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Ohyama S, Kotani T, Takeuchi T, Sunami T, Iijima Y, Okuwaki S, Aoki Y, Sakashita K, Iwata S, Sakuma T, Akazawa T, Inage K, Shiga Y, Minami S, Ohtori S. Analysis of the relationship between spinal alignment and retrocrural space area in adult spinal deformity surgery: Potential risk factors for acute celiac artery compression syndrome. J Orthop Sci 2024; 29:514-520. [PMID: 36931979 DOI: 10.1016/j.jos.2023.02.019] [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: 11/14/2022] [Revised: 02/05/2023] [Accepted: 02/23/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE This study was designed to reveal the association between spinal parameters and RCS area in patients with adult spinal deformities treated with spinal correction surgery. We hypothesized that reduction of the retrocrural space (RCS) area is related to thoracolumbar alignment, which may cause acute celiac artery compression syndrome (ACACS). METHODS Eighty-nine patients (age: 68.4 ± 7.6 years; sex: 7 male/82 female) with ASD treated by spinal correction surgery were enrolled. Preoperative and postoperative spinal parameters were measured, and the differences between these parameters were calculated. Postoperative T12 translation was measured and RCS area was evaluated using reconstructed computed tomography. The change of RCS area after surgery was defined as ΔRCS. Patients were divided into increased and decreased RCS groups by the ΔRCS value, and spinal parameters were compared between groups. The correlation between spinal parameters and ΔRCS was calculated. RESULTS The patients in the decreased RCS group had greater anterior T12 translation than those in the increased RCS group (p < 0.001). T12 translation was significantly correlated with ΔRCS (β = -0.31, p = 0.017). There were no correlations between ΔRCS and other spinal parameters. CONCLUSION Thoracolumbar alignment was associated with RCS area. Consistent with the hypothesis, overcorrection of the thoracolumbar junction was associated with reduced RCS area and might be one risk factor for ACACS.
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Affiliation(s)
- Shuhei Ohyama
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan.
| | - Toshiaki Kotani
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Takashi Takeuchi
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - Takahiro Sunami
- Department of Orthopedic Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yasushi Iijima
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Shun Okuwaki
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Yasuchika Aoki
- Department of Orthopedic Surgery, Eastern Chiba Medical Center, Togane, Chiba, Japan
| | - Kotaro Sakashita
- Department of Orthopedic Surgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shuhei Iwata
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsuyoshi Sakuma
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsutomu Akazawa
- Department of Orthopedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kazuhide Inage
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shohei Minami
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Limthongkul W, Praisarnti P, Tanasansomboon T, Prasertkul N, Kotheeranurak V, Yingsakmongkol W, Singhatanadgige W. An Expanded Surgical Corridor of Oblique Lateral Interbody Fusion at L4-5: A Magnetic Resonance Imaging Study. Neurospine 2023; 20:1450-1456. [PMID: 38171311 PMCID: PMC10762402 DOI: 10.14245/ns.2346678.339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/01/2023] [Accepted: 09/01/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE We introduced a new preoperative method, the "expanded surgical corridor," to evaluate the actual safety corridor, which may expand the possibility of performing oblique lateral interbody fusion (OLIF). METHODS Axial T2-weighted magnetic resonance images at the L4-5 disc level of 511 lumbar degenerative disease patients was evaluated. The distance between the medial edge of the left-sided psoas muscle and the major artery was measured as the conventional surgical corridor (CSc). The distance between the major vein and lumbar plexus was measured as the expanded surgical corridor (ESc). RESULTS The mean CSc and ESc were 13.9 ± 8.20 and 37.43 ± 10.1 mm, respectively. No surgical corridor was found in 7.05% of CSc and 1.76% of ESc, small corridor ( ≤ 1 cm) was found in 27.40% of CSc and 0.59% of ESc, moderate corridor (1-2 cm) was found in 42.07% of CSc and 1.96% of ESc, and large corridor ( > 2 cm) was found in 23.48% of CSc and 95.69% of ESc. A total of 33.83% (45 of 133) of whom were preoperatively categorized as having a limited surgical corridor by conventional measurement, underwent OLIF L4-5 successfully. CONCLUSION By using the ESc, only 2.35% were categorized as having a limited surgical corridor. The other 97.65% of the patients had an approachable corridor that could be successfully operated by experienced spine surgeons who employ meticulous surgical dissection and thorough understanding of the anatomical structures. The ESc may represent true accessibility to the disc space for OLIF, particularly at the L4-5 level.
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Affiliation(s)
- Worawat Limthongkul
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Pakawas Praisarnti
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Teerachat Tanasansomboon
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Natavut Prasertkul
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Vit Kotheeranurak
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Wicharn Yingsakmongkol
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Weerasak Singhatanadgige
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
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Soliman MAR, Diaz-Aguilar L, Kuo CC, Aguirre AO, Khan A, San Miguel-Ruiz JE, Amaral R, Abd-El-Barr MM, Moss IL, Smith T, Deol GS, Ehresman J, Battista M, Lee BS, McMains MC, Joseph SA, Schwartz D, Nguyen AD, Taylor WR, Pimenta L, Pollina J. Complications of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicenter Study. Neurosurgery 2023; 93:1106-1111. [PMID: 37272706 DOI: 10.1227/neu.0000000000002555] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/14/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of information in the literature on the complications of this procedure, with all published data consisting of small samples. We aimed to report the intraoperative and postoperative complications of PTP in the largest study to date. METHODS A retrospective electronic medical record review was conducted at 11 centers to identify consecutive patients who underwent LLIF through the PTP approach between January 1, 2021, and December 31, 2021. The following data were collected: intraoperative characteristics (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries]), postoperative complications, and hospital stay. RESULTS A total of 365 patients were included in the study. Among these patients, 2.2% had ALL rupture, 0.3% had cage subsidence, 0.3% had a vascular injury, 0.3% had a ureteric injury, and no other visceral injuries were reported. Mean operative time was 226.2 ± 147.9 minutes. Mean EBL was 138.4 ± 215.6 mL. Mean hospital stay was 2.7 ± 2.2 days. Postoperative complications included new sensory symptoms-8.2%, new lower extremity weakness-5.8%, wound infection-1.4%, cage subsidence-0.8%, psoas hematoma-0.5%, small bowel obstruction and ischemia-0.3%, and 90-day readmission-1.9%. CONCLUSION In this multicenter case series, the PTP approach was well tolerated and associated with a satisfactory safety profile.
