. [PMID: 30839417 DOI: 10.1097/bsd.0000000000000787] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
STUDY DESIGN This was a retrospective comparative study. OBJECTIVE The main objective of this article was to evaluate the clinical and radiologic efficacies of minimally invasive lateral lumbar interbody fusion (LLIF) for clinical adjacent segment pathology (ASP). SUMMARY OF BACKGROUND DATA Minimally invasive techniques have been increasingly applied for spinal surgery. No report has compared LLIF with conventional posterior lumbar interbody fusion for clinical ASP. METHODS Forty patients undergoing LLIF with posterior fusion (hybrid surgery) were compared with 40 patients undergoing conventional posterior lumbar interbody fusion (posterior surgery). The radiologic outcomes including indirect decompression in hybrid surgery group, and clinical outcomes such as the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were assessed. Postoperative major complications and reoperations were also compared between the 2 groups. RESULTS Correction of coronal Cobb's angle and segmental lordosis in the hybrid surgery were significantly greater postoperatively (2.8 vs. 0.9 degrees, P=0.012; 7.4 vs. 2.5 degrees, P=0.009) and at the last follow-up (2.4 vs. 0.5 degrees, P=0.026; 4.8 vs. 0.8 degrees, P=0.016) compared with posterior surgery. As regards indirect decompression of the LLIF, significant increases in thecal sac (83.4 vs. 113.8 mm) and foraminal height (17.8 vs. 20.9 mm) were noted on postoperative magnetic resonance imaging. Although postoperative back VAS (4.1 vs. 5.6, P=0.011) and ODI (48.9% vs. 59.6%, P=0.007) were significantly better in hybrid surgery, clinical outcomes at the last follow-up were similar. Moreover, intraoperative endplate fractures developed in 17.7% and lower leg symptoms occurred in 30.0% of patients undergoing hybrid surgery. CONCLUSIONS Hybrid surgery for clinical ASP has advantages of segmental coronal and sagittal correction, and indirect decompression compared with conventional posterior surgery. However, LLIF-related complications such as endplate fracture and lower leg symptoms also developed. LLIF should be performed considering advantages and approach-related complications for the clinical ASP.
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Epstein NE. Many Intraoperative Monitoring Modalities Have Been Developed To Limit Injury During Extreme Lateral Interbody Fusion (XLIF/MIS XLIF): Does That Mean XLIF/MIS XLIF Are Unsafe? Surg Neurol Int 2019; 10:233. [PMID: 31893134 PMCID: PMC6911673 DOI: 10.25259/sni_563_2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/26/2022] Open
Abstract
Background: Extreme lateral interbody fusions (XLIF) and Minimally Invasive (MIS) XLIF pose significant risks of neural injury to the; lumbar plexus, ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, and subcostal nerves. To limit these injuries, many intraoperative neural monitoring (IONM) modalities have been proposed. Methods: Multiple studies document various frequencies of neural injuries occurring during MIS XLIF/XLIF: plexus injuries (13.28%); sensory deficits (0-75%; permanent 62.5%); motor deficits (0.7-33.6%; most typically iliopsoas weakness (14.3%-31%)), and anterior thigh/groin pain (12.5-25%.-34%). To avoid/limit these injuries, multiple IONM techniques have been proposed. These include; using finger electrodes during operative dissection, employing motor evoked potentials (MEP), eliminating (no) muscle relaxants (NMR), and using “triggered” EMGs. Results: In one study, finger electrodes for XLIF at L4-L5 level for degenerative spondylolisthesis reduced transient postoperative neurological symptoms from 7 [38%] of 18 cases (e.g. without IONM) to 5 [14%] of 36 cases (with IONM). Two series showed that motor evoked potential monitoring (MEP) for XLIF reduced postoperative motor deficits; they, therefore, recommended their routine use for XLIF. Another study demonstrated that eliminating muscle relaxants during XLIF markedly reduced postoperative neurological deficits/thigh pain by allowing for better continuous EMG monitoring (e.g. NMR no muscle relaxants). Finally, a “triggered” EMG study” reduced postoperative motor neuropraxia, largely by limiting retraction time. Conclusion: Multiple studies have offered different IONM techniques to avert neurological injuries following MIS XLIF/XLIF. Does this mean that these procedures (e.g. XLIF/MIS XLIF) are unsafe?
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, New York, and Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience/Neurosurgery, Mineola, New York 11501, United States
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27
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Campbell PG, Nunley PD, Cavanaugh D, Kerr E, Utter PA, Frank K, Stone M. Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4-5. Neurosurg Focus 2019; 44:E6. [PMID: 29290128 DOI: 10.3171/2017.10.focus17566] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recently, authors have called into question the utility and complication index of the lateral lumbar interbody fusion procedure at the L4-5 level. Furthermore, the need for direct decompression has also been debated. Here, the authors report the clinical and radiographic outcomes of transpsoas lumbar interbody fusion, relying only on indirect decompression to treat patients with neurogenic claudication secondary to Grade 1 and 2 spondylolisthesis at the L4-5 level. METHODS The authors conducted a retrospective evaluation of 18 consecutive patients with Grade 1 or 2 spondylolisthesis from a prospectively maintained database. All patients underwent a transpsoas approach, followed by posterior percutaneous instrumentation without decompression. The Oswestry Disability Index (ODI) and SF-12 were administered during the clinical evaluations. Radiographic evaluation was also performed. The mean follow-up was 6.2 months. RESULTS Fifteen patients with Grade 1 and 3 patients with Grade 2 spondylolisthesis were identified and underwent fusion at a total of 20 levels. The mean operative time was 165 minutes for the combined anterior and posterior phases of the operation. The estimated blood loss was 113 ml. The most common cage width in the anteroposterior dimension was 22 mm (78%). Anterior thigh dysesthesia was identified on detailed sensory evaluation in 6 of 18 patients (33%); all patients experienced resolution within 6 months postoperatively. No patient had lasting sensory loss or motor deficit. The average ODI score improved 26 points by the 6-month follow-up. At the 6-month follow-up, the SF-12 mean Physical and Mental Component Summary scores improved by 11.9% and 9.6%, respectively. No patient required additional decompression postoperatively. CONCLUSIONS This study offers clinical results to establish lateral lumbar interbody fusion as an effective technique for the treatment of Grade 1 or 2 degenerative spondylolisthesis at L4-5. The use of this surgical approach provides a minimally invasive solution that offers excellent arthrodesis rates as well as favorable clinical and radiological outcomes, with low rates of postoperative complications. However, adhering to the techniques of transpsoas lateral surgery, such as minimal table break, an initial look-and-see approach to the psoas, clear identification of the plexus, minimal cranial caudal expansion of the retractor, mobilization of any traversing sensory nerves, and total psoas dilation times less than 20 minutes, ensures the lowest possible complication profile for both visceral and neural injuries even in the narrow safe zones when accessing the L4-5 disc space in patients with degenerative spondylolisthesis.
