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Van Pevenage PM, Tohmeh AG, Howell KM. Clinical and radiographic outcomes following 120 consecutive patients undergoing 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 2024:10.1007/s00586-024-08379-3. [PMID: 38937351 DOI: 10.1007/s00586-024-08379-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 05/14/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE The prone transpsoas approach is a single-position alternative to traditional lateral lumbar interbody fusion (LLIF). Earlier prone LLIF studies have focused on technique, feasibility, perioperative efficiencies, and immediate postoperative radiographic alignment. This study was undertaken to report longer-term clinical and radiographic outcomes, and to identify learnings from experiential evolution of the prone LLIF procedure. METHODS All consecutive patients undergoing prone LLIF for any indication at one institution were included (n = 120). Demographic, diagnostic, treatment, and outcomes data were captured via prospective institutional registry. Retrospective analysis identified 31 'pre-proceduralization' and 89 'post-proceduralization' prone LLIF approaches, enabling comparison across early and later cohorts. RESULTS 187 instrumented LLIF levels were performed. Operative time, retraction time, LLIF blood loss, and hospital stay averaged 150 min, 17 min, 50 ml, and 2.2 days, respectively. 79% of cases were without complication. Postoperative hip flexion weakness was identified in 14%, transient lower extremity weakness in 12%, and sensory deficits in 10%. At last follow-up, back pain, worst-leg pain, Oswestry, and EQ-5D health state improved by 55%, 46%, 48%, and 51%, respectively. 99% improved or maintained sagittal alignment with an average 6.5° segmental lordosis gain at LLIF levels. Only intra-psoas retraction time differed between pre- and post-proceduralization; proceduralization saved an average 3.4 min/level (p = 0.0371). CONCLUSIONS The largest single-center prone LLIF experience with the longest follow-up to-date shows that it results in few complications, quick recovery, improvements in pain and function, high patient satisfaction, and improved sagittal alignment at an average one year and up to four years postoperatively.
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Affiliation(s)
- Peyton M Van Pevenage
- MultiCare Neurosurgery and Spine, 605 E. Holland, Suite 202, Spokane, WA, 99218, USA
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Antoine G Tohmeh
- MultiCare Neurosurgery and Spine, 605 E. Holland, Suite 202, Spokane, WA, 99218, USA.
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Sadeghzadeh S, Yoo KH, Lopez I, Johnstone T, Schonfeld E, Haider G, Marianayagam NJ, Stienen MN, Veeravagu A. Impact of Supine versus Prone Positioning on Segmental Lumbar Lordosis in Patients Undergoing ALIF Followed by PSF: A Comparative Study. J Clin Med 2024; 13:3555. [PMID: 38930084 PMCID: PMC11204788 DOI: 10.3390/jcm13123555] [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: 03/27/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Anterior lumbar interbody fusion (ALIF) and posterior spinal fusion (PSF) play pivotal roles in restoring lumbar lordosis in spinal surgery. There is an ongoing debate between combined single-position surgery and traditional prone-position PSF for optimizing segmental lumbar lordosis. Methods: This retrospective study analyzed 59 patients who underwent ALIF in the supine position followed by PSF in the prone position at a single institution. Cobb angles were measured preoperatively, post-ALIF, and post-PSF using X-ray imaging. One-way repeated measures ANOVA and post-hoc analyses with Bonferroni adjustment were employed to compare mean Cobb angles at different time points. Cohen's d effect sizes were calculated to assess the magnitude of changes. Sample size calculations were performed to ensure statistical power. Results: The mean segmental Cobb angle significantly increased from preoperative (32.2 ± 13.8 degrees) to post-ALIF (42.2 ± 14.3 degrees, Cohen's d: -0.71, p < 0.0001) and post-PSF (43.6 ± 14.6 degrees, Cohen's d: -0.80, p < 0.0001). There was no significant difference between Cobb angles after ALIF and after PSF (Cohen's d: -0.10, p = 0.14). The findings remained consistent when Cobb angles were analyzed separately for single-screw and double-screw ALIF constructs. Conclusions: Both supine ALIF and prone PSF significantly increased segmental lumbar lordosis compared to preoperative measurements. The negligible difference between post-ALIF and post-PSF lordosis suggests that supine ALIF followed by prone PSF can be an effective approach, providing flexibility in surgical positioning without compromising lordosis improvement.
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Affiliation(s)
- Sina Sadeghzadeh
- Department of Neurosurgery, Stanford University, 453 Quarry Road, Stanford, CA 94305, USA; (S.S.); (I.L.); (T.J.); (E.S.); (G.H.); (N.J.M.)
| | - Kelly H. Yoo
- Department of Neurosurgery, Stanford University, 453 Quarry Road, Stanford, CA 94305, USA; (S.S.); (I.L.); (T.J.); (E.S.); (G.H.); (N.J.M.)
| | - Ivan Lopez
- Department of Neurosurgery, Stanford University, 453 Quarry Road, Stanford, CA 94305, USA; (S.S.); (I.L.); (T.J.); (E.S.); (G.H.); (N.J.M.)
| | - Thomas Johnstone
- Department of Neurosurgery, Stanford University, 453 Quarry Road, Stanford, CA 94305, USA; (S.S.); (I.L.); (T.J.); (E.S.); (G.H.); (N.J.M.)
| | - Ethan Schonfeld
- Department of Neurosurgery, Stanford University, 453 Quarry Road, Stanford, CA 94305, USA; (S.S.); (I.L.); (T.J.); (E.S.); (G.H.); (N.J.M.)
| | - Ghani Haider
- Department of Neurosurgery, Stanford University, 453 Quarry Road, Stanford, CA 94305, USA; (S.S.); (I.L.); (T.J.); (E.S.); (G.H.); (N.J.M.)
| | - Neelan J. Marianayagam
- Department of Neurosurgery, Stanford University, 453 Quarry Road, Stanford, CA 94305, USA; (S.S.); (I.L.); (T.J.); (E.S.); (G.H.); (N.J.M.)
| | - Martin N. Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Cantonal Hospital St. Gallen, Rorschacher Str. 95, CH-9007 St. Gallen, Switzerland;
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, 453 Quarry Road, Stanford, CA 94305, USA; (S.S.); (I.L.); (T.J.); (E.S.); (G.H.); (N.J.M.)
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Mok JM, Forsthoefel C, Diaz RL, Lin Y, Amirouche F. Biomechanical Comparison of Unilateral and Bilateral Pedicle Screw Fixation after Multilevel Lumbar Lateral Interbody Fusion. Global Spine J 2024; 14:1524-1531. [PMID: 36583232 DOI: 10.1177/21925682221149392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
STUDY DESIGN Human Cadaveric Biomechanical Study. OBJECTIVES Lumbar Lateral Interbody Fusion (LLIF) utilizing a wide cage has been reported as having favorable biomechanical characteristics. We examine the biomechanical stability of unilateral pedicle screw and rod fixation after multilevel LLIF utilizing 26 mm wide cages compared to bilateral fixation. METHODS Eight human cadaveric specimens of L1-L5 were included. Specimens were attached to a universal testing machine (MTS 30/G). Three-dimensional specimen range of motion (ROM) was recorded using an optical motion-tracking device. Specimens were tested in 3 conditions: 1) intact, 2) L1-L5 LLIF (4 levels) with unilateral rod, 3) L1-L5 LLIF with bilateral rods. RESULTS From the intact condition, LLIF with unilateral rod decreased flexion-extension by 77%, lateral bending by 53%, and axial rotation by 26%. In LLIF with bilateral rods, flexion-extension decreased by 83%, lateral bending by 64%, and axial rotation by 34%. Comparing unilateral and bilateral fixation, LLIF with bilateral rods reduced ROM by a further 23% in flexion-extension, 25% in lateral bending, and 11% in axial rotation. The difference was statistically significant in flexion-extension and lateral bending (P < .005). CONCLUSIONS Considerable decreases in ROM were observed after multilevel (4-level) LLIF utilizing 26 mm cages supplemented with both unilateral and bilateral pedicle screws and rods. The addition of bilateral fixation provides a 10-25% additional decrease in ROM. These results can inform surgeons of the incremental biomechanical benefit when considering unilateral or bilateral posterior fixation after multilevel LLIF.
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Affiliation(s)
- James M Mok
- NorthShore University HealthSystem, Skokie, IL, USA
| | - Craig Forsthoefel
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Ye Lin
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | - Farid Amirouche
- NorthShore University HealthSystem, Skokie, IL, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
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Bartlett AM, Dibble CF, Sykes DAW, Drossopoulos PN, Wang TY, Crutcher CL, Than KD, Bhomwick DA, Shaffrey CI, Abd-El-Barr MM. Early Experience with Prone Lateral Interbody Fusion in Deformity Correction: A Single-Institution Experience. J Clin Med 2024; 13:2279. [PMID: 38673552 PMCID: PMC11051569 DOI: 10.3390/jcm13082279] [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: 02/26/2024] [Revised: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: Lateral spine surgery offers effective minimally invasive deformity correction, but traditional approaches often involve separate anterior, lateral, and posterior procedures. The prone lateral technique streamlines this process by allowing single-position access for lateral and posterior surgery, potentially benefiting from the lordosing effect of prone positioning. While previous studies have compared prone lateral to direct lateral for adult degenerative diseases, this retrospective review focuses on the outcomes of adult deformity patients undergoing prone lateral interbody fusion. Methods: Ten adult patients underwent single-position prone lateral surgery for spine deformity correction, with a mean follow-up of 18 months. Results: Results showed significant improvements: sagittal vertical axis decreased by 2.4 cm, lumbar lordosis increased by 9.1°, pelvic tilt improved by 3.3°, segmental lordosis across the fusion construct increased by 12.2°, and coronal Cobb angle improved by 6.3°. These benefits remained consistent over the follow-up period. Correlational analysis showed a positive association between improvements in PROs and SVA and SL. When compared to hybrid approaches, prone lateral yielded greater improvements in SVA. Conclusions: Prone lateral surgery demonstrated favorable outcomes with reasonable perioperative risks. However, further research comparing this technique with standard minimally invasive lateral approaches, hybrid, and open approaches is warranted for a comprehensive evaluation.
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Affiliation(s)
- Alyssa M. Bartlett
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | - Christopher F. Dibble
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - David A. W. Sykes
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | | | - Timothy Y. Wang
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | | | - Khoi D. Than
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | - Deb A. Bhomwick
- Department of Neurosurgery, Duke University, Durham, NC 27710, USA; (A.M.B.)
| | | | - Muhammad M. Abd-El-Barr
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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Wu T, Yeo QY, Oh JYL. Single position, prone oblique lateral interbody fusion (OLIF)-case illustration and technical considerations. JOURNAL OF SPINE SURGERY (HONG KONG) 2024; 10:135-143. [PMID: 38567004 PMCID: PMC10982915 DOI: 10.21037/jss-23-95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/10/2023] [Indexed: 04/04/2024]
Abstract
Oblique lateral interbody fusion (OLIF) is a powerful method to treat various spinal conditions and is frequently combined with posterior instrumentation. This is traditionally performed in dual positions, with the patient first in lateral then turned prone. Single position lateral surgery (SPS-L) has been studied in a bid to improve surgical efficiency and reduce operative costs, but various limitations have been identified. More recently, the single position prone surgery (SPS-P) has been described as an alternative to address some of these limitations. This case illustrates a patient who underwent SPS-P using an OLIF corridor with subsequent posterior decompression and instrumentation. The benefits and limitations of this procedure compared to the conventional techniques are highlighted in this case. We present the case of a 75-year-old female presenting with thoracic myelopathy over T11/12 and concurrent L2-4 spinal stenosis. She underwent OLIF of L2/3 and L3/4, posterior decompression of T11/12 and L2/3, and posterior instrumented fusion from T10-L4 via a single prone position. We aim to describe the advantages of this approach and the challenges encountered through our experience. SPS-P offers numerous benefits compared to the already powerful SPS-L. In the upper levels of the lumbar spine, a pre-psoas approach may also be feasible. However, the prone lateral technique does not replace all patients suited for a lateral interbody fusion but should be seen as a viable option for selected cases such as those with previous fusion at the L5/S1 with adjacent degeneration requiring extension and posterior fixation.
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Affiliation(s)
- TianYi Wu
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Quan You Yeo
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Department of Orthopaedic Surgery, Woodlands Health, Singapore, Singapore
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Kadiyala ML, Merrell LA, Ganta A, Konda SR, Rivero SM, Leucht P, Tejwani NC, Egol KA. Does Flipping From Prone to Supine for Medial Malleolar Fixation of Trimalleolar Ankle Fractures Improve Results? J Foot Ankle Surg 2024; 63:291-294. [PMID: 38103721 DOI: 10.1053/j.jfas.2023.12.002] [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: 09/20/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 12/19/2023]
Abstract
There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow-up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep, and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p = .047), longer operative time in minutes (p < .001), and a higher use of plate and screw constructs for medial malleolar fixation (p = .019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.
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Affiliation(s)
- Manasa L Kadiyala
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Lauren A Merrell
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Sanjit R Konda
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY; Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, NY
| | - Steven M Rivero
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Nirmal C Tejwani
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, New York, NY.