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Affiliation(s)
- Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo , Egypt
| | - Luis Diaz-Aguilar
- Department of Neurological Surgery, University of California, San Diego, La Jolla , California , USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | | | - Rodrigo Amaral
- Department of Neurological Surgery, Instituto de Patologia da Coluna, São Palo Sul , Brazil
| | | | - Isaac L Moss
- Department of Orthopedic Surgery, University of Connecticut, Farmington , Connecticut , USA
| | - Tyler Smith
- Sierra Spine Institute, Roseville , California , USA
| | - Gurvinder S Deol
- Wake Orthopaedics, WakeMed Health and Hospitals, Raleigh , North Carolina , USA
| | - Jeff Ehresman
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix , Arizona , USA
| | - Madison Battista
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix , Arizona , USA
| | - Bryan S Lee
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix , Arizona , USA
| | | | | | | | - Andrew D Nguyen
- Department of Neurological Surgery, University of California, San Diego, La Jolla , California , USA
| | - William R Taylor
- Department of Neurological Surgery, University of California, San Diego, La Jolla , California , USA
| | - Luiz Pimenta
- Department of Neurological Surgery, Instituto de Patologia da Coluna, São Palo Sul , Brazil
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
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White MD, Uribe JS. Transpsoas Approaches to the Lumbar Spine: Lateral and Prone. Neurosurg Clin N Am 2023; 34:609-617. [PMID: 37718107 DOI: 10.1016/j.nec.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
The lateral transpsoas approach has become fundamental to minimally invasive spine surgery. The large interbody grafts that can be placed through this approach allow for robust arthrodesis of the anterior column, indirect decompression, and restoration of lordosis without disrupting the posterior musculature or ligamentous structures. The lateral decubitus position has traditionally been used for this approach but the prone position has gained popularity because it can reduce operating times for patients who also require posterior pedicle screw fixation. The transpsoas approach can be effectively performed in either position but surgeons should know the nuances that distinguish them.
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Affiliation(s)
- Michael D White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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5
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Epstein NE, Agulnick MA. Perspective; high frequency of intraoperative errors due to extreme, oblique, and lateral lumbar interbody fusions (XLIF, OLIF, LLIF): Are they "safe"? Surg Neurol Int 2023; 14:346. [PMID: 37810305 PMCID: PMC10559463 DOI: 10.25259/sni_691_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 10/10/2023] Open
Abstract
Background Extreme Lateral Lumbar Interbody Fusions (XLIF), Oblique Lateral Interbody Fusion (OLIF,) and Lateral Lumbar Interbody Fusion (LLIF) were largely developed to provide indirect lumbar decompressions for spinal stenosis, deformity, and/or instability. Methods Here, we have reviewed and updated the incidence of intraoperative errors attributed to XLIF, OLIF, and LLIF. Specifically, we focused on how often these procedures caused new neurological deficits, major vessel, visceral, and other injuries, including those warranting secondary surgery. Results Performing XLIF, OLIF, and LLIF can lead to significant intraoperative surgical errors that include varying rates of; new neurological injuries (i.e. iliopsoas motor deficits (4.3-19.7-33.6-40%), proximal hip/upper thigh sensory loss/dysesthesias (5.1% to 21.7% to 40%)), life-threatneing vascular injuries (i.e., XLIF (0% - 0.4%-1.8%), OLIF (3.2%), and LLIF (2%) involving the aorta, iliac artery, inferior vena cava, iliac vein, and segmental arteries), and bowel/viscarl injuries (0.03%-0.4%) leading to reoperations (i.e., XLIF (1.8%) vs. LLIF (3.8%) vs. XLIF/LLIF/OLIF 2.2%)). Conclusion Varying reports documented that XLIF, OLIF and LLIF caused up to a 40% incidence of new sensory/motor deficits, up to a 3.2% incidence of major vascular insults, a 0.4% frequency of visceral/bowel perforations, and a 3.8% need for reoperations. These high frequencies of intraoperative surgical errors attributed to XLIF, OLIF, and LLIF should prompt reconsideration of whether these procedures are "safe."
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of NY at Stony Brook and Editor-in-Chief Surgical Neurology International NY, USA, and c/o Dr. Marc Agulnick, 1122 Franklin Avenue Suite 106, Garden City, NY, USA
| | - Marc A Agulnick
- Assistant Clinical Professor of Orthopedics, NYU Langone Hospital, Long Island, NY, USA, 1122 Frankling Avenue Suite 106, Garden City, NY, USA
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Kotani T, Sakuma T, Iijima Y, Sato S, Nakanishi K, Ueda T, Hara T, Nakayama K, Sunami T, Asada T, Akazawa T, Kishida S, Sasaki Y, Inage K, Shiga Y, Minami S, Ohtori S. Acute celiac artery compression syndrome with superior mesenteric artery stenosis and aortic stenosis: A rare but life-threatening complication after adult spinal deformity surgery. J Orthop Sci 2023; 28:490-494. [PMID: 32819791 DOI: 10.1016/j.jos.2020.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Toshiaki Kotani
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan.
