Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach

The Association Between Corrective Surgery for Adult Spinal Deformity and Serum Levels of Hepatobiliary Enzymes

Background and objective The surgery to correct adult spinal deformity (ASD) is associated with a rare, but life-threatening complication called acute celiac artery compression syndrome (ACACS). To our knowledge, there is currently no study in the literature regarding the abnormal elevation of serum levels of hepatobiliary enzymes after surgery to correct the deformity. In light of this, the purpose of this study was to investigate this potential association. Materials and methods We collected data on 74 patients with ASD who underwent correction surgery at our institution. A Spearman's rank-order correlation was used to assess the association between serum levels of hepatobiliary enzymes and spinal parameters. Factors showing a correlation coefficient of 0.2 or more were combined in a stepwise multiple regression analysis. Results The mean age of the patients was 68.4 ± 7.7 years; the study comprised six men and 68 women. In our stepwise multiple regression analysis, there were two valid models that included spinal parameters as independent variables: changes in lactate dehydrogenase (LDH) - changes in thoracolumbar kyphosis (TLK) (B -0.0025 ± 0.0007, p<0.01), and changes in LDH - preoperative T12-L1 kyphosis (B 0.0031 ± 0.001, p<0.01). Additionally, both valid models contained median arcuate ligament (MAL) overlap defined as MAL crossing the base of the celiac artery (CA) as a significant independent variable. Conclusions Greater sagittal correction of TLK, larger preoperative T12-L1 kyphosis, and MAL overlap were factors associated with an elevated serum level of LDH. Although few patients were reported to have clinically severe symptoms, "potential" ACACS due to a temporary blood flow disturbance can occur in this patient population.

Single-Position Lateral Approach for Revision Thoracolumbar Corpectomy With Delayed Ipsilateral Kidney Atrophy: Technical Note and Discussion of Complications

Improvements in navigation technology have enabled surgeons to safely offer single-position fusion surgeries, demonstrating shorter operating times and reduced length of stay (LOS) as compared to traditional lateral and prone dual-position surgeries. However, no studies to date describe revision thoracolumbar corpectomy with simultaneous posterior rod removal and replacement in the lateral position. Furthermore, this is the first reported complication of delayed ipsilateral kidney atrophy following lateral lumbar surgery. A 56-year-old male patient with history of metastatic hepatocellular carcinoma and complex surgical history for a prior T12 pathologic fracture presented to the clinic for follow-up. Computed tomography (CT) demonstrated bilateral broken rods and subsidence of the T12 interbody cage, for which he underwent revision T12 corpectomy and posterior instrumentation revision via a single-position, left-sided lateral approach. Simultaneous exposure and removal of the broken rods enabled the placement of two short temporary rods between the T11-L1 screws posteriorly, allowing for rod distraction and the placement of the expandable corpectomy cage into the appropriate position. On follow-up cancer surveillance imaging, the left kidney became progressively atrophic within six months after surgery. According to a review of PubMed, Scopus, and Embase databases, we describe the first reported case of a single-position thoracolumbar revision corpectomy with simultaneous rod replacement. Of particular importance in this technique is the use of temporary rod placement for distraction across the index level to facilitate interbody cage placement. Furthermore, we discussed the first reported complication of delayed ipsilateral kidney atrophy following lateral lumbar fusion.

Fluoroscopy-based percutaneous posterior screw placement in the lateral position using the tunnel view technique: technical note

PURPOSE

Lumbar fusion using lateral single position surgery (LSPS) gained popularity during the last few years. While prone percutaneous pedicle screw placement is well described, placing percutaneous pedicle screws with the patient in the lateral position is considered the most complicated part of LSPS. In this article we describe the fluoroscopy navigated technique for lateral percutaneous screw placement using the tunnel view technique.

METHODS

The radiologic background and principles of the tunnel view technique are described. In addition, the special positioning of the patient, the C-arm and the surgical technique is discussed in detail.

RESULTS

This technique is used as the standard for percutaneous screw placement in the prone or lateral positions in our department since 2017. Since the introduction of this technique we have had 0% reoperation rate for symptomatic malpositioned pedicle screws.

CONCLUSION

The tunnel view technique simplifies pedicle screw placement while allowing for permanent observation of pedicle walls and the superior joint surface during placement of the Jamshidi needle. It also allows for confirmation of intrapedicular position of the screw after its implantation. This technique is safe and feasible in our clinical experience.