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Drossopoulos PN, Bardeesi A, Wang TY, Huang CC, Ononogbu-uche FC, Than KD, Crutcher C, Pokorny G, Shaffrey CI, Pollina J, Taylor W, Bhowmick DA, Pimenta L, Abd-El-Barr MM. Advancing Prone-Transpsoas Spine Surgery: A Narrative Review and Evolution of Indications with Representative Cases. J Clin Med 2024; 13:1112. [PMID: 38398424 PMCID: PMC10889296 DOI: 10.3390/jcm13041112] [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: 12/19/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
The Prone Transpsoas (PTP) approach to lumbar spine surgery, emerging as an evolution of lateral lumbar interbody fusion (LLIF), offers significant advantages over traditional methods. PTP has demonstrated increased lumbar lordosis gains compared to LLIF, owing to the natural increase in lordosis afforded by prone positioning. Additionally, the prone position offers anatomical advantages, with shifts in the psoas muscle and lumbar plexus, reducing the likelihood of postoperative femoral plexopathy and moving critical peritoneal contents away from the approach. Furthermore, operative efficiency is a notable benefit of PTP. By eliminating the need for intraoperative position changes, PTP reduces surgical time, which in turn decreases the risk of complications and operative costs. Finally, its versatility extends to various lumbar pathologies, including degeneration, adjacent segment disease, and deformities. The growing body of evidence indicates that PTP is at least as safe as traditional approaches, with a potentially better complication profile. In this narrative review, we review the historical evolution of lateral interbody fusion, culminating in the prone transpsoas approach. We also describe several adjuncts of PTP, including robotics and radiation-reduction methods. Finally, we illustrate the versatility of PTP and its uses, ranging from 'simple' degenerative cases to complex deformity surgeries.
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Affiliation(s)
- Peter N. Drossopoulos
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - Anas Bardeesi
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - Timothy Y. Wang
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - Chuan-Ching Huang
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - Favour C. Ononogbu-uche
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - Khoi D. Than
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - Clifford Crutcher
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - Gabriel Pokorny
- Institute of Spinal Pathology, Sao Paulo 04101000, SP, Brazil; (G.P.)
| | - Christopher I. Shaffrey
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA
| | - William Taylor
- Department of Neurological Surgery, University of California, La Jolla, San Diego, CA 92093, USA
| | - Deb A. Bhowmick
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
| | - Luiz Pimenta
- Institute of Spinal Pathology, Sao Paulo 04101000, SP, Brazil; (G.P.)
| | - Muhammad M. Abd-El-Barr
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (K.D.T.)
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Passias PG, Williamson TK, Krol O, Joujon-Roche R, Imbo B, Tretiakov P, Ahmad S, Bennett-Caso C, Lebovic J, Owusu-Sarpong S, Park P, Chou D, Vira S, Diebo BG, Schoenfeld AJ. Patient-Centered Outcomes Following Prone Lateral Single-Position Approach to Same-Day Circumferential Spine Surgery. Spine (Phila Pa 1976) 2024; 49:174-180. [PMID: 36972128 DOI: 10.1097/brs.0000000000004648] [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: 06/18/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Evaluate surgical characteristics and postoperative 2-year results of the PL approach to spinal fusion. SUMMARY OF BACKGROUND DATA Prone-lateral(PL) single positioning has recently gained popularity in spine surgery due to lower blood loss and operative time but has yet to be examined for other notable outcomes, including realignment and patient-reported measures. MATERIALS AND METHODS We included circumferential spine fusion patients with a minimum one-year follow-up. Patients were stratified into groups based on undergoing PL approach versus same-day staged (Staged). Mean comparison tests identified differences in baseline parameters. Multivariable logistic regression, controlling for age, levels fused, and Charlson Comorbidity Index were used to determine the influence of the approach on complication rates, radiographic and patient-reported outcomes up to two years. RESULTS One hundred twenty-two patients were included of which 72(59%) were same-day staged and 50(41%) were PL. PL patients were older with lower body mass index (both P <0.05). Patients undergoing PL procedures had lower estimated blood loss and operative time (both P <0.001), along with fewer osteotomies (63% vs. 91%, P <0.001). This translated to a shorter length of stay (3.8 d vs. 4.9, P =0.041). PL procedures demonstrated better correction in both PT (4.0 vs. -0.2, P =0.033 and pelvic incidence and lumbar lordosis (-3.7 vs. 3.1, P =0.012). PL procedures were more likely to improve in GAP relative pelvic version (OR: 2.3, [1.5-8.8]; P =0.003]. PL patients suffered lesser complications during the perioperative period and greater improvement in NRS-Back (-6.0 vs. -3.3, P =0.031), with less reoperations (0.0% vs. 4.8%, P =0.040) by two years. CONCLUSIONS Patients undergoing PL single-position procedures received less invasive procedures with better correction of pelvic compensation, as well as earlier discharge. The prone lateral cohort also demonstrated greater clinical improvement and a lower rate of reoperations by two years following spinal corrective surgery. LEVEL OF EVIDENCE Level-III.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Bailey Imbo
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Salman Ahmad
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Claudia Bennett-Caso
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Jordan Lebovic
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Stephane Owusu-Sarpong
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Dean Chou
- Department of Neurosurgery, Columbia University, New York, NY
| | - Shaleen Vira
- Departments of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Buckland AJ, Proctor DJ, Thomas JA, Protopsaltis TS, Ashayeri K, Braly BA. Single-Position Prone Lateral Lumbar Interbody Fusion Increases Operative Efficiency and Maintains Safety in Revision Lumbar Spinal Fusion. Spine (Phila Pa 1976) 2024; 49:E19-E24. [PMID: 37134133 DOI: 10.1097/brs.0000000000004699] [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] [Received: 12/28/2022] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
STUDY DESIGN Multi-centre retrospective cohort study. OBJECTIVE To evaluate the feasibility and safety of the single-position prone lateral lumbar interbody fusion (LLIF) technique for revision lumbar fusion surgery. BACKGROUND CONTEXT Prone LLIF (P-LLIF) is a novel technique allowing for placement of a lateral interbody in the prone position and allowing posterior decompression and revision of posterior instrumentation without patient repositioning. This study examines perioperative outcomes and complications of single position P-LLIF against traditional Lateral LLIF (L-LLIF) technique with patient repositioning. METHOD A multi-centre retrospective cohort study involving patients undergoing 1 to 4 level LLIF surgery was performed at 4 institutions in the US and Australia. Patients were included if their surgery was performed via either: P-LLIF with revision posterior fusion; or L-LLIF with repositioning to prone. Demographics, perioperative outcomes, complications, and radiological outcomes were compared using independent samples t-tests and chi-squared analyses as appropriate with significance set at P <0.05. RESULTS 101 patients undergoing revision LLIF surgery were included, of which 43 had P-LLIF and 58 had L-LLIF. Age, BMI and CCI were similar between groups. The number of posterior levels fused (2.21 P-LLIF vs. 2.66 L-LLIF, P =0.469) and number of LLIF levels (1.35 vs. 1.39, P =0.668) was similar between groups.Operative time was significantly less in the P-LLIF group (151 vs. 206 min, P =0.004). EBL was similar between groups (150mL P-LLIF vs. 182mL L-LLIF, P =0.31) and there was a trend toward reduced length of stay in the P-LLIF group (2.7 vs. 3.3d, P =0.09). No significant difference was demonstrated in complications between groups. Radiographic analysis demonstrated no significant differences in preoperative or postoperative sagittal alignment measurements. CONCLUSION P-LLIF significantly improves operative efficiency when compared to L-LLIF for revision lumbar fusion. No increase in complications was demonstrated by P-LLIF or trade-offs in sagittal alignment restoration. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Aaron J Buckland
- Melbourne Orthopaedic Group, Melbourne, Vic Australia
- Spine and Scoliosis Research Associates Australia, Melbourne, Vic Australia
- NYU Langone Health, New York, NY
| | | | - J Alex Thomas
- Atlantic Neurosurgical and Spine Specialists, Wilmington, NC
| | | | | | - Brett A Braly
- The Spine Clinic of Oklahoma City, Oklahoma City, OK
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10
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Buckland AJ, Thomas JA. Reply to letter to the editor regarding "Lateral decubitus single position anterior posterior surgery improves operative efficiency, improves perioperative outcomes, and maintains radiological outcomes comparable with traditional anterior posterior fusion at minimum 2-year follow-up". Spine J 2024; 24:187-188. [PMID: 38101880 DOI: 10.1016/j.spinee.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Aaron J Buckland
- Spine and Scoliosis Research Associates Australia, 33 The Ave, Windsor, VIC 3181, Australia; Melbourne Orthopaedic Group, 33 The Ave, Windsor, Vic 3181 Australia.
| | - J Alex Thomas
- Atlantic Brain and Spine, 2208 South 17th St, Wilmington, NC, 28401, USA
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11
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Chumnanvej S, Lekcharoensombat N. Comparison of standard and modified prone positioning for lateral lumbar spine fusion: a feasibility study to reduce lumbar plexus injury. JOURNAL OF SPINE SURGERY (HONG KONG) 2023; 9:463-471. [PMID: 38196723 PMCID: PMC10772666 DOI: 10.21037/jss-23-92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/21/2023] [Indexed: 01/11/2024]
Abstract
Single-prone-lateral (PL) positioning is a new technique that allows for simultaneous anterior and posterior lumbar spine surgery. However, there is a concern regarding the risk of lumbar plexus injury in PL positioning. This study compared the risk of lumbar plexus damage and the overall safety profile of a modified PL (mPL) position to the standard PL (sPL) position for lateral lumbar spine fusion surgery. A crossover soft cadaveric study was conducted with two raters examining the comparative outcomes of position A: sPL and position B: mPL. The mPL position differs from the sPL position in that the ipsilateral arm is placed at the side of the body rather than above the head. To assess positive results (no lumbar plexus injury) between positions A and B, a mixed effects logistic regression model was utilized. The odds ratio of a good result between positions B and A was also determined. The odds ratio of the favorable outcome between position B and A was 1.77, indicating significantly higher odds of a favorable outcome in the modified position B than in the control or position A. The mPL positioning outperformed the sPL positioning in terms of safety and efficacy for lateral lumbar spine fusion. The mPL positioning may reduce the risk of lumbar plexus injury by allowing for a more direct approach to the lumbar spine and by avoiding excessive stretching of the lumbar plexus.
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Affiliation(s)
| | - Nopporn Lekcharoensombat
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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12
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He J, Deng J, Yang Y, Zheng T, Luo F, Xu J, Zhang Z. Simultaneous Single-Position Oblique Lateral Interbody Fusion Combined With Unilateral Percutaneous Pedicle Screw Fixation for Single-Level Lumbar Tuberculosis: A 3-Year Retrospective Comparative Study. Neurospine 2023; 20:1306-1318. [PMID: 38171298 PMCID: PMC10762411 DOI: 10.14245/ns.2346692.346] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/10/2023] [Accepted: 09/18/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE To illustrate a simultaneous single-position oblique lateral interbody fusion (SPOLIF) combined with unilateral percutaneous pedicle screw fixation in treating single-level lumbar tuberculosis, compared with posterior-only approach in clinical and radiographic evaluations. METHODS Consecutive patients who had undergone surgeries for single-level lumbar tuberculosis from January 2018 to December 2020 were retrospectively reviewed. The patients included were divided into SP-OLIF and posterior-only groups according to surgical methods applied, with follow-up for at least 36 months. Outcomes included estimated blood loss, operative time, and complications for safety evaluation; visual analogue scale (VAS), Oswestry Disability Index (ODI) for efficacy evaluation; erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for evaluating tuberculosis activity; x-ray and computed tomography scan were used for radiographic evaluation. RESULTS A total of 136 patients had been enrolled in the study (60 for SP-OLIF and 76 for Posterior-only). The median operative time, blood loss, and hospital stay in SP-OLIF group were significantly less, with a lower complication rate. Meanwhile, the SP-OLIF group showed substantially lower VAS in 1 and 7 days and decreased ODI in the first month postoperatively, without significant difference afterward. Similarly, the median CRP and ESR in SP-OLIF group were significantly lower in 3 and 7 days postoperatively. All indicators had reduced to normal after 3 months. No recurrence had been reported throughout the whole follow-up. CONCLUSION SP-OLIF was an efficient minimally invasive protocol for single-level lumbar tuberculosis, facilitating earlier clinical improvement, with decreased blood loss, operative time and hospital stay compared with posterior-only approach.
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Affiliation(s)
- Jinyue He
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jiezhong Deng
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yusheng Yang
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Tingting Zheng
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Fei Luo
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jianzhong Xu
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zehua Zhang
- Department of Orthopedics, Southwest Hospital, Army Medical University, Chongqing, China
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13
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Hiyama A, Katoh H, Sakai D, Sato M, Watanabe M. Early Radiological Assessment of Static and Expandable Cages in Lateral Single Position for Indirect Decompression- Lateral Lumbar Interbody Fusion. World Neurosurg 2023; 178:e453-e464. [PMID: 37506844 DOI: 10.1016/j.wneu.2023.07.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVE This study aimed to compare the postoperative alignment of static and expandable cages in lateral single-position (LSP) for indirect decompression in lateral lumbar interbody fusion (LLIF). METHODS We included sixty-seven patients who underwent LSP-LLIF for lumbar degenerative disease. We performed radiological assessments preoperatively and two weeks postoperatively using computed tomography and magnetic resonance imaging. We divided the patients into the expandable cage group (23 patients) and the static cage group (44 patients). We measured disc height (DH), segmental lordosis (SL), and foraminal area (FA) from computed tomography images and the area of the dural sac from magnetic resonance imaging. We recorded surgical outcomes and complications. RESULTS Both static and expandable cages demonstrated improvements in DH, SL, FA, and dural sac expansion. However, we found no statistically significant differences in the average change in DH (4.4 ± 2.1 mm vs. 4.2 ± 1.8 mm, P = 0.685), the average change in SL (1.0 ± 4.4° vs. 1.9 ± 3.6°, P = 0.310), or FA change (32.5 ± 31.7 mm2 vs. 34.9 ± 29.5 mm2, P = 0.966) between the expandable and static cage groups. We also found no statistically significant difference in dural sac enlargement between the two groups. We observed no significant differences in operation time, estimated blood loss, or length of hospital stay between the two groups. No severe adverse events or additional surgeries were reported. CONCLUSIONS In LSP-LLIF without facet joint resection or other posterior techniques, static and expandable cages showed comparable effectiveness in achieving increased DH, SL, FA, and indirect decompression.