| | - Tsuyoshi Sakuma
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Yasushi Iijima
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Shinichi Sato
- Department of Gastroenterology, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Kazuya Nakanishi
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Narita Hospital, Narita, Chiba, Japan
| | - Takuya Ueda
- Department of Clinical Imaging, Tohoku University, Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Takeshi Hara
- Department of Radiology, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Keita Nakayama
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Takahiro Sunami
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tomoyuki Asada
- Department of Orthopedic Surgery, University of Tsukuba, Tsukuba, Japan
| | - Tsutomu Akazawa
- Department of Orthopedic Surgery, St. Marianna University, School of Medicine, Kawasaki, Japan
| | - Shunji Kishida
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Yu Sasaki
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Kazuhide Inage
- Department of Orthopedic Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopedic Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Shohei Minami
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan
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Jeon JM, Chung HW, Lee HD, Jeon CH, Chung NS. A Modified Anterior Column Realignment With Partial Anterior Longitudinal Ligament Release in Oblique Lateral Interbody Fusion. Spine (Phila Pa 1976) 2022; 47:1583-1589. [PMID: 35867596 DOI: 10.1097/brs.0000000000004433] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/22/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective radiological analysis. OBJECTIVE To demonstrate the radiological outcome after a modified anterior column realignment (mACR) with partial anterior longitudinal ligament (ALL) release in oblique lateral interbody fusion (OLIF). SUMMARY OF BACKGROUND DATA Anterior column realignment (ACR) remains a powerful sagittal correction technique in minimally invasive adult spinal deformity surgery and is often combined with posterior column osteotomy (PCO) to achieve more lordosis. OLIF is ideal for ACR because the anterior-to-psoas corridor typically involves the anterolateral half of the disk. METHODS This study included 112 operated disk levels of 101 consecutive patients who underwent OLIF between L2-L3 and L4-L5 using a 12° lateral cage. The mACR was performed at 73 (65.2%) levels with 30% to 50% sectioning of the ALL. Each operated level was grouped according to the mACR and additional PCO as: (1) no mACR, OLIF only (n=39); (2) mACR with no PCO (n=18); (3) mACR with grade 1 PCO (n=27); (4) mACR with grade 2 PCO (n=22); or (5) mACR with grade 3 PCO (n=6). RESULTS At the last follow-up, the mean disk lordotic angles were 10.9±2.9°, 12.6±3.0°, 13.3±3.9°, 16.7±3.2°, and 16.8±2.4° in the no mACR, mACR with no PCO, mACR with grade 1 PCO, mACR with grade 2 PCO, and mACR with grade 3 PCO groups, respectively ( P <0.001). The mean increases in disk lordotic angle were 5.8±4.1°, 12.1±6.1°, 13.5±8.7°, 15.8±6.7°, and 17.9±6.2° in each group, respectively ( P <0.001). CONCLUSIONS ACR can be performed with partial ALL release under direct vision in OLIF without deep dissection into the ventral disk space. The mACR in OLIF is a simple, safe, and effective technique for anterior column lengthening. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Jong-Min Jeon
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Gyeonggi Province, South Korea
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Mima Y, Yagi M, Suzuki S, Tsuji O, Nagoshi N, Okada E, Fujita N, Nakamura M, Matsumoto M, Watanabe K. Hidden blood loss in extreme lateral interbody fusion for adult spinal deformity. J Orthop Sci 2022; 28:509-514. [PMID: 35063334 DOI: 10.1016/j.jos.2022.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/24/2021] [Accepted: 01/03/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Extreme lateral interbody fusion (XLIF) is often used with posterior spinal fixation (PSF) to treat adult spinal deformity (ASD). However, the amount of intraoperative blood loss (IBL) reported for XLIF may underestimate the total blood loss (TBL). The objective of this study was to determine the total perioperative blood loss in XLIF for ASD. METHODS We assessed 30 consecutive ASD patients with Schwab-SRS type L (mean age: 68.7 ± 8.2 years; mean follow-up 2.0 ± 1.3 years) who were treated by multilevel XLIF (mean, 2.5 ± 0.6 levels) followed by PSF after 3-5 days. We calculated the TBL after XLIF by the Gross equation, by hemoglobin (Hb) balance, and by the Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) formula. We defined hidden blood loss (HBL) as the difference between the TBL and IBL. Pearson correlation, Spearman correlation, and multiple logistic regression analysis were performed to investigate the risk factors related to HBL. RESULTS Post-XLIF blood tests showed a significant decrease in the Hb (from 11.8 ± 1.1 mg/dl to 10.6 ± 1.1 mg/dl) and hematocrit (from 36.0 ± 3.2% to 32.5 ± 3.2%). Although the mean IBL was relatively small (33 ± 52 mL), we calculated the TBL as 291 ± 171 mL (Gross equation) and the HBL as 258 ± 168 mL by Gross equation, which was 8 times greater than the IBL on average. There was no difference in the results obtained using the three methods. Multiple logistic regression analysis indicated preoperative lumber lordosis was the risk factor of high HBL (Odds ratio = 1.085, 95%CI: 1.006-1.170, p = 0.035). CONCLUSIONS The HBL in XLIF was 8 times greater than the IBL. During the perioperative course of correction and fusion surgery for ASD with XLIF, surgeons need to pay attention not to underestimate the TBL.
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Affiliation(s)
- Yuichiro Mima
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan
| | - Satoshi Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan
| | - Eijiro Okada
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan
| | - Nobuyuki Fujita
- Department of Orthopedic Surgery, Fujita Health University School of Medicine, Dengakukekubo1-98, Kutsukakecho, Toyoake Shi, Aichi Ken, 470-1101, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku, Tokyo, 160-0016, Japan.
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Revisiting anterior longitudinal ligament release: Are we ready for an endoscopic approach? J Clin Neurosci 2021; 94:166-172. [PMID: 34863432 DOI: 10.1016/j.jocn.2021.10.011] [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: 05/22/2021] [Revised: 07/12/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
Anterior longitudinal ligament release is a proven method for restoring spinopelvic parameters. This technique is mostly described using either lateral or anterior approaches with paucity regarding a posterior method. This paper is the first to provide descriptive analysis of the neurovascular anatomy in the context of planning for a posterior endoscopic ALL release. A retrospective chart review was performed on patients underwent any lumbar surgery by a single surgeon. Anatomical data was obtained from pre-operative CT to describe the location of key neurovascular structures in relation to the ALL with focus on posterior approach. A total of 20 patients were included in data analysis. A posterior approach with endoscopic assistance would be feasible at L4/5 and L5/S1, where the bifurcation of the abdominal aorta has occurred with a vessel window that ranges from 18.85 mm to 33.45 mm with at least 2 mm space between the vessels and the corresponding disc spaces in the anterior-posterior dimension with slight predilection of the left side at the L5/S1 level to avoid any neurovascular structures. Our study confirmed the findings of previous studies examining the vascular anatomy associated with the lumbar spine. Interestingly, we found that direct midline would likely not be the best location for a posterior annulotomy, and that both the window between the iliac vessels as well as the distance in AP dimension between the spine and vessels increases as you descend the lumbar spine. This information will help guide future efforts to fully develop a safe and reproducible posterior endoscopic ALL release.