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Affiliation(s)
| | | | | | | | | | - Kelly Frank
- 3Clinical Research, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Marcus Stone
- 3Clinical Research, Spine Institute of Louisiana, Shreveport, Louisiana
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Clinical and Radiographic Evaluation of Multilevel Lateral Lumbar Interbody Fusion in Adult Degenerative Scoliosis. Clin Spine Surg 2019; 32:E386-E396. [PMID: 30864972 DOI: 10.1097/bsd.0000000000000812] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective review of prospective data. OBJECTIVE The objective of this study was to describe the clinical, radiographic, and complication-related outcomes through ≥1-year of 27 patients who underwent lateral lumbar interbody fusion (LLIF) with posterior instrumentation to treat ≥3 contiguous levels of degenerative lumbar scoliosis. SUMMARY OF BACKGROUND DATA Multilevel disease has traditionally been treated with open posterior fusion. Literature on multilevel LLIF is limited. We present our experience with utilizing LLIF to treat multilevel degenerative scoliosis. METHODS Clinical outcomes were evaluated using VAS, SF-12, and ODI. Radiographic outcomes included pelvic tilt, pelvic incidence, lumbar lordosis, pelvic incidence-lumbar lordosis mismatch, Cobb angle, and cage subsidence. Perioperative and long-term complications through the ≥1-year final-postoperative visit were reviewed; transient neurological disturbances were assessed independently. Demographic, comorbidity, operative, and recovery variables, including opioid use, were explored for association with primary outcomes. RESULTS Mean time to final-postoperative visit was 22.5 months; levels treated with LLIF per patient, 3.7; age, 66 years; and lateral operative time, 203 minutes. EBL was ≤100 mL in 74% of cases. Clinical outcomes remained significantly improved at ≥1-year. Cobb angle was corrected from 21.1 to 7.9 degrees (P<0.001), lordosis from 47.3 to 52.6 degrees (P<0.001), and mismatch from 11.4 to 6.4 degrees (P=0.003). High-grade subsidence occurred in 3 patients. Subsidence did not significantly impact primary outcomes. In total, 11.1% returned to the operating room for complication-related intervention over nearly 2-years; 37% experienced complications. Experiencing a complication was associated with having an open-posterior portion (P=0.048), but not with number of LLIF levels treated, or with clinical or radiographic outcomes. No patients experienced protracted neurological deficits; psoas weakness was associated with increased lateral operative time (P=0.049) and decreased surgeon experience (P=0.028). CONCLUSIONS Patients who underwent multilevel LLIF with adjunctive posterior surgery had significant clinical and radiographic improvements. Complication rates were similar compared to literature on single-level LLIF. LLIF is a viable treatment for multilevel degenerative scoliosis.
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Salzmann SN, Shirahata T, Okano I, Winter F, Sax OC, Yang J, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Does L4-L5 Pose Additional Neurologic Risk in Lateral Lumbar Interbody Fusion? World Neurosurg 2019; 129:e337-e342. [DOI: 10.1016/j.wneu.2019.05.144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 11/26/2022]
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York PJ, Gang CH, Qureshi SA. Patient education in an ambulatory surgical center setting. JOURNAL OF SPINE SURGERY 2019; 5:S206-S211. [PMID: 31656877 DOI: 10.21037/jss.2019.04.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Philip J York
- Department of Orthopedics, Hospital for Special Surgery, New York, USA
| | | | - Sheeraz A Qureshi
- Department of Orthopedics, Hospital for Special Surgery, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, USA
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Basques BA, Ferguson J, Kunze KN, Phillips FM. Lumbar spinal fusion in the outpatient setting: an update on management, surgical approaches and planning. JOURNAL OF SPINE SURGERY 2019; 5:S174-S180. [PMID: 31656872 DOI: 10.21037/jss.2019.04.14] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Outpatient lumbar spinal fusion surgery has the potential for improved patient satisfaction, speed of recovery, and economic advantages when compared to inpatient surgery. Despite the rise in the number of these procedures performed annually, the literature on this topic remains scarce. As such, there is a need for a comprehensive review of current concepts in indications and management. The current review will present the most recent literature regarding pre-operative, intra-operative, and post-operative considerations when performing outpatient lumbar spinal fusion surgery.