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Affiliation(s)
- Akihiko Hiyama
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masato Sato
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Shafi K, Lovecchio F, Song J, Qureshi S. Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion: Indications, Techniques, and Outcomes. JBJS Essent Surg Tech 2023; 13:e22.00022. [PMID: 38357472 PMCID: PMC10863943 DOI: 10.2106/jbjs.st.22.00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Background Lateral lumbar interbody fusion (LLIF) is a widely utilized minimally invasive surgical procedure for anterior fusion of the lumbar spine. However, posterior decompression or instrumentation often necessitates patient repositioning, which is associated with increased operative time and time under anesthesia1-3. The single-position prone transpsoas approach is a technique that allows surgeons to access both the anterior and posterior aspects of the spine, bypassing the need for intraoperative repositioning and therefore optimizing efficiency4. The use of robotic assistance allows for decreased radiation exposure and increased accuracy, both with placing instrumentation and navigating the lateral corridor. Description The patient is placed in the prone position, and pedicle screws are placed prior to interbody fusion. Pedicle screws are placed with robotic guidance. After posterior instrumentation, a skin incision for LLIF is made in the cephalocaudal direction, orthogonal to the disc space, with use of intraoperative (robotic) navigation. Fascia and abdominal muscles are incised to enter the retroperitoneal space. Under direct visualization, dilators are placed through the psoas muscle into the disc space, and an expandable retractor is placed and maintained with use of the robotic arm. Following a thorough discectomy, the disc space is sized with trial implants. The expandable cage is placed, and intraoperative fluoroscopy is utilized to verify good instrumentation positioning. Finally, posterior rods are placed percutaneously. Alternatives An alternative surgical approach is a traditional LLIF with the patient beginning in the lateral position, with intraoperative repositioning from the lateral to the prone position if circumferential fusion is warranted. Additional alternative surgical procedures include anterior or posterior lumbar interbody fusion techniques. Rationale LLIF is associated with reported advantages of decreased risks of vascular injury, visceral injury, dural tear, and perioperative infection5,6. The single-position prone transpsoas approach confers the added benefits of reduced operative time, anesthesia time, and surgical staffing requirements7. Other potential benefits of the prone lateral approach include improved lumbar lordosis correction, gravity-induced displacement of peritoneal contents, and ease of posterior decompression and instrumentation8-11. Additionally, the use of robotic assistance offers numerous benefits to minimally invasive techniques, including intraoperative navigation, instrumentation templating, a more streamlined workflow, and increased accuracy in placing instrumentation, while also providing a reduction in radiation exposure and operative time. In our experience, the table-mounted LLIF retractor has a tendency to drift toward the floor-i.e., anteriorly-when the patient is positioned prone, which may, in theory, increase the risk of iatrogenic bowel injury. The rigid robotic arm is much stiffer than the traditional retractor, thereby reducing this risk. Expected Outcomes Compared with traditional LLIF, with the patient in the lateral and then prone positions, the single-position prone LLIF has been shown to have several benefits. Guiroy et al. performed a systematic review comparing single and dual-position LLIF and found that the single-position surgical procedure was associated with significantly lower operative time (103.1 versus 306.6 minutes), estimated blood loss (97.3 versus 314.4 mL), and length of hospital stay (1.71 versus 4.08 days)17. Previous studies have reported improved control of segmental lordosis in the prone position, which may be advantageous for patients with sagittal imbalance18,19. Important Tips Adequate release of the deep fascial layers is critical for minimizing deflection of retractors and navigated instruments.The hip should be maximally extended to maximize lordosis, allowing for posterior translation of the femoral nerve and increasing the width of the lateral corridor.A bolster is placed against the rib cage to provide resistance to the laterally directed force when impacting the graft.The cranial and caudal limits of the approach are bounded by the ribcage and iliac crest; thus, surgery at the upper or lower lumbar levels may not be feasible for this approach. Preoperative radiographs should be evaluated to determine the feasibility of this approach at the intended levels.When operating at the L4-L5 disc space, posterior retraction places substantial tension on the femoral nerve. Thus, retractor time should be minimized as much as possible and limited to a maximum of approximately 20 minutes20-22.A depth of field (distance from the midline to the flank) of approximately 20 cm may be the limit for this approach with the current length of retractor blades19.In robotic-assisted surgical procedures, minor position shifts in surface landmarks, the robotic arm, or the patient may substantially impact the navigation software. It is critical for the patient and navigation components to remain fixed throughout the operation.In addition to somatosensory evoked potential and electromyographic monitoring, additional motor evoked potential neuromonitoring or monitoring of the saphenous nerve may be considered22.In the prone position, the tendency is for the retractor to migrate superficially and anteriorly. It is critical to be aware of this tendency and to maintain stable retractor positioning. Acronyms and Abbreviations LLIF = lateral lumbar interbody fusionMIS = minimally invasive surgeryPTP = prone transpsoasy.o. = years oldASIS = anterior superior iliac spinePSIS = posterior superior iliac spineALIF = anterior lumbar interbody fusionTLIF = transforaminal lumbar interbody fusionMEP = motor evoked potentialSSEP = somatosensory evoked potentialEMG = electromyographyCT = computed tomographyMRI = magnetic resonance imagingOR = operating roomPOD = postoperative dayIVC = inferior vena cavaA. = aortaPS. = psoas.
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Affiliation(s)
| | | | - Junho Song
- Hospital for Special Surgery, New York, NY
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15
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Patel HM, Fasani-Feldberg G, Patel H. Prone position lateral interbody fusion-a narrative review. JOURNAL OF SPINE SURGERY (HONG KONG) 2023; 9:331-341. [PMID: 37841787 PMCID: PMC10570633 DOI: 10.21037/jss-23-34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 08/31/2023] [Indexed: 10/17/2023]
Abstract
Background and Objective Lateral access lumbar interbody fusion is an increasingly popular procedure that allows for anterior column support through discectomy, endplate preparation, and interbody insertion. This procedure was initially described and performed with the patient in the lateral decubitus position. This would typically be followed by repositioning the patient to the prone position for pedicle screw fixation. Increasingly common is the lateral access lumbar interbody fusion in the prone position. This narrative review seeks to summarize the available literature on advantages, disadvantages, and unique features of the prone position lateral access lumbar interbody fusion. Methods We performed a narrative review of articles published up to 01 November 2022 through a PubMed search. The search terms "prone lateral spine surgery" and "lateral approach spine surgery" AND "prone position" were used. Articles not available in English were excluded. The search result abstracts were independently reviewed by 2 authors and 28 full text articles were reviewed. Both reviewing authors were orthopedic surgery chief residents. Key Content and Findings There are several unique advantages as well as disadvantages to the prone position lateral interbody fusion. Some advantages include ease of placing pedicle screws, simultaneous posterior and lateral access, greater ease in achieving segmental lumbar lordosis, and a relatively safer positioning of the psoas muscle, lumbar plexus, and abdominal structures. Disadvantages include more difficulties with exposure and retraction, as well as visualization, positioning and ergonomics of surgery. Conclusions Prone position lateral interbody fusion is an increasingly prevalent and useful surgical technique with several advantages and disadvantages when compared to lateral interbody fusion in the lateral decubitus position. There are several surgical indications and goals for which prone lateral interbody fusion may provide significant benefit when compared to other interbody fusion techniques.
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Affiliation(s)
- Hiren M. Patel
- Department of Orthopedic Surgery, New York Medical College, Valhalla, NY, USA
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Gregory Fasani-Feldberg
- Department of Orthopedic Surgery, New York Medical College, Valhalla, NY, USA
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Harshadkumar Patel
- Department of Orthopedic Surgery, New York Medical College, Valhalla, NY, USA
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY, USA
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16
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Alluri R, Clark N, Sheha E, Shafi K, Geiselmann M, Kim HJ, Qureshi S, Dowdell J. Location of the Femoral Nerve in the Lateral Decubitus Versus Prone Position. Global Spine J 2023; 13:1765-1770. [PMID: 34617812 PMCID: PMC10556917 DOI: 10.1177/21925682211049170] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Cadaveric study. OBJECTIVE To compare the position of the femoral nerve within the lumbar plexus at the L4-L5 disc space in the lateral decubitus vs prone position. METHODS Seven lumbar plexus specimens were dissected and the femoral nerve within the psoas muscle was identified and marked with radiopaque paint. Lateral fluoroscopic images of the cadaveric specimens in the lateral decubitus vs prone position were obtained. The location of the radiopaque femoral nerve at the L4-L5 disc space was normalized as a percentage of the L5 vertebral body (0% indicates posterior location and 100% indicates anterior location at the L4-L5 disc space). The location of the femoral nerve at L4-L5 in the lateral decubitus vs prone position was compared using a paired t test. RESULTS In the lateral decubitus position, the femoral nerve was located 28% anteriorly from the posterior edge of the L4-L5 disc space, and in the prone position, the femoral nerve was relatively more posterior, located 18% from the posterior edge of the L4-L5 disc space (P = .037). CONCLUSIONS The femoral nerve was on average more posteriorly located at the L4-L5 disc space in the prone position compared to lateral decubitus. This more posterior location allows for a larger safe zone at the L4-L5 disc space, which may decrease the incidence of neurologic complications associated with Lateral lumbar interbody fusion in the prone vs lateral decubitus position; however, further studies are needed to evaluate this possible clinical correlation.
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Affiliation(s)
- Ram Alluri
- Hospital for Special Surgery, New York, NY, USA
| | | | - Evan Sheha
- Hospital for Special Surgery, New York, NY, USA
| | - Karim Shafi
- Hospital for Special Surgery, New York, NY, USA
| | - Matthew Geiselmann
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
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17
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Urakawa H, Sivaganesan A, Vaishnav AS, Sheha E, Qureshi SA. The Feasibility of 3D Intraoperative Navigation in Lateral Lumbar Interbody Fusion: Perioperative Outcomes, Accuracy of Cage Placement and Radiation Exposure. Global Spine J 2023; 13:737-744. [PMID: 33906453 DOI: 10.1177/21925682211006700] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To evaluate perioperative outcomes, accuracy of cage placement and radiation exposure in lateral lumbar interbody fusion (LLIF) using 3D intraoperative navigation (ION), compared to conventional 2D fluoroscopy only. METHODS The perioperative outcomes and accuracy of cage placement were examined in all patients who underwent LLIF using ION (ION group) or fluoroscopy only (non-ION group) by a single surgeon. The radiation exposure was examined in patients who underwent stand-alone LLIF. RESULTS A total of 87 patients with 154 levels (ION 49 patients with 79 levels/ non-ION 38 patients with 75 levels) were included. There were no significant differences in operative time (ION 143.5 min vs. non-ION 126.0 min, P = .406), time from induction end to surgery start (ION 31.0 min vs. non-ION 31.0 min, P = .761), estimated blood loss (ION 37.5 ml vs. non-ION 50.0 ml, P = .351), perioperative complications (ION 16.3% vs. non-ION 7.9%, P = .335) and length of stay (ION 50.6 hours vs. non-ION 41.7 hours, P = .841). No significant difference was found in the accuracy of cage placement (P = .279). ION did not significantly increase total radiation dose (ION 51.0 mGy vs. non-ION 47.4 mGy, P = .237) and tended to reduce radiation dose during the procedure (ION 32.2 mGy vs. non-ION 47.4 mGy, P = .932). CONCLUSIONS The perioperative outcomes, accuracy of cage placement and radiation exposure in LLIF using ION were comparable to those using fluoroscopy only. The use of ION in LLIF was feasible, safe and accurate and may reduce radiation dose to the surgeon and surgical team.