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10
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Incidence of major and minor vascular injuries during lateral access lumbar interbody fusion procedures: a retrospective comparative study and systematic literature review. Neurosurg Rev 2021; 45:1275-1289. [PMID: 34850322 DOI: 10.1007/s10143-021-01699-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/02/2021] [Accepted: 11/17/2021] [Indexed: 12/13/2022]
Abstract
During lateral lumbar fusion, the trajectory of implant insertion approaches the great vessels anteriorly and the segmental arteries posteriorly, which carries the risk of vascular complications. We aimed to analyze vascular injuries for potential differences between oblique lateral interbody fusion (OLIF) and lateral lumbar interbody fusion (LLIF) procedures at our institution. This was coupled with a systematic literature review of vascular complications associated with lateral lumbar fusions. A retrospective chart review was completed to identify consecutive patients who underwent lateral access fusions. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used for the systematic review with the search terms "vascular injury" and "lateral lumbar surgery." Of 260 procedures performed at our institution, 211 (81.2%) patients underwent an LLIF and 49 (18.8%) underwent an OLIF. There were no major vascular complications in either group in this comparative study, but there were four (1.5%) minor vascular injuries (2 LLIF, 0.95%; 2 OLIF, 4.1%). Patients who experienced vascular injury experienced a greater amount of blood loss than those who did not (227.5 ± 147.28 vs. 59.32 ± 68.30 ml) (p = 0.11). In our systematic review of 63 articles, major vascular injury occurred in 0-15.4% and minor vascular injury occurred in 0-6% of lateral lumbar fusions. The systematic review and comparative study demonstrate an increased rate of vascular injury in OLIF when compared to LLIF. However, vascular injuries in either procedure are rare, and this study aids previous literature to support the safety of both approaches.
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Soliman MAR, Khan A, Pollina J. Comparison of Prone Transpsoas and Standard Lateral Lumbar Interbody Fusion Surgery for Degenerative Lumbar Spine Disease: A Retrospective Radiographic Propensity Score-Matched Analysis. World Neurosurg 2021; 157:e11-e21. [PMID: 34464774 DOI: 10.1016/j.wneu.2021.08.097] [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: 08/05/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Prone transpsoas lateral lumbar interbody fusion (PTP-LLIF) is a recently introduced modification to standard LLIF. To date, no study has compared the radiographic outcomes of standard LLIF and PTP-LLIF. We performed a radiographic parameter-based propensity score-matched analysis to compare postoperative clinical and radiographic outcomes between PTP-LLIF and standard LLIF for degenerative lumbar spine disease. METHODS A total of 30 consecutive patients met the inclusion criteria. The preoperative standing scoliosis radiographs were retrospectively reviewed for global and segmental sagittal alignment. Propensity score matching was calculated using the baseline radiographic parameters. One-to-one matching of patients who had undergone PTP-LLIF with those who had a similar propensity score but had undergone standard LLIF was performed to compare the radiographic (primary) and clinical (secondary) outcomes. RESULTS Propensity score matching resulted in 10 pairs of PTP-LLIF and standard LLIF patients. The PTP-LLIF group had had significantly better improvement in lumbar lordosis (P = 0.047). The difference in the improvement in pelvic incidence minus lumbar lordosis mismatch approached statistical significance for the PTP-LLIF group (P = 0.05). This led to better improvement in the short-form 12-item physical score (P = 0.03) and Oswestry disability index (P = 0.1) in the PTP-LLIF group. No significant differences were found between the 2 groups in the other clinical and radiographic outcomes. The PTP-LLIF group had a shorter operative time (P = 0.4) and hospital stay (P = 0.1), without a statistically difference, and shorter radiation exposure time (P = 0.5). The standard LLIF group had experienced less intraoperative bleeding, without a statistically significant difference (P = 0.3). The mean follow-up time was 10.2 ± 5.2 months in the PTP-LLIF group and 30.9 ± 17.2 months in the standard LLIF group (P < 0.05). CONCLUSIONS The PTP-LLIF group showed significantly better improvement in lumbar lordosis and short-form 12-item physical score.
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Affiliation(s)
- Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA; Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA.
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12
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Tanaka M, Uotani K, Fujiwara Y, Yamane K, Sonawane S, Arataki S, Yamauchi T. Navigated Lateral Osteotomy for Adult Spinal Deformity: A Technical Note. World Neurosurg 2021; 150:56-63. [PMID: 33774213 DOI: 10.1016/j.wneu.2021.03.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Minimally invasive surgery is receiving considerable attention as a technique for reducing the complications of adult spinal deformity (ASD) surgery. For this technique, a new lateral osteotomy plays an important role to release fused vertebrae. We describe herein a novel navigated lateral osteotomy technique not requiring C-arm fluoroscopy to correct adult spinal deformities. CASE DESCRIPTION A 68-year-old woman with symptomatic ASD and a 4-year history of severe low back pain affecting daily life was referred to our hospital. Surgery was performed without C-arm fluoroscopy. A navigated osteotome was used to release the fused L1/2 mass. The patient was successfully treated with surgery, and low back pain was well controlled. In terms of clinical outcomes, Oswestry Disability Index improved from 64%-19% and Visual Analog Scale score for low back pain improved from 74 mm-19 mm on final follow-up at 2 years. CONCLUSIONS This novel navigated lateral osteotomy for ASD is a useful technique that enables minimally invasive surgery for fixed deformity. With this new technique, surgeons and operating room staff can avoid adverse effects of intraoperative radiation.