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Affiliation(s)
- Bryce A Basques
- Division of Spine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Joseph Ferguson
- Division of Spine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kyle N Kunze
- Division of Spine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Frank M Phillips
- Division of Spine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Yilmaz E, von Glinski A, Ishak B, Abdul-Jabbar A, Blecher R, O'Lynnger T, Alonso F, Benca E, Chapman JR, Oskouian RJ. Outcome After Extreme Lateral Transpsoas Approach: Corpectomies Versus Interbody Fusion. World Neurosurg 2019; 131:e170-e175. [PMID: 31330334 DOI: 10.1016/j.wneu.2019.07.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The lateral transpsoas approach (LTPA) has gained popularity in thoracolumbar spine surgery procedures; however, there is an insufficient amount of data pertaining to motor and sensory complications that arise when a corpectomy is performed through the LTPA approach. METHODS Patients who underwent a corpectomy through a LTPA at a single institution between 2006 and 2016 were analyzed. Demographics, neurological outcomes, and complications were recorded. The minimum follow-up was 6 months. Univariate analysis was performed to compare demographics, surgical characteristics, complications, and outcome scores. To compare categorical variables, the χ2 test was used. For continuous outcomes, simple linear regression was used. Statistical significance was set at P < 0.05. RESULTS A total of 166 patients were included. The patients were divided into 2 groups; LTPA without corpectomy (n = 112) versus LTPA with corpectomy (n = 54). Patients without corpectomy showed a significantly lower rate of postoperative infections compared with patients with corpectomy (3.6% vs. 22.2%; P < 0.000). A higher percentage of postoperative complications was found in patients with corpectomy (31.5% vs. 13.4%; P = 0.006). The rate of neurologic complications at the 6-month follow-up and the reoperation rate (22.7% vs. 32.4%; P = 0.256) were higher in the corpectomy group (8.9% vs. 7.4%; P = 0.741), no significant difference was found between the groups. CONCLUSION Patients who underwent an LTPA corpectomy have a higher risk to suffer from postoperative complications. The results at the 6-month follow-up did not significantly differ between the groups.
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Affiliation(s)
- Emre Yilmaz
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA; Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, Bochum, Germany
| | - Alexander von Glinski
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA; Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, Bochum, Germany; Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, USA.
| | - Basem Ishak
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA; Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Amir Abdul-Jabbar
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Ronan Blecher
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Thomas O'Lynnger
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Fernando Alonso
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Eric Benca
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Jens R Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Rod J Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
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Hah R, Kang HP. Lateral and Oblique Lumbar Interbody Fusion-Current Concepts and a Review of Recent Literature. Curr Rev Musculoskelet Med 2019; 12:305-310. [PMID: 31230190 PMCID: PMC6684701 DOI: 10.1007/s12178-019-09562-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To review the relevant recent literature regarding minimally invasive, lateral, and oblique approaches to the anterior lumbar spine, with a particular focus on the operative and postoperative complications. METHODS A literature search was performed on Pubmed and Web of Science using combinations of the following keywords and their acronyms: lateral lumbar interbody fusion (LLIF), oblique lateral interbody fusion (OLIF), anterior-to-psoas approach (ATP), direct lateral interbody fusion (DLIF), extreme lateral interbody fusion (XLIF), and minimally invasive surgery (MIS). All results from January 2016 through January 2019 were evaluated and all studies evaluating complications and/or outcomes were included in the review. RECENT FINDINGS Transient neurological deficit, particularly sensorimotor symptoms of the ipsilateral thigh, remains the most common complication seen in LLIF. Best available current literature demonstrates that approximately 30-40% of patients have postoperative deficits, primarily of the proximal leg. Permanent symptoms are less common, affecting 4-5% of cases. Newer techniques to reduce this rate include different retractors, direct visualization of the nerves, and intraoperative neuromonitoring. OLIF may have lower deficit rates, but the available literature is limited. Subsidence rates in both LLIF and OLIF are comparable to ALIF (anterior lumbar interbody fusion), but further study is required. Supplemental posterior fixation is an active area of investigation that shows favorable biomechanical results, but additional clinical studies are needed. Minimally invasive lumbar interbody fusion techniques continue to advance rapidly. As these techniques continue to mature, evidence-based risk-stratification systems are required to better guide both the patient and clinician in the joint decision-making process for the optimal surgical approach.
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Affiliation(s)
- Raymond Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Suite 5400, Los Angeles, CA 90033 USA
| | - H. Paco Kang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Suite 5400, Los Angeles, CA 90033 USA
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Derman PB, Phillips FM. Complication avoidance in minimally invasive spinal surgery. JOURNAL OF SPINE SURGERY 2019; 5:S57-S67. [PMID: 31380493 DOI: 10.21037/jss.2019.04.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive techniques in spinal surgery allow surgeons to perform operations with less of the approach-related morbidity inherent to traditional open procedures. Yet these muscle-sparing procedures come with a unique set of risks that stem from the novel approaches, limited exposure, and/or a restricted working corridor that they employ. The literature suggests that these operations can be performed without an increased rate of complication once the associated learning curve has been surmounted, suggesting that knowledge of and experience with the nuances of these procedures are essential for patient safety. The present article describes the complications specific to a variety of minimally invasive spinal surgeries and provides guidance on how to avoid them.