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Affiliation(s)
| | | | | | - Evan Sheha
- 25062Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Sheeraz A Qureshi
- 25062Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
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18
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Guiroy A, Thomas JA, Bodon G, Patel A, Rogers M, Smith W, Seale J, Camino-Willhuber G, Menezes CM, Galgano M, Asghar J. Single-Position Transpsoas Corpectomy and Posterior Instrumentation in the Thoracolumbar Spine for Different Clinical Scenarios. Oper Neurosurg (Hagerstown) 2023; 24:310-317. [PMID: 36701571 DOI: 10.1227/ons.0000000000000523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/13/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The concept of single-position spine surgery has been gaining momentum because it has proven to reduce operative time, blood loss, and hospital length of stay with similar or better outcomes than traditional dual-position surgery. The latest development in single-position spine surgery techniques combines either open or posterior pedicle screw fixation with transpsoas corpectomy while in the lateral or prone positioning. OBJECTIVE To provide, through a multicenter study, the results of our first patients treated by single-position corpectomy. METHODS This is a multicenter retrospective study of patients who underwent corpectomy and instrumentation in the lateral or prone position without repositioning between the anterior and posterior techniques. Data regarding demographics, diagnosis, neurological status, surgical details, complications, and radiographic parameters were collected. The minimum follow-up for inclusion was 6 months. RESULTS Thirty-four patients were finally included in our study (24 male patients and 10 female patients), with a mean age of 51.2 (SD ± 17.5) years. Three-quarter of cases (n = 27) presented with thoracolumbar fracture as main diagnosis, followed by spinal metastases and primary spinal infection. Lateral positioning was used in 27 cases, and prone positioning was used in 7 cases. The overall rate of complications was 14.7%. CONCLUSION This is the first multicenter series of patients who underwent single-position corpectomy and fusion. This technique has shown to be safe and effective to treat a variety of spinal conditions with a relatively low rate of complications. More series are required to validate this technique as a possible standard approach when thoracolumbar corpectomies are indicated.
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Affiliation(s)
- Alfredo Guiroy
- Spine Surgery Department, Elite Spine Health and Wellness, Fort Lauderdale, Florida, USA
| | - J Alex Thomas
- Spine Surgery Division, Atlantic Brain and Spine, Wilmington, North Carolina, USA
| | - Gergely Bodon
- Department of Orthopaedic Surgery, Klinikum Esslingen, Esslingen am Neckar, Germany
| | - Ashish Patel
- Spine Surgery Department, The Spine Center, Duly Health and Care, Naperville, Illinois, USA
| | - Michael Rogers
- Spine Surgery Department, The Spine Center, Duly Health and Care, Naperville, Illinois, USA
| | - William Smith
- Neurosurgery Department, AIMIS Spine, Las Vegas, Nevada, USA
| | - Justin Seale
- Spine Surgery Division, OrthoArkansas Spine Institute, Little Rock, Arkansas, USA
| | | | - Cristiano M Menezes
- Columna Institute, Vila da Serra/Ortopédico Hospital, Belo Horizonte, Brazil
| | - Michael Galgano
- Department of Neurosurgery, University of North Carolina, USA
| | - Jahangir Asghar
- Spine Surgery Department, Elite Spine Health and Wellness, Fort Lauderdale, Florida, USA
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19
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Wellington IJ, Antonacci CL, Chaudhary C, Coskun E, Cote MP, Singh H, Mallozzi SS, Moss IL. Early Clinical Outcomes of the Prone Transpsoas Lumbar Interbody Fusion Technique. Int J Spine Surg 2023; 17:112-121. [PMID: 36690419 PMCID: PMC10025834 DOI: 10.14444/8390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a relatively novel technique. Currently, little is known about its associated complications and early patient-reported outcomes. The aim of this study was to investigate the effect of LLIF performed via the PTP approach on sagittal radiographic parameters, patient-reported outcome measures (PROMs), and rates of complications. METHODS A retrospective review was performed of 82 consecutive patients who underwent LLIF via a PTP technique. Lumbar lordosis (LL), segmental lordosis (SL), anterior disc height (ADH), and posterior disc height (PDH) were measured on preoperative, initial postoperative, and 3-month postoperative radiographs. PROMs including the Oswestry Disability Index (ODI); the visual analog scale (VAS); and pain portions of the EQ5D, VAS back, and VAS leg ratings were collected at the preoperative and subsequent postoperative visits. Length of hospital stay and postoperative complications related to the procedure were recorded. RESULTS Significant improvements were seen at the initial (4.5° ± 8.6°, P < 0.001) and 3-month (4.4° ± 7.2°, P < 0.001) postoperative periods for LL, as well as SL (6.8° ± 4.8°, P < 0.001; 6.7° ± 4.4°, P < 0.001), ADH (8.0 mm ± 3.6, P < 0.001; 7.4 mm ± 3.6, P < 0.001), and PDH (3.3 mm ± 2.4, P < 0.001; 3.1 mm ± 2.5, P < 0.001). Significant improvements were seen at 3 months postoperatively for ODI (P < 0.001), EQ5D pain (P = 0.016), VAS leg (P < 0.001), and VAS back (P < 0.001). The average length of stay was 2.7 ± 4.5 days. The most common complications were ipsilateral thigh pain/numbness (45.1%), ipsilateral hip flexor weakness (39.0%), and contralateral thigh pain/numbness (14.6%). CONCLUSIONS While early PROMs and correction of sagittal radiographic parameters show promising results for the PTP approach for LLIF, it is not without risks. CLINICAL RELEVANCE PTP interbody fusion is an emerging technique that allows for simultaneous access to the anterior and posterior columns of the lumbar spine. This early case series demonstrates significant improvement in functional outcomes and lumbar lordosis with a safety profile comparable to other well-established techniques. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Ian J Wellington
- Department of Orthopaedic Surgery, The University of Connecticut, Farmington, CT, USA
| | | | - Chirag Chaudhary
- Department of Orthopaedic Surgery, The University of Connecticut, Farmington, CT, USA
| | - Ergin Coskun
- Department of Orthopaedic Surgery, The University of Connecticut, Farmington, CT, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, The University of Connecticut, Farmington, CT, USA
| | - Hardeep Singh
- Department of Orthopaedic Surgery, The University of Connecticut, Farmington, CT, USA
| | - Scott S Mallozzi
- Department of Orthopaedic Surgery, The University of Connecticut, Farmington, CT, USA
| | - Isaac L Moss
- Department of Orthopaedic Surgery, The University of Connecticut, Farmington, CT, USA
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20
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Prone Lateral Interbody Fusion: A Narrative Review and Case Report. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
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21
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The Prone Lateral Approach for Lumbar Fusion-A Review of the Literature and Case Series. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020251. [PMID: 36837453 PMCID: PMC9967790 DOI: 10.3390/medicina59020251] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023]
Abstract
Lateral lumbar interbody fusion is an evolving procedure in spine surgery allowing for the placement of large interbody devices to achieve indirect decompression of segmental stenosis, deformity correction and high fusion rates through a minimally invasive approach. Traditionally, this technique has been performed in the lateral decubitus position. Many surgeons have adopted simultaneous posterior instrumentation in the lateral position to avoid patient repositioning; however, this technique presents several challenges and limitations. Recently, lateral interbody fusion in the prone position has been gaining in popularity due to the surgeon's ability to perform simultaneous posterior instrumentation as well as decompression procedures and corrective osteotomies. Furthermore, the prone position allows improved correction of sagittal plane imbalance due to increased lumbar lordosis when prone on most operative tables used for spinal surgery. In this paper, we describe the evolution of the prone lateral approach for interbody fusion and present our experience with this technique. Case examples are included for illustration.
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Buckland AJ, Braly BA, O'Malley NA, Ashayeri K, Protopsaltis TS, Kwon B, Cheng I, Thomas JA. Lateral decubitus single position anterior posterior surgery improves operative efficiency, improves perioperative outcomes, and maintains radiological outcomes comparable with traditional anterior posterior fusion at minimum 2-year follow-up. Spine J 2023; 23:685-694. [PMID: 36641035 DOI: 10.1016/j.spinee.2023.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 12/21/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND CONTEXT The advantages of Lateral Single Position surgery (LSPS) in the perioperative period has previously been demonstrated, however 2-year postoperative outcomes of this novel technique have not yet been compared to circumferential anterior-posterior fusion (FLIP) at 2-years postoperatively. PURPOSE Evaluate the safety and efficacy of LSPS versus gold-standard FLIP STUDY DESIGN/SETTING: Multi-center retrospective cohort review. PATIENT SAMPLE Four hundred forty- two patients undergoing lumbar fusion via LSPS or FLIP OUTCOME MEASURES: Levels fused, operative time, estimated blood loss, perioperative complications, and reasons for reoperation at 30-days, 90-days, 1-year, and 2-years. Radiographic outcomes included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), PI-LL mismatch, and segmental lumbar lordosis. METHODS Patients were grouped as LSPS if anterior and posterior portions of the procedure were performed in the lateral decubitus position, and FLIP if patients were repositioned from supine or lateral to prone position for the posterior portion of the procedure under the same anesthetic. Groups were compared in terms of demographics, intraoperative, perioperative and radiological outcomes, complications and reoperations up to 2-years follow-up. Measures were compared using independent samples or paired t-tests and chi-squared analyses with significance set at p<.05. RESULTS Four hundred forty- two pts met inclusion, including 352 LSPS and 90 FLIP pts. Significant differences were noted in age (62.4 vs 56.9; p≤.001) and smoking status (7% vs 16%; p=.023) between the LSPS and FLIP groups. LSPS demonstrated significantly lower Op time (97.7min vs 297.0 min; p<.001), fluoro dose (36.5mGy vs 78.8mGy; p<.001), EBL (88.8mL vs 270.0mL; p<.001), and LOS (1.91 days vs 3.61 days; p<.001) compared to FLIP. LSPS also demonstrated significantly fewer post-op complications than FLIP (21.9%vs 34.4%; p=.013), specifically regarding rates of ileus (0.0% vs 5.6%; p<.001). No differences in reoperation were noted at 30-day (1.7%LSPS vs 4.4%FLIP, p=.125), 90-day (5.1%LSPS vs 5.6%FLIP, p=.795) or 2-year follow-up (9.7%LSPS vs 12.2% FLIP; p=.441). LSPS group had a significantly lower preoperative PI-LL (4.1° LSPS vs 8.6°FLIP, p=.018), and a significantly greater postoperative LL (56.6° vs 51.8°, p = .006). No significant differences were noted in rates of fusion (94.3% LSPS vs 97.8% FLIP; p=.266) or subsidence (6.9% LSPS vs 12.2% FLIP; p=.260). CONCLUSIONS LSPS and circumferential fusions have similar outcomes at 2-years post-operatively, while reducing perioperative complications, improving perioperative efficiency and safety.
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Affiliation(s)
- Aaron J Buckland
- Melbourne Orthopaedic Group, Melbourne, VIC, Australia; Spine and Scoliosis Research Associates Australia, Melbourne, VIC, Australia; Spine Research Center, Departments of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA.
| | | | - Nicholas A O'Malley
- Spine Research Center, Departments of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA
| | - Kimberly Ashayeri
- Spine Research Center, Departments of Orthopaedic Surgery, NYU Langone Health, New York, NY, USA; Department of Neurosurgery, NYU Langone Health, New York, NY, USA
| | | | - Brian Kwon
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
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Wu MT, Chung TT, Chen SC, Kao TJ, Song WS. Oblique lateral interbody fusion in heterogenous lumbar diseases: Anterolateral screw fixation vs. posterior percutaneous pedicle screw fixation - A single center experience. Front Surg 2022; 9:989372. [PMID: 36632522 PMCID: PMC9826795 DOI: 10.3389/fsurg.2022.989372] [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] [Received: 07/08/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022] Open
Abstract
Background Oblique lateral interbody fusion (OLIF) is a type of minimally invasive lateral lumbar interbody fusion technique used for treating lumbar degenerative diseases. This study aimed to analyze the clinical and radiographic efficacy of OLIF with anterolateral screw fixation alone and OLIF requiring fixation with conventional posterior percutaneous pedicle screws for lumbar diseases. Methods Medical records of consecutive patients admitted to Cheng-Hsin Hospital who received OLIF between January 2019 and December 2020 were retrospectively reviewed. Patients were divided into two groups by screw fixation: patients who received anterolateral screw fixation alone were defined as one-stage OLIF (n = 9) and patients who received fixation with conventional posterior percutaneous pedicle screw were defined as two-stage OLIF (n = 16). Patient clinical characteristics, medical history, intraoperative blood loss, length of hospital stay, peri-operative, and post-operative complications were evaluated in all patients. Results During the study period, a total of 25 patients were successfully treated with OLIF (n = 9 one-stage; n = 16 two-stage). Two-stage OLIF was associated with longer operation times, longer hospital stays, shorter bed-rest time, and a greater likelihood of having a blood transfusion compared with the one-stage OLIF group. A higher proportion of grade I subsidence was observed at 6 months and 1 year after surgery in the two-stage group compared with the one-stage group. Post-operative complications included ileus, dystonia, and dystonia were higher in the two-stage OLIF group. Improvements in radiographic parameters were demonstrated after OLIF, and the improvements were comparable between one-stage and two-stage OLIF. Conclusions One-stage OLIF is a feasible and efficacious treatment method for single- and multiple-level degenerative lumbar diseases. Additional clinical follow-up is necessary to confirm long-term outcomes.