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Affiliation(s)
- Masato Tanaka
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama, Japan.
| | - Koji Uotani
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama, Japan
| | - Yoshihiro Fujiwara
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama, Japan
| | - Kentaro Yamane
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Sumeet Sonawane
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama, Japan
| | - Shinya Arataki
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama, Japan
| | - Taro Yamauchi
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama, Japan
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Mataki K, Koda M, Funayama T, Takahashi H, Yamazaki M. Sudden, Transient Intraoperative Hypotension During the Use of the Cantilever Technique for Correction of Adult Spine Deformity. Cureus 2021; 13:e13835. [PMID: 33854853 PMCID: PMC8036135 DOI: 10.7759/cureus.13835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intraoperative hypotension is a common but critical complication of spinal surgery. However, it is uncommon to experience sudden transient intraoperative hypotension in patients undergoing surgery for adult spine deformity (ASD) without the presence of major vascular injury, spinal cord injury, or cardiac events. We report a patient who experienced sudden transient intraoperative hypotension during the use of the cantilever technique for correction of an ASD. A 58-year-old woman underwent two-stage surgery (anterior correction followed by posterior fusion) for an ASD that caused low back pain. During the posterior fusion procedure, she experienced sudden transient intraoperative hypotension during the use of a cantilever technique. As soon as we paused the use of this technique, her hypotension resolved. Postoperative radiography revealed excessive segmental lordosis at the L4/5 level, suggesting an accidental rupture of the anterior longitudinal ligament (ALL). We believe that the mechanism of our patient’s sudden hypotension was a decrease in venous return due to compression and stretching of the inferior vena cava at the time of rod application when the use of the cantilever technique caused ALL rupture. Sudden hypotension during posterior spinal correction surgery is possible, especially in patients with a ruptured ALL.
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Affiliation(s)
- Kentaro Mataki
- Department of Orthopaedic Surgery, University of Tsukuba, Faculty of Medicine, Tsukuba, JPN
| | - Masao Koda
- Department of Orthopaedic Surgery, University of Tsukuba, Faculty of Medicine, Tsukuba, JPN
| | - Toru Funayama
- Department of Orthopaedic Surgery, University of Tsukuba, Faculty of Medicine, Tsukuba, JPN
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, University of Tsukuba, Faculty of Medicine, Tsukuba, JPN
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, University of Tsukuba, Faculty of Medicine, Tsukuba, JPN
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14
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Mousafeiris VK, Tsekouras V, Korovessis P. Simultaneous Combined Major Arterial and Lumbar Plexus Injury During Primary Extra Lateral Interbody Fusion: Case Report and Review of the Literature. Cureus 2021; 13:e13701. [PMID: 33833921 PMCID: PMC8019334 DOI: 10.7759/cureus.13701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Extra lateral interbody fusion (XLIF) has been established in recent years as an effective approach to address degenerative lumbar disc disease (DLDD). Although neurological and vascular complications during XLIF have been reported, to our knowledge, a combination of simultaneous vascular and neurovascular complication during XLIF has not been reported to date. A 72-year-old female patient was admitted to our orthopaedic department because of back pain associated with severe neuropathic radicular pain to her both lower extremities, incomplete paraplegia and low back fistula with serous secretion for several weeks. She had been wheel-chair bound since nine years before her admission in our department when she had her initial XLIF operation in another institution. Intraoperatively, an aorta lesion occurred, which was emergently addressed, along with lumbar plexus injury. Since then, she had an extensive history of subsequent operations that ended with a T10-S1 posterior lumbar fusion, with no improvement of her neurological condition, complicated by hardware-induced infection. She underwent her last operation in our department; removal of the posterior lumbar construct and extensive debridement of the posterior lumbar spine. We present this rare case and we perform an extensive literature review. Although XLIF has been established in recent years, the report of major vascular injuries, although rare, has questioned its safety profile. Spine surgeons should be aware of catastrophic major neurovascular complications associated with this procedure and be prepared to address them.
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Affiliation(s)
| | - Vasileios Tsekouras
- Orthopedics and Traumatology, General Hospital of Patras "Agios Andreas", Patras, GRC
| | - Panagiotis Korovessis
- Orthopedics and Traumatology, General Hospital of Patras "Agios Andreas", Patras, GRC
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15
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Screven R, Pressman E, Rao G, Freeman TB, Alikhani P. The Safety and Efficacy of Stand-Alone Lateral Lumbar Interbody Fusion for Adjacent Segment Disease in a Cohort of 44 Patients. World Neurosurg 2021; 149:e225-e230. [PMID: 33610868 DOI: 10.1016/j.wneu.2021.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND A mainstay of treatment for symptomatic adjacent segment disease (ASD) has consisted of revision with posterior decompression and fusion. This carries significant morbidity and can be technically difficult. An alternative is stand-alone lateral lumbar interbody fusion (LLIF), which may avoid complications associated with revision surgery. We describe the largest cohort of patients treated with LLIF for ASD to our knowledge. METHODS We conducted a retrospective cohort study on all patients who underwent transpsoas LLIF for ASD at a single academic center between 2012 and 2019. Postoperative improvement was measured using the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). RESULTS Forty-four patients who underwent LLIF for ASD were identified. Median age was 65 years. Median time from index surgery to ASD development was 78 months. Median levels fused via LLIF was 1. Our median follow-up was 358 days. At follow-up, the median VAS back pain score was 0 (mean, 0.884), median VAS leg pain score was 1 (mean, 0.953), and median ODI was 8. The median improvement for VAS back pain was 8, for VAS leg pain was 6, and for ODI was 40. No patients suffered new neurologic symptoms postoperatively. Of the 17 patients who initially presented with non-pain neurologic symptoms, 8 (47.1%) experienced complete resolution of symptoms, and 5 (29.4%) experienced only some improvement. CONCLUSIONS To our knowledge, this is the largest cohort study of patients to date evaluating stand-alone LLIF for ASD. Our patient outcomes show it is safe and effective with low risk of morbidity.
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Affiliation(s)
- Ryan Screven
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Gautam Rao
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Thomas B Freeman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.