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Affiliation(s)
| | - Frank M Phillips
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Walker CT, Farber SH, Cole TS, Xu DS, Godzik J, Whiting AC, Hartman C, Porter RW, Turner JD, Uribe J. Complications for minimally invasive lateral interbody arthrodesis: a systematic review and meta-analysis comparing prepsoas and transpsoas approaches. J Neurosurg Spine 2019; 30:446-460. [PMID: 30684932 DOI: 10.3171/2018.9.spine18800] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 09/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive anterolateral retroperitoneal approaches for lumbar interbody arthrodesis have distinct advantages attractive to spine surgeons. Prepsoas or transpsoas trajectories can be employed with differing complication profiles because of the inherent anatomical differences encountered in each approach. The evidence comparing them remains limited because of poor quality data. Here, the authors sought to systematically review the available literature and perform a meta-analysis comparing the two techniques. METHODS A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A database search was used to identify eligible studies. Prepsoas and transpsoas studies were compiled, and each study was assessed for inclusion criteria. Complication rates were recorded and compared between approach groups. Studies incorporating an analysis of postoperative subsidence and pseudarthrosis rates were also assessed and compared. RESULTS For the prepsoas studies, 20 studies for the complications analysis and 8 studies for the pseudarthrosis outcomes analysis were included. For the transpsoas studies, 39 studies for the complications analysis and 19 studies for the pseudarthrosis outcomes analysis were included. For the complications analysis, 1874 patients treated via the prepsoas approach and 4607 treated with the transpsoas approach were included. In the transpsoas group, there was a higher rate of transient sensory symptoms (21.7% vs 8.7%, p = 0.002), transient hip flexor weakness (19.7% vs 5.7%, p < 0.001), and permanent neurological weakness (2.8% vs 1.0%, p = 0.005). A higher rate of sympathetic nerve injury was seen in the prepsoas group (5.4% vs 0.0%, p = 0.03). Of the nonneurological complications, major vascular injury was significantly higher in the prepsoas approach (1.8% vs 0.4%, p = 0.01). There was no difference in urological or peritoneal/bowel injury, postoperative ileus, or hematomas (all p > 0.05). A higher infection rate was noted for the transpsoas group (3.1% vs 1.1%, p = 0.01). With regard to postoperative fusion outcomes, similar rates of subsidence (12.2% prepsoas vs 13.8% transpsoas, p = 0.78) and pseudarthrosis (9.9% vs 7.5%, respectively, p = 0.57) were seen between the groups at the last follow-up. CONCLUSIONS Complication rates vary for the prepsoas and transpsoas approaches owing to the variable retroperitoneal anatomy encountered during surgical dissection. While the risks of a lasting motor deficit and transient sensory disturbances are higher for the transpsoas approach, there is a reciprocal reduction in the risks of major vascular injury and sympathetic nerve injury. These results can facilitate informed decision-making and tailored surgical planning regarding the choice of minimally invasive anterolateral access to the spine.
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Eguchi Y, Norimoto M, Suzuki M, Haga R, Yamanaka H, Tamai H, Kobayashi T, Orita S, Suzuki M, Inage K, Kanamoto H, Abe K, Umimura T, Sato T, Aoki Y, Watanabe A, Koda M, Furuya T, Nakamura J, Akazawa T, Takahashi K, Ohtori S. Diffusion tensor tractography of the lumbar nerves before a direct lateral transpsoas approach to treat degenerative lumbar scoliosis. J Neurosurg Spine 2019; 30:461-469. [PMID: 30684934 DOI: 10.3171/2018.9.spine18834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the relationship between vertebral bodies, psoas major morphology, and the course of lumbar nerve tracts using diffusion tensor imaging (DTI) before lateral interbody fusion (LIF) to treat spinal deformities. METHODS DTI findings in a group of 12 patients (all women, mean age 74.3 years) with degenerative lumbar scoliosis (DLS) were compared with those obtained in a matched control group of 10 patients (all women, mean age 69.8 years) with low-back pain but without scoliosis. A T2-weighted sagittal view was fused to tractography from L3 to L5 and separated into 6 zones (zone A, zones 1-4, and zone P) comprising equal quarters of the anteroposterior diameters, and anterior and posterior to the vertebral body, to determine the distribution of nerves at various intervertebral levels (L3-4, L4-5, and L5-S1). To determine psoas morphology, the authors examined images for a rising psoas sign at the level of L4-5, and the ratio of the anteroposterior diameter (AP) to the lateral diameter (lat), or AP/lat ratio, was calculated. They assessed the relationship between apical vertebrae, psoas major morphology, and the course of nerve tracts. RESULTS Although only 30% of patients in the control group showed a rising psoas sign, it was present in 100% of those in the DLS group. The psoas major was significantly extended on the concave side (AP/lat ratio: 2.1 concave side, 1.2 convex side). In 75% of patients in the DLS group, the apex of the curve was at L2 or higher (upper apex) and the psoas major was extended on the concave side. In the remaining 25%, the apex was at L3 or lower (lower apex) and the psoas major was extended on the convex side. Significant anterior shifts of lumbar nerves compared with controls were noted at each intervertebral level in patients with DLS. Nerves on the extended side of the psoas major were significantly shifted anteriorly. Nerve pathways on the convex side of the scoliotic curve were shifted posteriorly. CONCLUSIONS A significant anterior shift of lumbar nerves was noted at all intervertebral levels in patients with DLS in comparison with findings in controls. On the convex side, the nerves showed a posterior shift. In LIF, a convex approach is relatively safer than an approach from the concave side. Lumbar nerve course tracking with DTI is useful for assessing patients with DLS before LIF.