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Affiliation(s)
- Meng-Ting Wu
- Division of Neurosurgery, Department of Surgery, Cheng-Hsin General Hospital, Taipei, Taiwan,Ph.D. Program of Electrical and Communications Engineering, Feng Chia University, Taichung City, Taiwan,Correspondence: Meng-Ting Wu
| | - Tzu-Tsao Chung
- Division of Neurosurgery, Department of Surgery, Cheng-Hsin General Hospital, Taipei, Taiwan,Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shao-Ching Chen
- Division of Neurosurgery, Department of Surgery, Cheng-Hsin General Hospital, Taipei, Taiwan,Institute of Neuroscience, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tzu-Jen Kao
- Ph.D. Program in Medical Neuroscience, Taipei Medical University, Taipei, Taiwan,International Master Program in Medical Neuroscience, Taipei Medical University, Taipei, Taiwan
| | - Wen-Shin Song
- Division of Neurosurgery, Department of Surgery, Cheng-Hsin General Hospital, Taipei, Taiwan,Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Kramer DE, Woodhouse C, Kerolus MG, Yu A. Lumbar plexus safe working zones with lateral lumbar interbody fusion: a systematic review and meta-analysis. 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; 31:2527-2535. [PMID: 35984508 DOI: 10.1007/s00586-022-07352-2] [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: 06/20/2022] [Revised: 06/20/2022] [Accepted: 08/10/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Significant risk of injury to the lumbar plexus and its departing motor and sensory nerves exists with lateral lumbar interbody fusion (LLIF). Several cadaveric and imaging studies have investigated the lumbar plexus position with respect to the vertebral body anteroposterior plane. To date, no systematic review and meta-analysis of the lumbar plexus safe working zones for LLIF has been performed. METHODS This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies reporting on the position of the lumbar plexus with relation to the vertebral body in the anteroposterior plane were identified from a PubMed database query. Quantitative analysis was performed using Welch's t test. RESULTS Eighteen studies were included, encompassing 1005 subjects and 2472 intervertebral levels. Eleven studies used supine magnetic resonance imaging (MRI) with in vivo subjects. Seven studies used cadavers, five of which performed dissection in the left lateral decubitus position. A significant correlation (p < 0.001) existed between anterior lumbar plexus displacement and evaluation with in vivo MRI at all levels between L1-L5 compared with cadaveric measurement. Supine position was also associated with significant (p < 0.001) anterior shift of the lumbar plexus at all levels between L1-L5. CONCLUSIONS This is the first comprehensive systematic review and meta-analysis of the lumbar neural components and safe working zones for LLIF. Our analysis suggests that the lumbar plexus is significantly displaced ventrally with the supine compared to lateral decubitus position, and that MRI may overestimate ventral encroachment of lumbar plexus.
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Affiliation(s)
- Dallas E Kramer
- Department of Neurosurgery, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA, 15212, USA.
| | - Cody Woodhouse
- Department of Neurosurgery, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA, 15212, USA
| | - Mena G Kerolus
- Department of Neurological Surgery, Rush University Medical Center, 1725 West Harrison Street, Suite 855, Chicago, IL, 60612, USA
| | - Alexander Yu
- Department of Neurosurgery, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA, 15212, USA
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Zhang C, Protopsaltis T. Single-Position Prone Lateral Interbody Fusion and Robotic-Assisted Pedicle Screw Fixation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e170. [PMID: 35972098 DOI: 10.1227/ons.0000000000000297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/03/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Casey Zhang
- NYU Grossman School of Medicine, New York, New York, USA
| | - Themistocles Protopsaltis
- NYU Langone, Division of Spine Surgery, New York, New York, USA.,Department of Orthopaedic Surgery, NYU Grossman School of Medicine, New York, New York, USA.,Department of Neurosurgery, NYU Grossman School of Medicine, New York, New York, USA
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Thomas JA, Menezes C, Buckland AJ, Khajavi K, Ashayeri K, Braly BA, Kwon B, Cheng I, Berjano P. Single-position circumferential lumbar spinal fusion: an overview of terminology, concepts, rationale and the current evidence base. 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; 31:2167-2174. [PMID: 35913621 DOI: 10.1007/s00586-022-07229-4] [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: 08/28/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To provide definitions and a conceptual framework for single position surgery (SPS) applied to circumferential fusion of the lumbar spine. METHODS Narrative literature review and experts' opinion. RESULTS Two major limitations of lateral lumbar interbody fusion (LLIF) have been (a) a perceived need to reposition the patient to the prone position for posterior fixation, and (b) the lack of a robust solution for fusion at the L5/S1 level. Recently, two strategies for performing single-position circumferential lumbar spinal fusion have been described. The combination of anterior lumbar interbody fusion (ALIF) in the lateral decubitus position (LALIF), LLIF and percutaneous pedicle screw fixation (pPSF) in the lateral decubitus position is known as lateral single-position surgery (LSPS). Prone LLIF (PLLIF) involves transpsoas LLIF done in the prone position that is more familiar for surgeons to then implant pedicle screw fixation. This can be referred to as prone single-position surgery (PSPS). In this review, we describe the evolution of and rationale for single-position spinal surgery. Pertinent studies validating LSPS and PSPS are reviewed and future questions regarding the future of these techniques are posed. Lastly, we present an algorithm for single-position surgery that describes the utility of LALIF, LLIF and PLLIF in the treatment of patients requiring AP lumbar fusions. CONCLUSIONS Single position surgery in circumferential fusion of the lumbar spine includes posterior fixation in association with any of the following: lateral position LLIF, prone position LLIF, lateral position ALIF, and their combination (lateral position LLIF+ALIF). Preliminary studies have validated these methods.
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Affiliation(s)
- J Alex Thomas
- Atlantic Neurosurgical and Spine Specialists, Wilmington, NC, USA.
| | | | | | - Kaveh Khajavi
- Georgia Spine and Neurosurgery Center, Atlanta, Georgia
| | | | - Brett A Braly
- The Spine Clinic of Oklahoma City, Oklahoma City, OK, USA
| | - Brian Kwon
- New England Baptist Hospital, Boston, MA, USA
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Fayed I, Tai A, Triano MJ, Weitz D, Sayah A, Voyadzis JM, Sandhu FA. Lateral versus prone robot-assisted percutaneous pedicle screw placement: a CT-based comparative assessment of accuracy. J Neurosurg Spine 2022; 37:112-120. [PMID: 35120316 DOI: 10.3171/2021.12.spine211176] [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: 09/02/2021] [Accepted: 12/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Single-position lateral lumbar interbody fusion (SP-LLIF) has recently gained significant popularity due to increased operative efficiency, but it remains technically challenging. Robot-assisted percutaneous pedicle screw (RA-PPS) placement can facilitate screw placement in the lateral position. The authors have reported their initial experience with SP-LLIF with RA-PPS placement in the lateral position, and they have compared this accuracy with that of RA-PPS placement in the prone position. METHODS The authors reviewed prospectively collected data from their first 100 lateral-position RA-PPSs. The authors graded screw accuracy on CT and compared it to the accuracy of all prone-position RA-PPS procedures during the same time period. The authors analyzed the effect of several demographic and perioperative metrics, as a whole and specifically for lateral-position RA-PPS placement. RESULTS The authors placed 99 lateral-position RA-PPSs by using the ExcelsiusGPS robotic platform in the first 18 consecutive patients who underwent SP-LLIF with postoperative CT imaging; these patients were compared with 346 prone-position RA-PPSs that were placed in the first consecutive 64 patients during the same time period. All screws were placed at L1 to S1. Overall, the lateral group had 14 breaches (14.1%) and the prone group had 25 breaches (7.2%) (p = 0.032). The lateral group had 5 breaches (5.1%) greater than 2 mm (grade C or worse), and the prone group had 4 (1.2%) (p = 0.015). The operative level had an effect on the breach rate, with breach rates (grade C or worse) of 7.1% at L3 and 2.8% at L4. Most breaches were grade B (< 2 mm) and lateral, and no breach had clinical sequelae or required revision. Within the lateral group, multivariate regression analysis demonstrated that BMI and number of levels affected accuracy, but the side that was positioned up or down did not. CONCLUSIONS RA-PPSs can improve the feasibility of SP-LLIF. Spine surgeons should be cautious and selective with this technique owing to decreased accuracy in the lateral position, particularly in obese patients. Further studies should compare SP-LLIF techniques performed while the patient is in the prone and lateral positions.
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Affiliation(s)
- Islam Fayed
- 1Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Alexander Tai
- 1Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | | | - Daniel Weitz
- 2Georgetown University School of Medicine, Washington, DC; and
| | - Anousheh Sayah
- 3Department of Radiology, MedStar Georgetown University Hospital, Washington, DC
| | - Jean-Marc Voyadzis
- 1Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Faheem A Sandhu
- 1Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
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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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Postoperative spinal alignment comparison of lateral versus supine patient position L5-S1 anterior 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; 31:2248-2254. [PMID: 35610486 DOI: 10.1007/s00586-022-07252-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 04/18/2022] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Over the past decade, alternative patient positions for the treatment of the anterior lumbar spine have been explored in an effort to maximize the benefits of direct anterior column access while minimizing the inefficiencies of single or multiple intraoperative patient repositionings. The lateral technique allows for access from L1 to L5 through a retroperitoneal, muscle-splitting, transpsoas approach with placement of a large intervertebral spacer than can reliably improve segmental lordosis, though its inability to be used at L5-S1 limits its overall adoption, as L5-S1 is one of the most common levels treated and where high levels of lordosis are optimal. Recent developments in instrumentation and techniques for lateral-position treatment of the L5-S1 level with a modified anterior lumbar interbody fusion (ALIF) approach have expanded the lateral position to L5-S1, though the positional effect on L5-S1 lordosis is heretofore unreported. The purpose of this study was to compare local and regional alignment differences between ALIFs performed with the patient in the lateral (L-ALIF) versus supine position (S-ALIF). METHODS Retrospective, multi-center data and radiographs were collected from 476 consecutive patients who underwent L5-S1 L-ALIF (n = 316) or S-ALIF (n = 160) for degenerative lumbar conditions. Patients treated at L4-5 and above with other single-position interbody fusion and posterior fixation techniques were included in the analysis. Baseline patient characteristics were similar between the groups, though L-ALIF patients were slightly older (58 vs. 54 years), with a greater preoperative mean L5-S1 disk height (7.8 vs. 5.8 mm), and with less preoperative slip (6.6 vs. 8.5 mm), respectively. 262 patients were treated with only L-ALIF or S-ALIF at L5-S1 while the remaining 214 patients were treated with either L-ALIF or S-ALIF at L5-S1 along with fusions at other thoracolumbar levels. Lumbar lordosis (LL), L5-S1 segmental lordosis, L5-S1 disk space height, and slip reduction in L5-S1 spondylolisthesis were measured on preoperative and postoperative lateral X-ray images. LL was only compared between single-level ALIFs, given the variability of other procedures performed at the levels above L5-S1. RESULTS Mean pre- to postoperative L5-S1 segmental lordosis improved 39% (6.6°) and 31% (4.9°) in the L-ALIF and S-ALIF groups, respectively (p = 0.063). Mean L5-S1 disk height increased by 6.5 mm (89%) in the L-ALIF and 6.4 mm (110%) in the S-ALIF cohorts, (p = 0.650). Spondylolisthesis, in those patients with a preoperative slip, average reduction in the L-ALIF group was 1.5 mm and 2.2 mm in the S-ALIF group (p = 0.175). In patients treated only at L5-S1 with ALIF, mean segmental alignment improved significantly more in the L-ALIF compared to the S-ALIF cohort (7.8 vs. 5.4°, p = 0.035), while lumbar lordosis increased 4.1° and 3.6° in the respective groups (p = 0.648). CONCLUSION Use of the lateral patient position for L5-S1 ALIF, compared to traditional supine L5-S1 ALIF, resulted in at least equivalent alignment and radiographic outcomes, with significantly greater improvement in segmental lordosis in patients treated only at L5-S1. These data, from the largest lateral ALIF dataset reported to date, suggest that-radiographically-the lateral patient position can be considered as an alternative to traditional ALIF positional techniques.
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Setting for single position surgery: survey from expert spinal surgeons. 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; 31:2239-2247. [PMID: 35524824 DOI: 10.1007/s00586-022-07228-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 03/20/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To describe a comprehensive setting of the different alternatives for performing a single position fusion surgery based on the opinion of leading surgeons in the field. METHODS Between April and May of 2021, a specifically designed two round survey was distributed by mail to a group of leaders in the field of Single Position Surgery (SPS). The questionnaire included a variety of domains which were focused on highlighting tips and recommendations regarding improving the efficiency of the performance of SPS. This includes operation room setting, positioning, use of technology, approach, retractors specific details, intraoperative neuromonitoring and tips for inserting percutaneous pedicle screws in the lateral position. It asked questions focused on Lateral Single Position Surgery (LSPS), Lateral ALIF (LA) and Prone Lateral Surgery (PLS). Strong agreement was defined as an agreement of more than 80% of surgeons for each specific question. The number of surgeries performed in SPS by each surgeon was used as an indirect element to aid in exhibiting the expertise of the surgeons being surveyed. RESULTS Twenty-four surgeons completed both rounds of the questionnaire. Moderate or strong agreement was found for more than 50% of the items. A definition for Single Position Surgery and a step-by-step recommendation workflow was built to create a better understanding of surgeons who are starting the learning curve in this technique. CONCLUSION A recommendation of the setting for performing single position fusion surgery procedure (LSPS, LA and PLS) was developed based on a survey of leaders in the field.