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16
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Cheng C, Wang K, Zhang C, Wu H, Jian F. Clinical results and complications associated with oblique lumbar interbody fusion technique. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:16. [PMID: 33553309 PMCID: PMC7859744 DOI: 10.21037/atm-20-2159] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Oblique lumbar interbody fusion (OLIF) is a minimally invasive technique performed through the antero-oblique trajectory to address a wide range of lumbar pathologies. However, it can lead to complications. We reviewed the results of OLIF and discussed the effective methods to avoid such complications. Methods Seventy-nine consecutive patients who underwent OLIF between May 2016 and July 2019 were retrospectively analyzed. They were divided into three groups: stand-alone, posterior, and lateral fixation, according to whether they were followed up with auxiliary internal fixation as well as the fixation methods. Preoperative and last follow-up visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were used to assess the improvement in the lower back and leg pain as well as neurological conditions. We analyzed intervertebral disc height (DH), segmental lumbar lordotic angle (SLL), lumbar lordotic angle (LL), pelvic tilt (PT), pelvic incidence-lumbar lordosis (PI-LL) mismatch, and the cross-section area (CSA) on axial magnetic resonance imaging (MRI) image in different groups. Complications, including thigh symptoms, cage subsidence, neurological injury, and vascular injury, were also noted. Results Seventy-nine patients were followed up postoperatively for 23.2±11.5 (range, 12-48) months. Forty-eight (61%) patients underwent stand-alone surgery (without fixation), 15 (19%) patients underwent supplemental percutaneous pedicle screw fixation (posterior fixation), and 16 (20%) patients underwent lateral vertebral instrumentation (lateral fixation). In all three groups, the VAS score and the ODI score had significantly decreased at the final follow-up compared to pre-operation. The DH, SLL, LL, CSA, PT, and PI-LL mismatch had also improved by final follow-up. The most common approach-related complication was thigh symptoms. Of the 79 patients, ipsilateral transient psoas paresis occurred in 9 (11.4%), ipsilateral transient quadriceps weakness in 2 (2.5%), and groin/thigh numbness and pain in 17 (21.5%). Cage subsidence occurred in 8 (10.1%) patients, including five cases of grade 0, one of grade I, and two of grade II. Three (3.8%) patients in this study had a vascular injury. Conclusions OLIF is a minimally invasive and effective technique for dealing with degenerative lumbar diseases. However, it should also be noted that this approach carries risks of complications.
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Affiliation(s)
- Cheng Cheng
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China.,Department of Neurosurgery, the Third Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, China
| | - Kai Wang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Can Zhang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
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17
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Konomi T, Kaneko S, Zakaria AF, Fujiyoshi K, Yamane J, Asazuma T, Yato Y. Clinical Efficacies of the Minimal Retroperitoneal Approach for Infectious Spondylodiscitis: A Clinical Case Series. Spine Surg Relat Res 2020; 5:176-181. [PMID: 34179555 PMCID: PMC8208947 DOI: 10.22603/ssrr.2020-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/23/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction An anterior surgical approach for severe infectious spondylodiscitis in the lumbar region is optimal but not always atraumatic. The aim of this study was to evaluate the efficacy and safety of a minimal anterior-lateral retroperitoneal approach, also known as a surgical approach for oblique lumbar interbody fusion, for cases with severe infectious spondylodiscitis with osseous defects. Methods Twenty-four consecutive patients who underwent anterior debridement and spinal fusion with an autologous strut bone graft for infectious spondylodiscitis with osseous defects were reviewed retrospectively. Eleven patients underwent the minimal retroperitoneal approach (Group M), and 13 underwent the conventional open approach (Group C). Peri- and postoperative clinical outcomes, that is, estimated blood loss (EBL), operative time (OT), creatine kinase (CK) level, visual analog scale (VAS), and rates of bone union and additional posterior instrumentation, were evaluated, and the differences between both groups were assessed statistically. Results Mean EBL, serum CK on the 1st postoperative day, and VAS on the 14th postoperative day were 202.1 mL, 390.9 IU/L, and 9.5 mm in Group M and 648.3 mL, 925.5 IU/L, and 22.3 mm in Group C, respectively, with statistically significant differences between the groups. There were no statistically significant intergroup differences in OT and rates of bone union and additional posterior instrumentation. Conclusions Anterior debridement and spinal fusion using the minimal retroperitoneal approach is a useful and safe surgical technique. Although a preponderance of the minimal approach regarding early bone union is not validated, this technique has the advantages of conventional open surgery, but reduces blood loss, muscle injury, and pain postoperatively.
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Affiliation(s)
- Tsunehiko Konomi
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
| | - Shinjiro Kaneko
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan.,Department of Spine and Spinal Cord Surgery, Fujita Health University Hospital, Toyoake, Japan
| | - Amir Fariz Zakaria
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan.,Department of Spine and Spinal Cord Surgery, Fujita Health University Hospital, Toyoake, Japan.,Department of Orthopaedic Surgery, Hospital Raja Permaisuri Bainun, Ipoh, Malaysia
| | - Kanehiro Fujiyoshi
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
| | - Junichi Yamane
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
| | - Takashi Asazuma
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
| | - Yoshiyuki Yato
- Department of Orthopaedic Surgery, Murayama Medical Center, National Hospital Organization, Tokyo, Japan
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Garg B, Mehta N, Vijayakumar V, Gupta A. Defining a safe working zone for lateral lumbar interbody fusion: a radiographic, cross-sectional study. 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 2020; 30:164-172. [PMID: 33044660 DOI: 10.1007/s00586-020-06624-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/02/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To present a radiographic analysis of the anatomy of the lumbar plexus and retroperitoneal blood vessels with respect to psoas morphology and safe working zones (SWZ) for LLIF. METHODS A retrospective radiographic analysis of 158 MRI scans was performed. Selected morphometric measurements were performed at L1-L2, L2-L3, L3-L4 and L4-L5 levels: disc anteroposterior distance, psoas anteroposterior distance, lumbar plexus-anterior disc distance, lumbar plexus-anterior psoas distance, vena cava-anterior disc distance and calculation of SWZ in psoas on both left and right sides. The morphometric measurements were analysed for differences with sex and the level. RESULTS All the morphometric parameters differed significantly at all levels between males and females. The SWZ was significantly wider on the left side compared to the right-at L2-L3, L3-L4 and L4-L5 levels in females and at L3-L4 and L4-L5 levels in males. The SWZ at L4-L5 was narrowest on both left and right sides-and significantly reduced compared to other levels. 6.9% patients had a SWZ > 20 mm on the left side, and 44.9% patients had SWZ < 20 mm on the right side. With caudal progression of levels, the lumbar plexus and psoas muscle migrated anteriorly and the vena cava/right iliac vein migrated posteriorly. CONCLUSION A detailed study of preoperative MRI scans should be carried out in patients planned for LLIF-particularly, at L4-L5 level and in females. A left-sided trans-psoas approach is safer to perform compared to the right side-a right-sided approach should be avoided at L4-L5 considering the narrow SWZ at that level.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.