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Affiliation(s)
| | - Masaki Norimoto
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | | | - Ryota Haga
- 3Radiology, Shimoshizu National Hospital, Yotsukaido, Chiba
| | | | | | | | - Sumihisa Orita
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Miyako Suzuki
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Kazuhide Inage
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Hirohito Kanamoto
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Koki Abe
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Tomotaka Umimura
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Takashi Sato
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Yasuchika Aoki
- 4Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Chiba
| | - Atsuya Watanabe
- 4Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Chiba
| | - Masao Koda
- 5Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba City, Ibaraki; and
| | - Takeo Furuya
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Junichi Nakamura
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Tsutomu Akazawa
- 6Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Kazuhisa Takahashi
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Seiji Ohtori
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
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Evaluation of retraction time as a predictor of postoperative motor dysfunction after minimally invasive transpsoas interbody fusion at L4-L5. J Clin Neurosci 2019; 61:124-129. [DOI: 10.1016/j.jocn.2018.10.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/27/2018] [Indexed: 11/24/2022]
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Ebata S, Ohba T, Haro H. New Intramuscular Electromyographic Monitoring with a Probe in Lateral Lumbar Interbody Fusion Surgery. Spine Surg Relat Res 2019; 3:106-111. [PMID: 31435562 PMCID: PMC6690128 DOI: 10.22603/ssrr.2018-0079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/03/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The lateral lumbar interbody fusion (LLIF) surgical approach is minimally invasive and safely accesses the target region. Therefore, it is widely used in cases of lumbar spinal stenosis and spinal deformity. Intraoperative neuromonitoring is necessary to avoid nerve injury, whereas postoperative anterior thigh symptoms are not necessarily prevented. TECHNICAL NOTE In our institute, 85 LLIF operations have been performed. The first 30 cases were excluded from the present study to avoid surgical learning curve effects; conventional monitoring was used in 30 cases, whereas a new method with a probe to monitor intramuscular potential was used in 25 other cases. Anterior thigh symptoms and motor deficits were assessed postoperatively. The location of the electromyographic threshold decrease was at the posterior part of the disc at L2-3, but at the anterior part at L4-5. Compared with conventional monitoring, the new intramuscular monitoring significantly decreased the prevalence of motor deficits of the iliopsoas at 1 day and 30 days; anterior thigh pain at 1 day, 30, and 90 days; and anterior thigh numbness at 30 and 90 days postoperatively. CONCLUSIONS Compared with conventional monitoring, the new intramuscular monitoring with a less invasive probe may reduce anterior thigh symptoms.
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Affiliation(s)
- Shigeto Ebata
- Department of Orthopaedic Surgery, Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Hirotaka Haro
- Department of Orthopaedic Surgery, Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
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Fogel GR, Rosen L, Koltsov JCB, Cheng I. Neurologic adverse event avoidance in lateral lumbar interbody fusion: technical considerations using muscle relaxants. JOURNAL OF SPINE SURGERY 2018; 4:247-253. [PMID: 30069514 DOI: 10.21037/jss.2018.06.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The retroperitoneal trans-psoas extreme lateral interbody fusion (XLIF) technique has improved over the last decade with increased efficiency and an emphasis on complication avoidance. After all known procedural safeguards are enacted, the most common failure of neuro-monitoring precision may be the use of non-depolarizing muscle relaxants (MR) for induction that is standard of care for anesthesia. Even when non-depolarizing MRs are minimized there is often a small dose given to decrease risk of vocal cord injury with intubation. The most common neurological adverse events (AE) attendant to the lateral approach are thigh dysesthetic pain and hip flexor weakness. The purpose of this study is to present a consecutive series of L3-4 and L4-5 XLIF patients treated by a single surgeon using all procedural safeguards with and without the use of a low dose of non-depolarizing MRs prior to intubation. Methods A retrospective review of 74 consecutive patients treated at 150 levels with XLIF and no muscle relaxants (NMR) were compared to a group of 124 consecutive XLIF patients treated at 238 levels with MR. The surgeon upon discovering a small dose of rocuronium was used for intubation, questioned the effect on the neuromonitoring and NMR group was begun. All procedural technique details remained the same. All patients had XLIF at L3-4, L4-5, or both levels. Perioperative variables were collected, including evoked and free-run EMG readings and postoperative neural and muscular side effects. Hospital records including progress notes describing postoperative symptoms and anesthesia records describing the drugs, dosages, and timing were studied. Clinical records were reviewed at 1, 3 and 6 months for complaints of neurologic AE. Results NMR patients had a perfect twitch test (>99%) immediately. MR patients had slower arrival of the twitch and often settled at a lower level (80-92%). No surgery was attempted until the twitch test was at least 80%. NMR had 8/74 (10.8%) and MR 36/125 (28.8%) thigh AE (thigh dysthetic pain) at 1 month (P<0.005). No lower extremity weaknesses (femoral nerve injury) were observed in the NMR group and three in the MR group. All NMR thigh AEs resolved by the third month postoperative visit compared with 17/125 at 3 months (P=0.001) and 6/125 at 6 months (P=0.176) with persistent thigh AEs in the MR group. Conclusions Eliminating MRs altogether appears to have allowed the evoked and free running EMG to be more reliable and accurate in predicting the proximity of the neurologic structures. Thigh AEs related to neural and muscular integrity in NMR patients were limited and eliminated by the 3rd month. The MR group was significantly more likely to have a thigh AE at 1 month and persistent at 3 months. Neurologic AEs may be limited or eliminated when MRs are avoided in lateral lumbar fusion surgery.
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Affiliation(s)
- Guy R Fogel
- Spine Pain Be Gone Clinic, San Antonio, TX, USA
| | | | | | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Pimenta L, Tohmeh A, Jones D, Amaral R, Marchi L, Oliveira L, Pittman BC, Bae H. Rational decision making in a wide scenario of different minimally invasive lumbar interbody fusion approaches and devices. JOURNAL OF SPINE SURGERY 2018; 4:142-155. [PMID: 29732435 DOI: 10.21037/jss.2018.03.09] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
With the proliferation of a variety of modern MIS spine surgery procedures, it is mandatory that the surgeon dominate all aspects involved in surgical indication. The information related to the decision making in patient selection for specific procedures is mandatory for surgical success. The objective of this study is to present decision-making criteria in minimally invasive surgery (MIS) selection for a variety of patients and pathologies. In this article, practicing surgeons who specialize in various MIS approaches for spinal fusion were engaged to provide expert opinion and literature review on decision making criteria for several MIS procedures. Pros, cons, relative limitations, and case examples are provided for patient selection in treatment with MIS posterolateral fusion (MIS-PLF), mini anterior lumbar interbody fusion (mini-ALIF), lateral interbody fusion (LLIF), MIS posterior lumbar interbody fusion (MIS-PLIF) and MIS transforaminal lumbar interbody fusion (MIS-TLIF). There is a variety of aspects to consider when deciding which modern MIS surgical approach is most appropriate to use based on patient and pathologic characteristics. The surgeon must adapt them to the characteristic of each type of patients, helping them to choose the most effective and efficient therapeutic option for each case.