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Gandhi SV, Dugan R, Farber SH, Godzik J, Alhilali L, Uribe JS. Anatomical positional changes in the 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; 31:2220-2226. [PMID: 35428915 DOI: 10.1007/s00586-022-07195-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 01/13/2022] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION ALIFs and LLIFs are now becoming more utilized for adult spinal disease. As technologies advance, so do surgical techniques, with surgeons now modifying traditional supine-ALIF and lateral-LLIF to lateral-ALIF and prone-LLIF approaches to allow for more efficient surgeries. The objective of this study is to characterize the anatomical changes in the surgical corridor that occur with changes in patient positioning. METHODS MRIs of ten healthy volunteers were evaluated in five positions: supine, prone with hips flexed, prone with hips extended, lateral with hips flexed, and lateral with hips extended. All lateral scans were in the left lateral decubitus position. The anatomical changes of the psoas muscles, inferior vena cava, aorta, iliac vessels were assessed with relation to fixed landmarks on the disc spaces from L1 to S1. RESULTS The most anteriorly elongated ipsilateral to approach psoas when compared to supine was seen in lateral-flexed position (- 5.82 mm, p < 0.001), followed by lateral-extended (- 2.23 mm, p < 0.001), then prone-flexed (- 1.40 mm, p = 0.014), and finally supine and prone-extended (- 0.21 mm, p = 0.643). The most laterally extending or "thickest" psoas was seen in prone-flexed (- 1.40 mm, p = 0.004) and prone-extended (- 1.17 mm, p = 0.002). The psoas was "thinnest" in lateral-extended (2.03 mm, p < 0.001) followed by lateral-flexed (1.11 mm, p = 0.239). The contralateral psoas did not move as anteriorly as the ipsilateral. 3D volumetric analysis showed that the greatest changes in the psoas occur at its proximal and distal poles near T12-L1 and L4-S1. In lateral-flexed compared to prone-extended, the IVC moves medially to the left (p < 0.001). The aorta moves laterally to the left (p = 0.005). The venous structures appeared more full and open in the lateral positions and flattened in the supine and prone positions. The arteries remain in full calibre. CONCLUSION The MRI anatomical evaluation shows that the psoas, and therefore lumbar plexus, and vasculature move significantly with changes in positioning. This is important for preoperative planning for proper intraoperative execution from preoperative supine MRI. Understanding that the psoas and vessels move the most anteriorly in the lateral-flexed position and to a least degree in the prone-extended is essential for safe and efficient utilization of techniques such as the traditional LLIF, traditional ALIF, prone-LLIF.
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Affiliation(s)
- Shashank V Gandhi
- Texas Back Institute, 6020 W. Parker Road, Suite 200, Plano, TX, 75093, USA.
| | - Robert Dugan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Samuel H Farber
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Lea Alhilali
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
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Lopez G, Sayari AJ, Phillips F. Single-Position Anterior Column Lateral Lumbar Interbody Fusion. Int J Spine Surg 2022; 16:S17-S25. [PMID: 35387885 PMCID: PMC9983566 DOI: 10.14444/8232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Lateral lumbar fusion is a commonly used spinal fusion technique that allows for indirect neural decompression while correcting sagittal malalignment. The lateral position has evolved to include placement of percutaneous pedicle screw fixation, anterior longitudinal ligament release, and approach the L5-S1 segment. This review article focuses on the anatomy and technique of the single-position anterior column spinal fusion and highlights the recent trends, outcomes, and future directions for the approach.
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Menezes CM, Menezes ÉG, Asghar J, Guiroy A. When to Consider Stand-Alone Lateral Lumbar Interbody Fusion: Is There a Role for a Comeback With New Implants? Int J Spine Surg 2022; 16:S69-S75. [PMID: 35387891 PMCID: PMC9983564 DOI: 10.14444/8238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To perform a comprehensive review of the literature about the role of stand-alone lateral lumbar interbody fusion (LLIF). METHODS A MEDLINE review was conducted including studies about stand-alone LLIF for any condition. The opinions of the authors were also considered. Studies that included biomechanical, cadaveric, or clinical aspects of stand-alone cages were revised to obtain data about the pros, cons, and limitations of the technique. Comparative studies with 360° (lateral + posterior) fusions were also analyzed. RESULTS A total of 36 studies were identified. After reviewing the abstracts, 18 full articles of interest for the objective of this review were analyzed. Recommendations based on the literature were made. Although most of the recommendations in the literature were about augmentation with pedicle screws, there may be a role for stand-alone LLIF in some particular cases. Specific technical aspects should be considered to reduce the failure rate. CONCLUSION Although there might be some specific indications for stand-alone LLIF, it should be considered an exception rather than the rule. LEVEL OF EVIDENCE: 4
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Affiliation(s)
| | - Érica Godinho Menezes
- Columna Institute, University Center of Belo Horizonte – UNIBH, Belo Horizonte, Brazil
| | - Jahangir Asghar
- The Paley Orthopedic and Spine Institute at Saint Mary´s Medical Hospital, West Palm Beach, Florida, USA
| | - Alfredo Guiroy
- The Paley Orthopedic and Spine Institute at Saint Mary´s Medical Hospital, West Palm Beach, Florida, USA
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Goldberg JL, McGrath LB, Kirnaz S, Sommer F, Carnevale JA, Medary B, Härtl R. Single-Position Fluoroscopy-Guided Lateral Lumbar Interbody Fusion With Intraoperative Computed Tomography-Navigated Posterior Pedicle Screw Fixation: Technical Report and Literature Review. Int J Spine Surg 2022; 16:S9-S16. [PMID: 35387884 PMCID: PMC9983565 DOI: 10.14444/8231] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Lateral lumbar interbody fusion (LLIF) is a powerful tool in minimally invasive spine surgery with high rates of fusion, excellent indirect decompression, and deformity correction. LLIF offers advantages compared with anterior lumbar interbody fusion including a more favorable complication profile. Traditionally, the interbody fusion is performed in the lateral position and fluoroscopy-assisted pedicle screw fixation performed with the patient repositioned prone. The evolution of both pedicle screw technology and intraoperative navigation has enhanced the feasibility of single (lateral)-position surgery. Early reports using fluoroscopy-assisted pedicle screws and computer or robotic navigation suggest this technique can be performed safely and accurately. The purpose of this brief report is to provide the technical steps, workflow, as well as pearls and pitfalls for single-position LLIF with true intraoperative computed tomography navigation-guided percutaneous pedicle screw fixation. A case example is included for illustration.
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Affiliation(s)
- Jacob L. Goldberg
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell MedicineNew York, NY, USA
| | - Lynn B. McGrath
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell MedicineNew York, NY, USA
| | - Sertac Kirnaz
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell MedicineNew York, NY, USA
| | - Fabian Sommer
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell MedicineNew York, NY, USA
| | - Joseph A. Carnevale
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell MedicineNew York, NY, USA
| | - Branden Medary
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell MedicineNew York, NY, USA
| | - Roger Härtl
- Department of Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medicine New York, NY, USA
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Sinkov V, Lockey SD, Cunningham BW. Single Position Lateral Lumbar Interbody Fusion With Posterior Instrumentation Utilizing Computer Navigation and Robotic Assistance: Retrospective case review and surgical technique considerations. Global Spine J 2022; 12:75S-81S. [PMID: 35393884 PMCID: PMC8998483 DOI: 10.1177/21925682221083909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine safety and short-term outcomes of single-position lateral lumbar interbody fusion (LLIF) with bilateral posterior instrumentation and robotic assistance. The article also describes surgical technique considerations for the procedure. METHODS 20 patients underwent single-position LLIF with posterior instrumentation and robotic assistance. The patients were followed for a minimum of 3 months post-operatively. RESULTS Average operative time was 211 ± 34 minutes, average blood loss was 51.25 ± 17 cc's, and average length of stay was 1.4 ± .75 days. There were no intraoperative complications, readmissions, revision surgeries, and no incidence of hardware malposition. Significant improvement in pain and ODI scores was noted at 3 month follow up. CONCLUSIONS The study demonstrated safety and short-term clinical efficacy of minimally invasive single-position lateral lumbar interbody fusion with bilateral posterior instrumentation utilizing robotic assistance and navigation. There are certain surgical technique considerations that must be followed to ensure optimal surgical workflow and predictable outcomes.
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Ashayeri K, Leon C, Tigchelaar S, Fatemi P, Follett M, Cheng I, Thomas JA, Medley M, Braly B, Kwon B, Eisen L, Protopsaltis TS, Buckland AJ. Single position lateral decubitus anterior lumbar interbody fusion (ALIF) and posterior fusion reduces complications and improves perioperative outcomes compared with traditional anterior-posterior lumbar fusion. Spine J 2022; 22:419-428. [PMID: 34600110 DOI: 10.1016/j.spinee.2021.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lateral decubitus single position anterior-posterior (AP) fusion utilizing anterior lumbar interbody fusion and percutaneous posterior fixation is a novel, minimally invasive surgical technique. Single position lumbar surgery (SPLS) with anterior lumbar interbody fusion (ALIF) or lateral lumbar interbody fusion (LLIF) has been shown to be a safe, effective technique. This study directly compares perioperative outcomes of SPLS with lateral ALIF vs. traditional supine ALIF with repositioning (FLIP) for degenerative pathologies. PURPOSE To determine if SPLS with lateral ALIF improves perioperative outcomes compared to FLIP with supine ALIF. STUDY DESIGN/SETTING Multicenter retrospective cohort study. PATIENT SAMPLE Patients undergoing primary AP fusions with ALIF at 5 institutions from 2015 to 2020. OUTCOME MEASURES Levels fused, inclusion of L4-L5, L5-S1, radiation dosage, operative time, estimated blood loss (EBL), length of stay (LOS), perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), and PI-LL mismatch. METHODS Retrospective analysis of primary ALIFs with bilateral percutaneous pedicle screw fixation between L4-S1 over 5 years at 5 institutions. Patients were grouped as FLIP or SPLS. Demographic, procedural, perioperative, and radiographic outcome measures were compared using independent samples t-tests and chi-squared analyses with significance set at p <.05. Cohorts were propensity-matched for demographic or procedural differences. RESULTS A total of 321 patients were included; 124 SPS and 197 Flip patients. Propensity-matching yielded 248 patients: 124 SPLS and 124 FLIP. The SPLS cohort demonstrated significantly reduced operative time (132.95±77.45 vs. 261.79±91.65 min; p <0.001), EBL (120.44±217.08 vs. 224.29±243.99 mL; p <.001), LOS (2.07±1.26 vs. 3.47±1.40 days; p <.001), and rate of perioperative ileus (0.00% vs. 6.45%; p =.005). Radiation dose (39.79±31.66 vs. 37.54±35.85 mGy; p =.719) and perioperative complications including vascular injury (1.61% vs. 1.61%; p =.000), retrograde ejaculation (0.00% vs. 0.81%, p =.328), abdominal wall (0.81% vs. 2.42%; p =.338), neuropraxia (1.61% vs. 0.81%; p =.532), persistent motor deficit (0.00% vs. 1.61%; p =.166), wound complications (1.61% vs. 1.61%; p =.000), or VTE (0.81% vs. 0.81%; p =.972) were similar. No difference was seen in 90-day return to OR. Similar results were noted in sub-analyses of single-level L4-L5 or L5-S1 fusions. On radiographic analysis, the SPLS cohort had greater changes in LL (4.23±11.14 vs. 0.43±8.07 deg; p =.005) and PI-LL mismatch (-4.78±8.77 vs. -0.39±7.51 deg; p =.002). CONCLUSIONS Single position lateral ALIF with percutaneous posterior fixation improves operative time, EBL, LOS, rate of ileus, and maintains safety compared to supine ALIF with prone percutaneous pedicle screws between L4-S1.
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Affiliation(s)
- Kimberly Ashayeri
- Department of Neurosurgery, NYU Langone Medical Center, 462 1st Avenue, Suite 7S4, New York, NY, 10016, USA.