Incidence of major and minor vascular injuries during lateral access lumbar interbody fusion procedures: a retrospective comparative study and systematic literature review

During lateral lumbar fusion, the trajectory of implant insertion approaches the great vessels anteriorly and the segmental arteries posteriorly, which carries the risk of vascular complications. We aimed to analyze vascular injuries for potential differences between oblique lateral interbody fusion (OLIF) and lateral lumbar interbody fusion (LLIF) procedures at our institution. This was coupled with a systematic literature review of vascular complications associated with lateral lumbar fusions. A retrospective chart review was completed to identify consecutive patients who underwent lateral access fusions. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used for the systematic review with the search terms "vascular injury" and "lateral lumbar surgery." Of 260 procedures performed at our institution, 211 (81.2%) patients underwent an LLIF and 49 (18.8%) underwent an OLIF. There were no major vascular complications in either group in this comparative study, but there were four (1.5%) minor vascular injuries (2 LLIF, 0.95%; 2 OLIF, 4.1%). Patients who experienced vascular injury experienced a greater amount of blood loss than those who did not (227.5 ± 147.28 vs. 59.32 ± 68.30 ml) (p = 0.11). In our systematic review of 63 articles, major vascular injury occurred in 0-15.4% and minor vascular injury occurred in 0-6% of lateral lumbar fusions. The systematic review and comparative study demonstrate an increased rate of vascular injury in OLIF when compared to LLIF. However, vascular injuries in either procedure are rare, and this study aids previous literature to support the safety of both approaches.

Expert Consensus on Clinical Application of Lateral Lumbar Interbody Fusion: Results From a Modified Delphi Study

STUDY DESIGN

Modified Delphi study.

OBJECTIVE

The objective of this study was to establish expert consensus on the application of lateral lumbar interbody fusion (LLIF) by using the modified Delphi study.

METHODS

From June 2019 to March 2020, Members of the Chinese Study Group for Lateral Lumbar Spine Surgery were selected to collect expert feedback using the modified Delphi method where 65 spine surgeons from all over China agreed to participate. Four rounds were performed: 1 face-to-face meeting and 3 subsequent survey rounds. The consensus was achieved with ≥a 70.0% agreement for each question. The recommendation of grade A was defined as ≥90.0% of the agreement for each question. The recommendation of grade B was defined as 80.0-89.9% of the agreement for each question. The recommendation of grade C was defined as 70.0-79.9% of the agreement for each question.

RESULTS

A total of 65 experts formed a panelist group, and the number of questionnaires collected was 63, 59, and 62 in the 3 rounds. In total, 5 sections, 71 questions, and 382 items achieved consensus after the Delphi rounds including summary; preoperative evaluation; application at the lumbar spinal stenosis, lumbar disc herniation, lumbar spondylolisthesis, adult degenerative scoliosis, postoperative adjacent segmental degeneration, and revision surgery; complications; and postoperative follow-up evaluation of LLIF.

CONCLUSION

The modified Delphi method was utilized to ascertain an expert consensus from the Chinese Study Group for Lateral Lumbar Spine Surgery to inform clinical decision-making in the application of LLIF. The salient grade A recommendations of the survey are enumerated.

[Abdominal pseudohernia: diagnosis and treatment]

OBJECTIVE

To present an effective treatment strategy for abdominal pseudohernia considering own clinical experience and literature data.

MATERIAL AND METHODS

The authors report surgical treatment of 2 patients and therapeutic management of 1 patient with abdominal pseudohernia. Moreover, current state of this problem is analyzed according to literature data in Pubmed, Google and e-library databases.

RESULTS. P

Seudohernia is followed by asymmetrical protrusion of abdominal wall, prolapsed site is not involved in breathing; patients cannot tense muscles in the affected area. T8-L2 skin sensitivity impairment or hyperesthesia may be observed. Denervation is confirmed by electroneuromyography. Ultrasound, CT and MRI reveal no defect in abdominal wall. However, its thinning within denervation area is visualized. Treatment is determined by the cause and reversibility of denervation. If mechanical damage (intersection) of T8-L2 nerves following trauma or any manipulation is absent, the main cause is herpes zoster neuropathy. Surgical treatment is not indicated. Antiherpetic therapy and physical therapy result functional restoration of abdominal wall muscles within 2-4 months. In case of mechanical cause of pseudohernia, it is advisable to wait at least a year after denervation for real assessment of situation. Partial or complete re-innervation is possible throughout this period. Surgical treatment is indicated if re-innervation is absent. An effective technique presented in this manuscript is reconstruction of the prolapsed area with several imbrication sutures in several planes up to symmetry with contralateral area with subsequent reinforcement with a mesh implant if necessary. There were no relapses in 2 our patients within 5 and 7 years, respectively.

CONCLUSION

In our opinion, this report is the first manuscript devoted to systematic analysis of diagnosis and treatment of abdominal pseudohernia in available literature. Surgical treatment is not indicated for postherpetic pseudohernia. It is carried out for pseudohernia persisting for more than 1 year if its cause is trauma or any manipulation.