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Affiliation(s)
- Luiz Pimenta
- Instituto de Patalogia da Coluna (IPC), São Paulo, SP, Brazil
| | | | - David Jones
- Carolina Spine and Neurosurgery Associates, Greensboro, NC, USA
| | - Rodrigo Amaral
- Instituto de Patalogia da Coluna (IPC), São Paulo, SP, Brazil
| | - Luis Marchi
- Instituto de Patalogia da Coluna (IPC), São Paulo, SP, Brazil
| | | | - Bruce C Pittman
- Carolina Spine and Neurosurgery Associates, Greensboro, NC, USA
| | - Hyun Bae
- Cedars-Sinai, Los Angeles, CA, USA
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Hadley MN, Shank CD, Rozzelle CJ, Walters BC. Guidelines for the Use of Electrophysiological Monitoring for Surgery of the Human Spinal Column and Spinal Cord. Neurosurgery 2017; 81:713-732. [DOI: 10.1093/neuros/nyx466] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/05/2017] [Indexed: 01/12/2023] Open
Affiliation(s)
- Mark N Hadley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christopher D Shank
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Curtis J Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beverly C Walters
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Liu X, Joseph JR, Smith BW, Saadeh Y, Park P. Analysis of Intraoperative Cone-Beam Computed Tomography Combined With Image Guidance for Lateral Lumbar Interbody Fusion. Oper Neurosurg (Hagerstown) 2017; 14:620-626. [DOI: 10.1093/ons/opx176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/13/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Minimally invasive lateral lumbar interbody fusion (LLIF) is traditionally performed with biplanar fluoroscopy. Recent literature demonstrates that intraoperative cone-beam computed tomography combined with spinal navigation can be safely utilized for localization and cage placement in LLIF.
OBJECTIVE
To evaluate the accuracy and safety of cage placement using spinal navigation in LLIF, as well as to evaluate the radiation exposure to surgeon and staff during the procedure.
METHODS
The authors performed a retrospective analysis of a prospectively acquired database of patients undergoing LLIF with image-based navigation performed from April 2014 to July 2016 at a single institution. The medical records were reviewed, and data on clinical outcomes, cage accuracy, complications, and radiation exposure were recorded. All patients underwent a minimum 30-d clinical follow-up to assess intraoperative and short-term complications associated with their LLIF.
RESULTS
Sixty-three patients comprising 117 spinal levels were included in the study. There were 36 (57.1%) female and 27 (42.9%) male patients. Mean age was 62.7 yr (range 24-79 yr). A mean 1.9 (range 1-4) levels per patient were treated. Cages were placed in the anterior or middle of 115 (98.3%) disc spaces. Image-guided cage trajectory was accurate in 116/117 levels (99.1%). In a subgroup analysis of 18 patients, mean fluoroscopy time was 11.7 ± 9.7 s per level. Sixteen (25.4%) patients experienced a complication related to approach.
CONCLUSION
Use of intraoperative cone-beam computed tomography combined with spinal navigation for LLIF results in accurate and safe cage placement as well as significantly decreased surgeon and staff radiation exposure.
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Affiliation(s)
- Xilin Liu
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Jacob R Joseph
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Yamaan Saadeh
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Abel NA, Januszewski J, Vivas AC, Uribe JS. Femoral nerve and lumbar plexus injury after minimally invasive lateral retroperitoneal transpsoas approach: electrodiagnostic prognostic indicators and a roadmap to recovery. Neurosurg Rev 2017; 41:457-464. [PMID: 28560607 DOI: 10.1007/s10143-017-0863-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/12/2017] [Indexed: 10/19/2022]
Abstract
Injury to the lumbosacral (LS) plexus is a well-described complication after lateral retroperitoneal transpsoas approaches to the spine. The prognosis for functional recovery after lumbosacral plexopathy or femoral/obturator neuropathy is unclear. We designed a retrospective case-control study with patients undergoing one-level lateral retroperitoneal transpsoas lumbar interbody fusion (LLIF) between January 2011 and June 2016 to correlate electrodiagnostic assessments (EDX) to physiologic concepts of nerve injury and reinnervation, and attempt to build a timeline for patient evaluation and recovery. Cases with post-operative obturator or femoral neuropathy were identified. Post-operative MRI, nerve conduction studies (NCS), electromyography (EMG), and physical examinations were performed at intervals to assess clinical and electrophysiologic recovery of function. Two hundred thirty patients underwent LLIF. Six patients (2.6%) suffered severe femoral or femoral/obturator neuropathy. Five patients (2.2%) had immediate post-operative weakness. One of the six patients developed delayed weakness due to a retroperitoneal hematoma. Five out of six patients (83%) demonstrated EDX findings at 6 weeks consistent with axonotmesis. All patients improved to at least MRC 4/5 within 12 months of injury. In conclusion, neurapraxia is the most common LS plexus injury, and complete recovery is expected after 3 months. Most severe nerve injuries are a combination of neurapraxia and variable degrees of axonotmesis. EDX performed at 6 weeks and 3, 6, and 9 months provides prognostic information for recovery. In severe injuries of proximal femoral and obturator nerves, observation of proximal to distal progression of small-amplitude, short-duration (SASD) motor unit potentials may be the most significant prognostic indicator.