| | - Carlos Leon
- Department of Orthopedic Surgery, NYU Langone Medical Center, 333 East 38th Street, 6th Floor, New York, NY 10016
| | - Seth Tigchelaar
- Department of Orthopedic Surgery, Stanford University, Stanford, 430 Broadway Street, MC: 6342, Pavilion C, 4th Floor, Redwood City, CA 94063-3132 CA, USA
| | - Parastou Fatemi
- Department of Orthopedic Surgery, Stanford University, Stanford, 430 Broadway Street, MC: 6342, Pavilion C, 4th Floor, Redwood City, CA 94063-3132 CA, USA
| | - Matt Follett
- Department of Orthopedic Surgery, Stanford University, Stanford, 430 Broadway Street, MC: 6342, Pavilion C, 4th Floor, Redwood City, CA 94063-3132 CA, USA
| | - Ivan Cheng
- St. David's Medical Center, Austin Spine Surgery, Austin, Austin Spine - Central Austin Office 3000 N IH 35, Suite 708 Austin, TX 78705 TX, USA
| | - J Alex Thomas
- New Hanover Regional Medical Center, Atlantic Neurosurgical and Spine Specialists, 2208 South 17th St. Wilmington, NC 28401, Wilmington, NC, USA
| | - Mark Medley
- New Hanover Regional Medical Center, Atlantic Neurosurgical and Spine Specialists, 2208 South 17th St. Wilmington, NC 28401, Wilmington, NC, USA
| | - Brett Braly
- Healthcare Partners Investments, Inc, Oklahoma Sports, Science and Orthopaedics, 9800 Broadway Ext., Ste. 203OKC, OK 73114, Oklahoma City, OK
| | - Brian Kwon
- Division of Spine Surgery, New England Baptist Hospital, 125 Parker Hill Avenue, Converse 4, Suite 1 Boston, MA 02120, Boston, MA
| | - Leon Eisen
- Department of Orthopedic Surgery, NYU Langone Medical Center, 333 East 38th Street, 6th Floor, New York, NY 10016
| | - Themistocles S Protopsaltis
- Department of Orthopedic Surgery, NYU Langone Medical Center, 333 East 38th Street, 6th Floor, New York, NY 10016
| | - Aaron J Buckland
- Department of Orthopedic Surgery, NYU Langone Medical Center, 333 East 38th Street, 6th Floor, New York, NY 10016
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Mills ES, Treloar J, Idowu O, Shelby T, Alluri RK, Hah RJ. Single position lumbar fusion: a systematic review and meta-analysis. Spine J 2022; 22:429-443. [PMID: 34699998 DOI: 10.1016/j.spinee.2021.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/19/2021] [Accepted: 10/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Recently, a single position lumbar fusion has been described in which both the anterior or lateral interbody fusion as well as posterior percutaneous pedicle screw fixation are performed in a single position. PURPOSE The purpose of this study was to present and analyze the current evidence for single position lumbar fusion. STUDY DESIGN/SETTING This is a systematic review and meta-analysis. PATIENT SAMPLE Prospective or retrospective studies published in English that assessed outcomes of single position lumbar fusion surgery for patients with lumbar degenerative disease, spondylolisthesis, or radiculopathy were included. OUTCOME MEASURES Outcome measures included operative time, estimated blood loss, hospital length of stay, X-Ray exposure time, and postoperative outcomes including leg numbness or pain, leg weakness, lumbar lordosis, and segmental lordosis. METHODS This systematic review was performed in accordance with PRISMA guidelines. Two separate meta-analyses were performed. The first compared single position (SP) surgery, both lateral and prone, to dual position or flipped (F) surgery. The second meta-analysis compared lateral single position (LSP) surgery to prone single position (PSP) surgery. Variables were included if (1) they were a mean with a reported standard deviation or (2) if they were a categorical variable. For calculating standard error of the mean, we used sample size, mean, and standard deviation. A random effects model was used. The heterogeneity among studies was assessed with a significance level of <0.05. RESULTS Twenty-one articles were included for analysis. Three studies were prospective nonrandomized studies, while 18 were retrospective. Seven articles studied lateral single position only, 10 articles compared lateral single position to traditional repositioning surgery, three articles studied prone single position surgery, and one article compared prone single position surgery to traditional repositioning surgery. A detailed review is provided for all 21 articles. Seventeen studies were included for meta-analysis comparing the SP versus F groups, for a total of 942 patients in the SP group and 254 in the F group. Mean operative time was significantly less for the SP group compared with the F group (SP: 127.5±7.9, F: 188.7±15.5, p<.001). Average hospital length of stay was 2.87±0.3 days in the SP group and 6.63±0.6 days in the F group (p<.001). Complication rates did not significantly differ between groups. Pedicle screws placed in the lateral position had a higher rate of complication as compared with those placed in a prone position (L: 10.2±2%, P: 1.6±1%, p=.015). Seventeen studies were included in the LSP versus PSP analysis, including 13 in the LSP group and four in the PSP group, with a total of 785 patients in the LSP group and 85 patients in the PSP group. Operative time and X-Ray exposure was significantly less in the LSP compared with the PSP group (117.1±5.5 minutes vs. 166.9±21.9 minutes, p<.001; 43.7±15.5 minutes vs. 171.0±25.8 minutes, p<.001). Postoperative segmental lordosis was greater in the prone single position group (p<.001). CONCLUSIONS Single position surgery decreases operative times and hospital length of stay, while maintaining similar complication rates and radiographic outcomes. PSP surgery was found to be longer in duration and have increased radiation exposure time compared with LSP, while increasing postoperative segmental lordosis.
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Affiliation(s)
- Emily S Mills
- Keck School of Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA.
| | - Joshua Treloar
- Keck School of Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Olumuyiwa Idowu
- Keck School of Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Tara Shelby
- Keck School of Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ram K Alluri
- Keck School of Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Raymond J Hah
- Keck School of Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
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Surgical fixation of pathologic and traumatic spinal fractures using single position surgery technique in lateral decubitus position. 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; 31:2212-2219. [PMID: 35122503 DOI: 10.1007/s00586-022-07128-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/15/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
STUDY DESIGN Retrospective Case Series. OBJECTIVES This study aims to determine complications, readmission, and revision surgery rates in patients undergoing single position surgery (SPS) for surgical treatment of traumatic and pathologic thoracolumbar fractures. METHODS A multi-center review of patients who underwent SPS in the lateral decubitus position (LSPS) for surgical management of traumatic or pathologic thoracolumbar fractures between January 2016 and May 2020 was conducted. Operative time, estimated blood loss (EBL), intraoperative complications, postoperative complications, readmissions, and revision surgeries were collected. RESULTS A total of 12 patients with a mean age of 45 years (66.67% male) were included. The majority of patients underwent operative treatment for acute thoracolumbar trauma (66.67%) with a mean injury severity score (ISS) of 16.71. Mean operative time was 175.5 min, mean EBL of 816.67 cc. Five patients experienced a complication, two of which required revision surgery for additional decompression during the initial admission. All ambulatory patients were mobilized on postoperative day 1. The mean hospital length of stay (LOS) was 9.67 days. CONCLUSION The results of this case series supports LSPS as a feasible alternative to the traditional combined anterior-posterior approach for surgical treatment of pathologic and thoracolumbar fractures. These results are similar to reductions in operative time, EBL, and LOS seen in the elective spine literature with LSPS. LEVEL OF EVIDENCE IV.
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State of the art review of new technologies in spine deformity surgery-robotics and navigation. Spine Deform 2022; 10:5-17. [PMID: 34487345 PMCID: PMC8741671 DOI: 10.1007/s43390-021-00403-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/14/2021] [Indexed: 12/24/2022]
Abstract
STUDY DESIGN/METHODS Review article. OBJECTIVES The goal of this article is to review the available evidence for computerized navigation and robotics as an accuracy improvement tool for spinal deformity surgery, as well as to consider potential complications, impact on clinical outcomes, radiation exposure, and costs. Pedicle screw and rod construct are widely utilized for posterior spinal fixation in spinal deformity correction. Freehand placement of pedicle screws has long been utilized, although there is variable potential for inaccuracy depending on surgeon skill and experience. Malpositioned pedicle screws may have significant clinical implications ranging from nerve root irritation, inadequate fixation, CSF leak, perforation of the great vessels, or spinal cord damage. Computer-based navigation and robotics systems were developed to improve pedicle screw insertion accuracy and consistency, and decrease the risk of malpositioned pedicle fixation. The available evidence suggests that computer-based navigation and robotic-assisted guidance systems for pedicle cannulation are at least equivalent, and in several reports superior, to freehand techniques in terms of accuracy. CT and robotic navigation systems do appear to decrease radiation exposure to the operative team in some reports. Published reports do indicate longer operative times with use of robotic navigation compared with traditional freehand techniques for pedicle screw placement. To date, there is no conclusive evidence that use of CT or robotic navigation has any measurable impact on patient outcomes or overall complication reduction. There are theoretical advantages with robotic and CT navigation in terms of both speed and accuracy for severe spinal deformity or complex revision cases, however, there is a need for studies to investigate this technology in these specific cases. There is no evidence to date demonstrating the cost effectiveness of CT or robotic navigation as compared with traditional pedicle cannulation techniques. CONCLUSIONS The review of available evidence suggests that computer-based navigation and robotic-assisted guidance systems for pedicle cannulation are at least equivalent, and in several reports superior, to freehand techniques in terms of radiographic accuracy. There is no current clinical evidence that the use of navigation or robotic techniques leads to improved patient outcomes or decreased overall complications or reoperation rates, and the use of these systems may substantially increase surgical costs. LEVEL OF EVIDENCE V.
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Farber SH, Naeem K, Bhargava M, Porter RW. Single-position prone lateral transpsoas approach: early experience and outcomes. J Neurosurg Spine 2021:1-8. [PMID: 34678768 DOI: 10.3171/2021.6.spine21420] [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: 03/19/2021] [Accepted: 06/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lateral lumbar interbody fusion (LLIF) via a transpsoas approach is a workhorse minimally invasive approach for lumbar arthrodesis that is often combined with posterior pedicle screw fixation. There has been increasing interest in performing single-position surgery, allowing access to the anterolateral and posterior spine without requiring patient repositioning. The feasibility of the transpsoas approach in patients in the prone position has been reported. Herein, the authors present a consecutive case series of all patients who underwent single-position prone transpsoas LLIF performed by an individual surgeon since adopting this approach. METHODS A retrospective review was performed of a consecutive case series of adult patients (≥ 18 years old) who underwent single-position prone LLIF for any indication between October 2019 and November 2020. Pertinent operative details (levels, cage use, surgery duration, estimated blood loss, complications) and 3-month clinical outcomes were recorded. Intraoperative and 3-month postoperative radiographs were reviewed to assess for interbody subsidence. RESULTS Twenty-eight of 29 patients (97%) underwent successful treatment with the prone lateral approach over the study interval; the approach was aborted in 1 patient, whose data were excluded. The mean (SD) age of patients was 67.9 (9.3) years; 75% (21) were women. Thirty-nine levels were treated: 18 patients (64%) had single-level fusion, 9 (32%) had 2-level fusion, and 1 (4%) had 3-level fusion. The most commonly treated levels were L3-4 (n = 15), L2-3 (n = 12), and L4-5 (n = 11). L1-2 was fused in 1 patient. The mean operative time was 286.5 (100.6) minutes, and the mean retractor time was 29.2 (13.5) minutes per level. The mean fluoroscopy duration was 215.5 (99.6) seconds, and the mean intraoperative radiation dose was 170.1 (94.8) mGy. Intraoperative subsidence was noted in 1 patient (4% of patients, 3% of levels). Intraoperative lateral access complications occurred in 11% of patients (1 cage repositioning, 2 inadvertent ruptures of anterior longitudinal ligament). Subsidence occurred in 5 of 22 patients (23%) with radiographic follow-up, affecting 6 of 33 levels (18%). Postoperative functional testing (Oswestry Disability Index, SF-36, visual analog scale-back and leg pain) identified significant improvement. CONCLUSIONS This single-surgeon consecutive case series demonstrates that this novel technique is well tolerated and has acceptable clinical and radiographic outcomes. Larger patient series with longer follow-up are needed to further elucidate the safety profile and long-term outcomes of single-position prone LLIF.
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Hiyama A, Katoh H, Nomura S, Sakai D, Watanabe M. Intraoperative computed tomography-guided navigation versus fluoroscopy for single-position surgery after lateral lumbar interbody fusion. J Clin Neurosci 2021; 93:75-81. [PMID: 34656265 DOI: 10.1016/j.jocn.2021.08.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/20/2021] [Accepted: 08/24/2021] [Indexed: 02/02/2023]
Abstract
There are no reports comparing fluoroscopy and intraoperative computed tomography (CT) navigation in lateral single-position surgery (SPS) in terms of surgical outcomes or implant-related complications. Therefore, the purpose of this study was to use radiological evaluation to compare the incidence of instrument-related complications in SPS of lateral lumbar interbody fusion (LLIF) using fluoroscopy with that using CT navigation techniques. We evaluated 99 patients who underwent lateral SPS. Twenty-six patients had a percutaneous pedicle screw (PPS) inserted under fluoroscopy (SPS-C group), and 73 patients had a PPS inserted under intraoperative CT navigation (SPS-O group). Average operation time was shorter in the SPS-C group than in the SPS-O group (88.4 ± 24.4 min versus 111.9 ± 35.3 min, respectively, P = 0.003). However, there was no significant difference between the two groups in postoperative thigh symptoms or reoperation rate. The screw insertion angle of the SPS-C group was smaller than that of the SPS-O group, but there was no significant difference in the rate of screw misplacement (4.6% versus 3.4%, respectively, P = 0.556). By contrast, facet joint violation (FJV) was significantly lower in the SPS-O group than in the SPS-C group (8.4% versus 21.3%, respectively, P < 0.001). While fluoroscopy was superior to intraoperative CT navigation in terms of mean surgery time, there was no significant difference in the accuracy of PPS insertion between fluoroscopy and intraoperative CT navigation. The advantage of intraoperative CT navigation over fluoroscopy is that it significantly decreases the occurrence of FJV in SPS.
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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.