| | - Vivek Vijayakumar
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Anupam Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Lateral Lumbar Interbody Fusion: Review of Surgical Technique and Postoperative Multimodality Imaging Findings. AJR Am J Roentgenol 2020; 217:480-494. [PMID: 32903050 DOI: 10.2214/ajr.20.24074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The lateral lumbar interbody fusion (LLIF) approach is a minimally invasive surgery that can be used as an alternative to traditional lumbar interbody fusion techniques. LLIF accesses the intervertebral disk through the retroperitoneum and psoas muscle to avoid major vessels and visceral organs. The exposure of retroperitoneal structures during LLIF leads to unique complications compared with other surgical approaches. An understanding of the surgical technique and its associated potential complications is necessary for radiologists who interpret imaging before and after LLIF. Preoperative imaging must carefully assess the location of anatomic structures, including major retroperitoneal vasculature, lumbar nerve roots, lumbosacral plexus, and the genitofemoral nerve, relative to the psoas muscle. Multiple imaging modalities can be used in postoperative assessment including radiographs, CT, CT myelography, and MRI. Of these, CT is the preferred modality, because it can assess a range of complications relating to both the retroperitoneal exposure and the spinal instrumentation, as well as bone integrity and fusion status. This article describes surgical approaches for lumbar interbody fusion, comparing the approaches' indications, contraindications, advantages, and disadvantages; reviews the surgical technique of LLIF and relevant anatomic considerations; and illustrates for interpreting radiologists the normal postoperative findings and potential postsurgical complications of LLIF.
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20
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Choi J, Rhee I, Ruparel S. Assessment of Great Vessels for Anterior Access of L5/S1 Using Patient Positioning. Asian Spine J 2020; 14:438-444. [PMID: 32791768 PMCID: PMC7435306 DOI: 10.31616/asj.2020.0078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/20/2020] [Indexed: 01/06/2023] Open
Abstract
STUDY DESIGN This was a prospective cross-sectional study. PURPOSE The aim was to describe the effect of patient positioning, from supine to lateral decubitus position, on the width of the L5/S1 anterior disk space defined by the great vessels. OVERVIEW OF LITERATURE The application of the lateral decubitus position interbody fusion has been rapidly increasing; however, there are concerns regarding the access to the lumbosacral region due to the great vessels, which necessitates further morphometric data. METHODS A total of 20 consecutive live patients awaiting lumbar surgery were subjected to two magnetic resonance imaging scans on the same day in both supine and lateral decubitus positions at a single center to investigate the anterior L5/S1 disk space. RESULTS The bare anterior L5/S1 disk window was present in all patients of this study population, and the mean width was 27 mm in the supine and 22 mm in the lateral decubitus position, with a mean reduction of 5.2 mm between the positions. The oblique corridor angle was measured at a mean of 33°. CONCLUSIONS The bare window of L5/S1 disk space was present within this population group, and it was found to be mobile and changed significantly with patient positioning. Therefore, the spine surgeon or the access surgeon must consider the increased potential vascular risk during disk access in lateral decubitus anterior lumbar interbody spinal fusion surgery.
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Affiliation(s)
- John Choi
- Spine Ortho Clinic, The Bays Hospital, Mornington, Australia
| | - Isaac Rhee
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Sameer Ruparel
- Department of Orthopaedic-Spine Surgery, Global Hospital, Mumbai, India
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21
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Iatrogenic vascular laceration during posterior lumbar disc surgery: a literature review. Neurosurg Rev 2020; 44:821-842. [PMID: 32399729 DOI: 10.1007/s10143-020-01311-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 04/14/2020] [Accepted: 04/29/2020] [Indexed: 11/27/2022]
Abstract
Iatrogenic vascular laceration is a rare but well-known complication of posterior lumbar disc surgery (PLUDS). We performed a review of the literature to evaluate the management of this life-threatening complication. A total of 54 papers containing 100 cases of vascular laceration following PLUDS between 1969 and 2018 were analyzed with our representative case with a left common iliac artery (CIA) laceration during a posterior approach for a far lateral L4-L5 disc herniation. There were 54 females and 35 males (12 cases with unreported gender) with ages ranging from 20 to 72 years. The most commonly involved spinal level was L4-L5 (n = 67). The duration from the causative surgery to the symptom of the vascular injury ranged from 0 to 50 h (mean, 7.3 h). Only 47.3% of patients underwent postoperative imaging and the most commonly injured vessel was the CIA (n = 49). Vascular repair, open surgery, and/or an endovascular procedure was performed in 95 patients. The most frequent complications were deep venous thrombosis in the leg and pulmonary emboli, where a complete recovery was seen in 75.3% of patients. The mortality rate was 18.8%. In hemodynamically unstable cases, an emergent exploratory laparotomy was life-saving even without vascular imaging, although angiography with/without endovascular intervention may be used in stable patients.