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Affiliation(s)
- Naomi A Abel
- Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA
| | - Jacob Januszewski
- Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA.
| | - Andrew C Vivas
- Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA
| | - Juan S Uribe
- Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA
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Oikawa Y, Eguchi Y, Watanabe A, Orita S, Yamauchi K, Suzuki M, Sakuma Y, Kubota G, Inage K, Sainoh T, Sato J, Fujimoto K, Koda M, Furuya T, Matsumoto K, Masuda Y, Aoki Y, Takahashi K, Ohtori S. Anatomical evaluation of lumbar nerves using diffusion tensor imaging and implications of lateral decubitus for lateral transpsoas approach. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2804-2810. [PMID: 28389885 DOI: 10.1007/s00586-017-5082-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/19/2017] [Accepted: 03/30/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Recently, lateral interbody fusion (LIF) has become more prevalent, and evaluation of lumbar nerves has taken on new importance. We report on the assessment of anatomical relationships between lumbar nerves and vertebral bodies using diffusion tensor imaging (DTI). METHODS Fifty patients with degenerative lumbar disease and ten healthy subjects underwent DTI. In patients with lumbar degenerative disease, we studied nerve courses with patients in the supine positions and with hips flexed. In healthy subjects, we evaluated nerve courses in three different positions: supine with hips flexed (the standard position for MRI); supine with hips extended; and the right lateral decubitus position with hips flexed. In conjunction with tractography from L3 to L5 using T2-weighted sagittal imaging, the vertebral body anteroposterior span was divided into four equally wide zones, with six total zones defined, including an anterior and a posterior zone (zone A, zones 1-4, zone P). We used this to characterize nerve courses at disc levels L3/4, L4/5, and L5/S1. RESULTS In patients with degenerative lumbar disease, in the supine position with hips flexed, all lumbar nerve roots were located posterior to the vertebral body centers in L3/4 and L4/5. In healthy individuals, the L3/4 nerve courses were displaced forward in hips extended compared with the standard position, whereas in the lateral decubitus position, the L4/5 and L5/S nerve courses were displaced posteriorly compared with the standard position. CONCLUSIONS The L3/4 and L4/5 nerve roots are located posterior to the vertebral body center. These were found to be offset to the rear when the hip is flexed or the lateral decubitus position is assumed. The present study is the first to elucidate changes in the course of the lumbar nerves as this varies by position. The lateral decubitus position or the position supine with hips flexed may be useful for avoiding nerve damage in a direct lateral transpsoas approach. Preoperative DTI seems to be useful in evaluating the lumbar nerve course as it relates anatomically to the vertebral body.
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Affiliation(s)
- Yasuhiro Oikawa
- Division of Orthopaedic Surgery, Chiba Children's Hospital, 579-1 Heta-Chou, Midori-ku, Chiba, 266-0007, Japan
| | - Yawara Eguchi
- Department of Orthopeadic Surgery, Shimoshizu National Hospital, 934-5, Shikawatashi, Yotsukaido, Chiba, 284-0003, Japan.
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2, Okayamadai, Togane, Chiba, 283-8686, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kazuyo Yamauchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Miyako Suzuki
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yoshihiro Sakuma
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Go Kubota
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2, Okayamadai, Togane, Chiba, 283-8686, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takeshi Sainoh
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Jun Sato
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kazuki Fujimoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masao Koda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Koji Matsumoto
- Department of Radiology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yoshitada Masuda
- Department of Radiology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2, Okayamadai, Togane, Chiba, 283-8686, Japan
| | - Kazuhisa Takahashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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Turel MK, Kerolus MG, O'Toole JE. Minimally invasive "separation surgery" plus adjuvant stereotactic radiotherapy in the management of spinal epidural metastases. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:119-126. [PMID: 28694595 PMCID: PMC5490345 DOI: 10.4103/jcvjs.jcvjs_13_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Aim: This study aimed to describe the application of minimally invasive surgery (MIS) in separation surgery combined with postoperative stereotactic body radiation therapy (SBRT) in patients with symptomatic metastatic epidural spinal disease. Methods: Three techniques are described: (1) MIS posterior separation surgery alone, (2) MIS posterolateral separation surgery with percutaneous pedicle screw placement, and (3) MIS lateral corpectomy with percutaneous pedicle screw placement. Seven representative cases are presented in which the above techniques were applied and after which postoperative SBRT was performed. Results: The seven representative patients (3 male, 4 female) had a mean age of 54 years (range, 46–62 years). Two patients had a primary diagnosis of cholangiocarcinoma and in one patient each a diagnosis of breast, renal, lung adenocarcinoma, melanoma, and urothelial squamous cell carcinoma as their primary tumor. All patients had additional multiorgan disease apart from the metastatic spine involvement. Three patients underwent operations in the lumbar spine, two in the thoracic spine, and one in each of the thoraco-lumbar and lumbo-sacral spine. The average operating time was 149 ± 60.3 min (range, 90–240 min). The mean estimated blood loss was 188.8 cc. The mean length of stay in the hospital was 4 days (range, 3–7 days). There were no surgical complications. All patients received postoperative SBRT (typically 24 Gy in 3 fractions) at a mean of 43.2 days after surgery (range, 30–83). Conclusions: Early reports such as this suggest that MIS techniques can be successfully and safely applied in accomplishing “separation surgery” with adjuvant SBRT in the management of metastatic spinal disease. The potential advantages conferred by MIS techniques such as shortened hospital stay, decreased blood loss, reduced perioperative complications, and earlier initiation of adjuvant radiation are highly desirable in the treatment of this challenging patient population.