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
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Yee TJ, Strong MJ, North RY, Oppenlander ME. Commentary: Single-Position Surgery: Prone Lateral Lumbar Interbody Fusion: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E370-E372. [PMID: 33554251 DOI: 10.1093/ons/opab026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 11/12/2022] Open
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North RY, Strong MJ, Park P. Commentary: Prone Transpsoas Technique for Simultaneous Single-Position Access to the Anterior and Posterior Lumbar Spine. Oper Neurosurg (Hagerstown) 2021; 20:E13-E16. [PMID: 33316812 DOI: 10.1093/ons/opaa354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 11/12/2022] Open
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Warren SI, Wadhwa H, Koltsov JCB, Michaud JB, Cheng I. One surgeon's learning curve with single position lateral lumbar interbody fusion: perioperative outcomes and complications. JOURNAL OF SPINE SURGERY (HONG KONG) 2021; 7:162-169. [PMID: 34296028 PMCID: PMC8261560 DOI: 10.21037/jss-21-13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/02/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Single position (SP) lateral transpsoas lumbar interbody fusion (LLIF) with posterior pedicle screw fixation (PPSF) reduces operative time compared to dual positioning. However, the learning curve has not yet been described. The purpose of this study was to define the learning curve SP LLIF with PPSF. METHODS This retrospective case series included the first 161 consecutive patients who underwent SP LLIF and PPSF with the senior author. Primary analysis of operative time versus case number included single level cases without adjacent level procedures. Secondary analyses included 1-3 level cases without adjacent level procedures. Operative time for 2 and 3 level procedures was normalized to single-level cases. The learning curve was assessed with linear regression, which was found to fit the data better than logarithmic regression as judged by R2 values and data visualization. Perioperative outcomes as a function of case number were analyzed by least squares linear regression and Mann Whitney U-tests. RESULTS For single level surgeries without adjacent procedures (n=87), operative time decreased by a total of 28.7 (95% CI, 9.6, 47.9) minutes over the series (P<0.001). For 1-3 level cases with no adjacent procedures (n=131), normalized operative time decreased by 23.1 (7.6, 38.6) minutes (P<0.001). Post-operative change in hematocrit, length of hospital stay, post-operative change in lordosis, 90-day complications, suboptimal screw placement, and 6-week post-operative Oswestry Disability Index (ODI) score did not correlate with case number. Intraoperative fluids decreased 3.7 mL (95% CI, 0.7, 6.7) per case (P=0.015). CONCLUSIONS In SP LLIF with PPSF, case number correlated with decreased operative time, but not complications. The surgeon's prior experience with dual position (DP) LLIF likely contributed to the minimal learning curve observed. Surgeons adopting SP LLIF with minimal prior DP LLIF experience may experience a steeper curve.
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Affiliation(s)
- Shay I. Warren
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Harsh Wadhwa
- School of Medicine, Stanford University, Stanford, CA, USA
| | | | | | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
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Bodon G, Kiraly K, Baksa G, Barany L, Kiss M, Hirt B, Pussert A, Timothy J, Stubbs L, Khajavi K, Braly B. Applied anatomy and surgical technique of the lateral single-position L5-S1 fusion. Clin Anat 2021; 34:774-784. [PMID: 33909306 DOI: 10.1002/ca.23733] [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: 01/26/2021] [Revised: 03/03/2021] [Accepted: 03/11/2021] [Indexed: 11/11/2022]
Abstract
The latest development in the anterior lumbar interbody fusion (ALIF) procedure is its application in the lateral position to allow for simultaneous posterior percutaneous screw placement. The technical details of the lateral ALIF technique have not yet been described. To describe the surgical anatomy relevant to the lateral ALIF approach we performed a comprehensive anatomical study. In addition, the preoperative imaging, patient positioning, planning of the skin incision, positioning of the C-arm, surgical approach, and surgical technique are discussed in detail. The technique described led to the successful use of the lateral ALIF technique in our clinical cases. No lateral ALIF procedure needed to be aborted during these cases. Our present work gives detailed anatomical background and technical details for the lateral ALIF approach. This teaching article can provide readers with sufficient technical and anatomical knowledge to assist them in performing their first lateral ALIF procedure.
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Affiliation(s)
- Gergely Bodon
- Department of Orthopaedic Surgery and Traumatology, Klinikum Esslingen, Esslingen am Neckar, Germany.,Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embriology, Semmelweis University, Budapest, Hungary.,Clinical Anatomy Tübingen, University of Tübingen, Tübingen, Germany
| | - Kristof Kiraly
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embriology, Semmelweis University, Budapest, Hungary
| | - Gabor Baksa
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embriology, Semmelweis University, Budapest, Hungary
| | - Laszlo Barany
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embriology, Semmelweis University, Budapest, Hungary
| | - Mate Kiss
- Department of Orthopaedic Surgery and Traumatology, Klinikum Esslingen, Esslingen am Neckar, Germany
| | - Bernhard Hirt
- Clinical Anatomy Tübingen, University of Tübingen, Tübingen, Germany
| | - Arndt Pussert
- Department of Orthopaedic Surgery and Traumatology, Klinikum Esslingen, Esslingen am Neckar, Germany
| | - Jake Timothy
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Lenny Stubbs
- Oklahoma Heart Hospital, Oklahoma City, Oklahoma, USA
| | - Kaveh Khajavi
- Georgia Spine & Neurosurgery Center, Atlanta, Georgia, USA
| | - Brett Braly
- The Spine Clinic of Oklahoma City, Oklahoma City, Oklahoma, USA
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Buckland AJ, Ashayeri K, Leon C, Manning J, Eisen L, Medley M, Protopsaltis TS, Thomas JA. Single position circumferential fusion improves operative efficiency, reduces complications and length of stay compared with traditional circumferential fusion. Spine J 2021; 21:810-820. [PMID: 33197616 DOI: 10.1016/j.spinee.2020.11.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) with percutaneous posterior screw fixation are two techniques used to address degenerative lumbar pathologies. Traditionally, these anterior-posterior (AP) surgeries involve repositioning the patient from the supine or lateral decubitus position to prone for posterior fixation. To reduce operative time (OpTime) and subsequent complications of prolonged anesthesia, single-position lumbar surgery (SPLS) is a novel, minimally invasive alternative performed entirely from the lateral decubitus position. PURPOSE Assess the perioperative safety and efficacy of single position AP lumbar fusion surgery (SPLS). STUDY DESIGN Multicenter retrospective cohort study. PATIENT SAMPLE Three hundred and ninety patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group. OUTCOME MEASURES Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence, pelvic tilt, and segmental LL. METHODS Patients undergoing primary ALIF and/or LLIF surgery with bilateral percutaneous pedicle screw fixation between L2-S1 were included over a 4-year period. Patients were classified as either traditional repositioned "Flip" surgery or SPLS. Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, EBL, LOS, perioperative complications. Radiographic analysis included LL, pelvic incidence, pelvic tilt, and segmental LL. All measures were compared using independent samples t-tests and chi-squared analyses as appropriate with significance set at p < .05. Propensity matching was completed where demographic differences were found. RESULTS Three hundred and ninety patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group. Age, gender, BMI, and CCI were similar between groups. Levels fused (1.47 SPLS vs 1.52 Flip, p = .468) and percent cases including L5-S1 (31% SPLS, 35% Flip, p = .405) were similar between cohorts. SPLS significantly reduced OpTime (103 min vs 306 min, p < .001), EBL (97 vs 313 mL, p < .001), LOS (1.71 vs 4.12 days, p < .001), and fluoroscopy radiation dosage (32 vs 88 mGy, p < .001) compared to Flip. Perioperative complications were similar between cohorts with the exception of postoperative ileus, which was significantly lower in the SPLS group (0% vs 5%, p < .001). There was no significant difference in wound, vascular injury, neurological complications, or Venous Thrombotic Event. There was no significant difference found in 90-day return to operating room (OR). CONCLUSIONS SPLS improves operative efficiency in addition to reducing blood loss, LOS and ileus in this large cohort study, while maintaining safety.
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Affiliation(s)
- Aaron J Buckland
- NYU Langone Orthopedic Hospital, New York, 530 1st Ave, Suite 8R, NY 10016, USA
| | - Kimberly Ashayeri
- Department of Neurosurgery, NYU Langone Medical Center, New York, 530 1st Ave, Suite 8R, NY 10016, USA.
| | - Carlos Leon
- NYU Langone Orthopedic Hospital, New York, 530 1st Ave, Suite 8R, NY 10016, USA
| | - Jordan Manning
- NYU Langone Orthopedic Hospital, New York, 530 1st Ave, Suite 8R, NY 10016, USA
| | - Leon Eisen
- NYU Langone Orthopedic Hospital, New York, 530 1st Ave, Suite 8R, NY 10016, USA
| | - Mark Medley
- Atlantic Neurosurgical and Spine Specialists, Wilmington, 2208 S 17th St, NC 28401, USA
| | | | - J Alex Thomas
- Atlantic Neurosurgical and Spine Specialists, Wilmington, 2208 S 17th St, NC 28401, USA
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Ikuma H, Hirose T, Takao S, Otsuka K, Kawasaki K. The usefulness and safety of the simultaneous parallel anterior and posterior combined lumbar spine surgery using intraoperative 3D fluoroscopy-based navigation (SPAPS). NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 5:100047. [PMID: 35141613 PMCID: PMC8819967 DOI: 10.1016/j.xnsj.2020.100047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/17/2020] [Accepted: 12/19/2020] [Indexed: 10/28/2022]
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Swiatek PR, McCarthy MH, Weiner J, Bhargava S, Vaishnav AS, Iyer S. Intraoperative image guidance for lateral position surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:90. [PMID: 33553383 PMCID: PMC7859765 DOI: 10.21037/atm-2020-ioi-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Recent advances in minimally invasive spine surgery techniques have precipitated the popularity of lateral position spine surgery, such as lateral lumbar interbody fusion (LLIF) and oblique lumbar interbody fusion (OLIF). Lateral position surgery offers a unique, minimally invasive approach to the lumbar spine that allows for preservation of anterior and posterior spinal elements. Traditionally, surgeons have relied upon fluoroscopy for triangulation and implant placement. Over the last decade, intraoperative 3-dimensional navigation (ION) has risen to the forefront of innovation in LLIF and OLIF. This technology utilizes intra-operative advanced imaging, such as comminuted tomography (CT), to map the patient’s 3D anatomy and allows the surgeon to accurately visualize instruments and implants in spatial relationship to the patient’s anatomy in real time. ION has the potential to improve accuracy during instrumentation, decrease operating room times, lower radiation exposure to the surgeon and staff, and increase feasibility of single-position surgery during which the spine is instrumented both laterally and posteriorly while the patient remains in the lateral decubitus position. Despite the advantages of ION, the intra-operative radiation exposure risk to patients is controversial. Future directions include continued innovation in ultra low radiation imaging (ULRI) techniques and image enhancement technology and in uses of robot-assisted navigation in single-position spine surgery.
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Affiliation(s)
- Peter R Swiatek
- Department of Orthopaedic Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Michael H McCarthy
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Joseph Weiner
- Department of Orthopaedic Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
| | | | - Avani S Vaishnav
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sravisht Iyer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Godzik J, Ohiorhenuan IE, Xu DS, de Andrada Pereira B, Walker CT, Whiting AC, Turner JD, Uribe JS. Single-position prone lateral approach: cadaveric feasibility study and early clinical experience. Neurosurg Focus 2020; 49:E15. [DOI: 10.3171/2020.6.focus20359] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVELateral 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.METHODSA 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.RESULTSA 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.CONCLUSIONSPerforming 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.
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Affiliation(s)
- Jakub Godzik
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
| | - Ifije E. Ohiorhenuan
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
| | - David S. Xu
- 2Neurosurgery Department, Houston Methodist Hospital, Houston, Texas
| | - Bernardo de Andrada Pereira
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
| | - Corey T. Walker
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
| | - Alexander C. Whiting
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
| | - Jay D. Turner
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
| | - Juan S. Uribe
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
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Thomas JA, Thomason CIM, Braly BA, Menezes CM. Rate of failure of indirect decompression in lateral single-position surgery: clinical results. Neurosurg Focus 2020; 49:E5. [DOI: 10.3171/2020.6.focus20375] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVELateral single-position surgery (LSPS) of the lumbar spine generally involves anterior lumbar interbody fusion (ALIF) performed in the lateral position (LALIF) at L5–S1 with or without lateral lumbar interbody fusion (LLIF) at L4–5 and above, followed by bilateral pedicle screw fixation (PSF) without repositioning the patient. One obstacle to more widespread adoption of LSPS is the perceived need for direct decompression of the neural elements, which typically requires flipping the patient to the prone position. The purpose of this study was to examine the rate of failure of indirect decompression in a cohort of patients undergoing LSPS from L4 to S1.METHODSA multicenter, post hoc analysis was undertaken from prospectively collected data of patients at 3 institutions who underwent LALIF at L5–S1 with or without LLIF at L4–5 with bilateral PSF in the lateral decubitus position between March 2018 and March 2020. Inclusion criteria were symptoms of radiculopathy or neurogenic claudication, central or foraminal stenosis (regardless of degree or etiology), and indication for interbody fusion at L5–S1 or L4–S1. Patients with back pain only; those who were younger than 18 years; those with tumor, trauma, or suspicion of infection; those needing revision surgery; and patients who required greater than 2 levels of fusion were excluded. Baseline patient demographic information and surgical data were collected and analyzed. The number of patients in whom indirect decompression failed was recorded and each individual case of failure was analyzed.RESULTSA total of 178 consecutive patients underwent LSPS during the time period (105 patients underwent LALIF at L5–S1 and 73 patients underwent LALIF at L5–S1 with LLIF at L4–5). The mean follow-up duration was 10.9 ± 6.5 months. Bilateral PSF was placed with the patient in the lateral decubitus position in 149 patients, and there were 29 stand-alone cases. The mean case time was 101.9 ± 41.5 minutes: 79.3 minutes for single-level cases and 134.5 minutes for 2-level cases. Three patients (1.7%) required reoperation for failure of indirect decompression.CONCLUSIONSThe rate of failure of indirect decompression in LSPS from L4 to S1 is exceedingly low. This low risk of failure should be weighed against the risks associated with direct decompression as well as the risks of the extra operative time needed to perform this decompression.
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Affiliation(s)
- J. Alex Thomas
- 1Atlantic Neurosurgical and Spine Specialists, Wilmington, North Carolina
| | | | - Brett A. Braly
- 2The Spine Clinic of Oklahoma City, Oklahoma City, Oklahoma; and
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