Single-position prone lateral approach: cadaveric feasibility study and early clinical experience

OBJECTIVE

Lateral lumbar interbody fusion (LLIF) is a useful minimally invasive technique for achieving anterior interbody fusion and preserving or restoring lumbar lordosis. However, achieving circumferential fusion via posterior instrumentation after an LLIF can be challenging, requiring either repositioning the patient or placing pedicle screws in the lateral position. Here, the authors explore an alternative single-position approach: LLIF in the prone lateral (PL) position.

METHODS

A cadaveric feasibility study was performed using 2 human cadaveric specimens. A retrospective 2-center early clinical series was performed for patients who had undergone a minimally invasive lateral procedure in the prone position between August 2019 and March 2020. Case duration, retractor time, electrophysiological thresholds, implant size, screw accuracy, and complications were recorded. Early postoperative radiographic outcomes were reported.

RESULTS

A PL LLIF was successfully performed in 2 cadavers without causing injury to a vessel or the bowel. No intraoperative subsidence was observed. In the clinical series, 12 patients underwent attempted PL surgery, although 1 case was converted to standard lateral positioning. Thus, 11 patients successfully underwent PL LLIF (89%) across 14 levels: L2–3 (2 of 14 [14%]), L3–4 (6 of 14 [43%]), and L4–5 (6 of 14 [43%]). For the 11 PL patients, the mean (± SD) age was 61 ± 16 years, mean BMI was 25.8 ± 4.8, and mean retractor time per level was 15 ± 6 minutes with the longest retractor time at L2–3 and the shortest at L4–5. No intraoperative subsidence was noted on routine postoperative imaging.

CONCLUSIONS

Performing single-position lateral transpsoas interbody fusion with the patient prone is anatomically feasible, and in an early clinical experience, it appeared safe and reproducible. Prone positioning for a lateral approach presents an exciting opportunity for streamlining surgical access to the lumbar spine and facilitating more efficient surgical solutions with potential clinical and economic advantages.

Differences in radiographic and clinical outcomes of oblique lateral interbody fusion and lateral lumbar interbody fusion for degenerative lumbar disease: a meta-analysis

Background

In the current surgical therapeutic regimen for the degenerative lumbar disease, both oblique lateral interbody fusion (OLIF) and lateral lumbar interbody fusion (LLIF) are gradually accepted. Thus, the objective of this study is to compare the radiographic and clinical outcomes of OLIF and LLIF for the degenerative lumbar disease.

Methods

We conducted an exhaustive literature search of MEDLINE, EMBASE, and the Cochrane Library to find the relevant studies about OLIF and LLIF for the degenerative lumbar disease. Random-effects model was performed to pool the outcomes about disc height (DH), fusion, operative blood loss, operative time, length of hospital stays, complications, visual analog scale (VAS), and Oswestry disability index (ODI).

Results

56 studies were included in this study. The two groups of patients had similar changes in terms of DH, operative blood loss, operative time, hospital stay and the fusion rate (over 90%). The OLIF group showed slightly better VAS and ODI scores improvement. The incidence of perioperative complications of OLIF and LLIF was 26.7 and 27.8% respectively. Higher rates of nerve injury and psoas weakness (21.2%) were reported for LLIF, while higher rates of cage subsidence (5.1%), endplate damage (5.2%) and vascular injury (1.7%) were reported for OLIF.

Conclusions

The two groups are similar in terms of radiographic outcomes, operative blood loss, operative time and the length of hospital stay. The OLIF group shows advantages in VAS and ODI scores improvement. Though the incidence of perioperative complications of OLIF and LLIF is similar, the incidence of main complications is significantly different.

Novel Application of a New Lateral System for Adjacent-level Revision Surgery: A Case Report

In recent years, lateral lumbar interbody fusion (LLIF) has grown in popularity as a minimally invasive spine surgery (MISS) approach that can be offered to patients with prior surgeries from a posterior approach. In this report, we present a patient with a focal disease and a history of multiple posterior lumbar surgeries who underwent LLIF with a novel application of the Duo^TM system (Spineology Inc., MN, USA) adjacent to prior surgical levels and without posterior instrumentation. At one year postoperatively, she continued to have no back pain or complaints relating to her lumbar pathology. The case demonstrates the novel use of a new MISS LLIF system that requires minimal exposure as compared to current LLIF systems to treat a patient with adjacent segment disease and progressive symptoms following multiple posterior decompressive surgeries.

Lateral and Oblique Lumbar Interbody Fusion-Current Concepts and a Review of Recent Literature

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.