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Affiliation(s)
- Mazda K Turel
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mena G Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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Perioperative Complications in 155 Patients Who Underwent Oblique Lateral Interbody Fusion Surgery: Perspectives and Indications From a Retrospective, Multicenter Survey. Spine (Phila Pa 1976) 2017; 42:55-62. [PMID: 27116114 DOI: 10.1097/brs.0000000000001650] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective multicenter survey. OBJECTIVE To investigate the perioperative complications of oblique lateral interbody fusion (OLIF) surgery. SUMMARY OF BACKGROUND DATA OLIF has been widely performed to achieve minimally invasive, rigid lumbar lateral interbody fusion. The associated perioperative complications are not yet well described. METHODS The participants were patients who underwent OLIF surgery under the diagnosis of degenerative lumbar diseases between April 2013 and May 2015 at 11 affiliated medical institutions. The collected data were classified into intraoperative and early-stage postoperative (≤1 mo) complications. The intraoperative complications were then subcategorized into organ damage (neural, vertebral, vascular, and others) and other complications, mainly related to instrumental failure. The collected data were also divided and analyzed based on whether the surgeon was certified to perform the surgery and the incidence of complications in the early (April 2013-March 2014) and late stages (April 2014-May 2015) of OLIF introduction. RESULTS In the 155 included patients, 75 complications were reported (incidence rate, 48.3%). The most common complication was endplate fracture/subsidence (18.7%), followed by transient psoas weakness and thigh numbness (13.5%) and segmental artery injury (2.6%). Almost all these complications were transient, except for three patients who had permanent damage: one had ureteral injury and two had neurological injury. Postoperative complications included surgical site infection (1.9%) and reoperation (1.9%). Whether the primary operator was experienced did not affect the incidence of complications. Regarding the introductory stage, the incidence of complications was 50% in the early stage and 38% in the late stage. CONCLUSION The overall incidence of perioperative complications of OLIF surgery reached 48.3%, of which only 1.9% resulted in permanent damage. Our analysis based on surgeon experience indicated that the OLIF procedure could be performed without increasing incidence of complications, under the guidance of experienced supervisors. LEVEL OF EVIDENCE 3.
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Keorochana G, Setrkraising K, Woratanarat P, Arirachakaran A, Kongtharvonskul J. Clinical outcomes after minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion for treatment of degenerative lumbar disease: a systematic review and meta-analysis. Neurosurg Rev 2016; 41:755-770. [PMID: 28013419 DOI: 10.1007/s10143-016-0806-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 11/13/2016] [Accepted: 12/07/2016] [Indexed: 01/03/2023]
Abstract
The surgical procedures used for arthrodesis in the lumbar spine for degenerative lumbar diseases remain controversial. This systematic review aims to assess and compare clinical outcomes along with the complications and fusion of each technique (minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) or minimally invasive lateral lumbar interbody fusion (MIS LLIF)) for treatment of degenerative lumbar diseases. Relevant studies were identified from Medline and Scopus from inception to July 19, 2016 that reported Oswestry Disability Index (ODI), back and leg pain visual analog score (VAS), postoperative complications, and fusion of either technique. Fifty-eight studies were included for the analysis of MIS-TLIF; 40 studies were included for analysis of LLIF, and 1 randomized controlled trial (RCT) study was included for comparison of MIS-TLIF to LLIF. Overall, there were 9506 patients (5728 in the MIS-TLIF group and 3778 in the LLIF group). Indirect meta-analysis, MIS-TLIF provided better postoperative back and leg pain (VAS), disabilities (ODI), and risk of having complications when compared to LLIF technique, but the fusion rate was not significantly different between the two techniques. However, direct meta-analysis between RCT study and pooled indirect meta-analysis of MIS-TLIF have better pain, disabilities, and complication but no statistically significant difference when compared to LLIF. In LLIF, the pooled mean ODI and VAS back pain were 2.91 (95% CI 2.49, 3.33) and 23.24 (95% CI 18.96, 27.51) in MIS approach whereas 3.14 (95% CI 2.29, 4.04) and 28.29 (95% CI 21.92, 34.67) in traditional approach. In terms of complications and fusion rate, there was no difference in both groups. In lumbar interbody fusion, MIS-TLIF had better ODI, VAS pain, and complication rate when compared to LLIF with direct and indirect meta-analysis methods. However, in terms of fusion rates, there were no differences between the two techniques.
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Affiliation(s)
- Gun Keorochana
- Orthopedics Department, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Patarawan Woratanarat
- Orthopedics Department, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Jatupon Kongtharvonskul
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand.
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Abstract
The number of surgeries performed for adult spinal deformity (ASD) has been increasing due to an aging population, longer life expectancy, and studies supporting an improvement in health-related quality of life scores after operative intervention. However, medical and surgical complication rates remain high, and neurological complications such as spinal cord injury and motor deficits can be especially debilitating to patients. Several independent factors potentially influence the likelihood of neurological complications including surgical approach (anterior, lateral, or posterior), use of osteotomies, thoracic hyperkyphosis, spinal region, patient characteristics, and revision surgery status. The majority of ASD surgeries are performed by a posterior approach to the thoracic and/or lumbar spine, but anterior and lateral approaches are commonly performed and are associated with unique neural complications such as femoral nerve palsy and lumbar plexus injuries. Spinal morphology, such as that of hyperkyphosis, has been reported to be a risk factor for complications in addition to three-column osteotomies, which are often utilized to correct large deformities. Additionally, revision surgeries are common in ASD and these patients are at an increased risk of procedure-related complications and nervous system injury. Patient selection, surgical technique, and use of intraoperative neuromonitoring may reduce the incidence of complications and optimize outcomes.
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Affiliation(s)
- Justin A Iorio
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Patrick Reid
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Han Jo Kim
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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