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22
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Epstein NE. Incidence of Major Vascular Injuries with Extreme Lateral Interbody Fusion (XLIF). Surg Neurol Int 2020; 11:70. [PMID: 32363065 PMCID: PMC7193196 DOI: 10.25259/sni_113_2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/21/2020] [Indexed: 11/26/2022] Open
Abstract
Background: Extreme lateral interbody fusions (XLIF) and minimally invasive (MI) XLIF theoretically offer wide access to the lumbar disc space. The theoretical advantages of XLIF include; minimally disturbing surrounding structures (e.g. neural, vascular, soft-tissue), while offering stability. In addition to the well-known increased frequency of neurological deficits attributed to XLIF, here we explored how often major vascular injures occur with XLIF/MI XLIF procedures. Methods: In 13 XLIF/MI XLIF studies, we evaluated the frequency of major vascular injuries. Results: The studies citing the different frequencies of vascular injuries associated with XLIF/MI XLIF were broken down into three categories. Of the 5 small and larger case series, involving a total of 6,732 patients (e.g. range of 12 to 4,607 patients/study), the incidence of vascular injuries ranged from 0% (3 studies) up to 0.4%. Three case reports presented major vascular injuries attributed to XLIF/MI XLIF. Two involved the L4-L5 level. The three complications included: one fatal injury, one, a retroperitoneal hematoma with hemorrhagic shock, and one major vascular injury. For the 5 review articles, major vascular complications were just discussed in 2, one study cited 3 specific major vascular injuries (e.g. 1 fatal, 1 life threating, and 1 lumbar artery pseudoaneurysm requiring embolization), while 2 other studies stated the frequency of these injuries was 0.4% for XLIF, and 1.7 % for OLIF (Oblique Lumbar Interbody Fusion). Conclusions: According to 5 small and larger case series, 3 case reports, and 5 review articles, the incidence of major vascular injuries occurring during XLIF/MI XLIF ranges from 0 to 0.03% to 0.4%.
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Affiliation(s)
- Nancy E Epstein
- Adjunct Clinical Professor of Neurological Surgery School of Medicine State University of N.Y. at Stony Brook
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Manning J, Wang E, Varlotta C, Woo D, Ayres E, Eisen L, Bendo J, Goldstein J, Spivak J, Protopsaltis TS, Passias PG, Buckland AJ. The effect of vascular approach surgeons on perioperative complications in lateral transpsoas lumbar interbody fusions. Spine J 2020; 20:313-320. [PMID: 31669613 DOI: 10.1016/j.spinee.2019.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lateral lumbar interbody fusion (LLIF) is a popular technique used in spine surgery. It is minimally invasive, provides indirect decompression, and allows for coronal plane deformity correction. Despite these benefits, the approach to LLIF has been linked to complications associated with the lumbosacral plexus and vascular anatomy. As a result, vascular surgeons may be recruited for the exposure portion of the procedure. PURPOSE The purpose of this study was to compare exposure-related complication and postoperative (postop) neuropraxia rates between exposure (EXP) and spine surgeon only (SSO) groups while performing the approach for LLIF. STUDY DESIGN/SETTING Retrospective analysis of patients treated at a single institution. PATIENT SAMPLE Patients undergoing LLIF procedures between 2012 and 2018. OUTCOME MEASURES Operative time, estimated blood loss, fluoroscopy, length of stay (LOS), intra- and postoperative complications, and physiologic measures including pre- and postoperative motor examinations and unresolved neuropraxia. METHODS Patients who underwent LLIF were separated into EXP and SSO groups based on the presence or absence of vascular/general surgeon during the approach. The entire clinical history of patients with a decrease in pre- and postop motor examination was reviewed for the presence of neuropraxia. All other intra- and postop exposure-related complications were recorded for comparison. Propensity score matching (PSM) was performed to account for age, Charlson Comorbidity Index (CCI) percentage of LLIFs including L4-L5, and number of levels fused. Independent t test and chi-square analyses were used to identify significant differences between EXP and SSO groups. Statistical significance was set at p<.05. RESULTS Two hundred and seventy-five patients underwent LLIF procedures, 155 SSO and 120 EXP. Postoperatively, 26 patients (11.1%) experienced a drop in any Medical Research Council (MRC) score, and two patients (0.7%) experienced unresolved quadriceps palsies. The mean recovery time for MRC scores was 84.4 days. Other complications included 2 pneumothoraces (0.7%), 1 iliac vein injury (0.4%), 14 cases of ileus (5.1%), 3 pulmonary emboli (1.1%), 2 deep vein thrombosis (0.7%), 3 cases of abdominal wall paresis (1.1%), and one abdominal hematoma (0.4%). After PSM, demographics including age, gender, body mass index, CCI, levels fused, and operative time were similar between cohorts. Twenty patients had changes in pre- to postop motor scores (SSO 9.4%, EXP 12.4%, p>.05). Iliopsoas motor scores decreased at the highest rate (EXP 12.4%, SSO 8.2%, p>.05) followed by quadriceps (EXP 5.2%, SSO 4.7%, p>.05). One SSO patient's postop course was complicated by a foot drop but returned to baseline within 1 year. One patient in EXP group developed an unresolved quadriceps palsy (EXP 1.0%, SSO 0.0%, p>.05). Intraoperative exposure complications included one pneumothorax (EXP 1.0%, SSO 0.0%, p>.05). There were no differences in PE/DVT, Ileus, or LOS. In the EXP cohort, three patients experienced abdominal wall paresis (EXP 2.9%, SSO 0.00%, p=.246). CONCLUSIONS Comparing the LLIF exposures performed by EXP and SSO, we found no significant difference in the rates of complications. Additional research is needed to determine the etiology of the abdominal wall complications. In conclusion, neuropraxia- and approach-related complications are similarly low between exposure and spine surgeons.
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Affiliation(s)
- Jordan Manning
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Erik Wang
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | | | - Dainn Woo
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Ethan Ayres
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Leon Eisen
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - John Bendo
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Jeffrey Goldstein
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Jeffrey Spivak
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | | | - Peter G Passias
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Aaron J Buckland
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA.
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Salzmann SN, Fantini GA, Okano I, Sama AA, Hughes AP, Girardi FP. Mini-Open Access for Lateral Lumbar Interbody Fusion: Indications, Technique, and Outcomes. JBJS Essent Surg Tech 2019; 9:ST-D-19-00013. [PMID: 32051785 DOI: 10.2106/jbjs.st.19.00013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Lateral lumbar interbody fusion (LLIF) is a relatively new procedure. It was established as a minimally invasive alternative to traditional open interbody fusion. LLIF allows the surgeon to access the disc space via a retroperitoneal transpsoas muscle approach. Theoretical advantages of the LLIF technique include preservation of the longitudinal ligaments, augmentation of disc height with indirect decompression of neural elements, and insertion of large footprint cages spanning the dense apophyseal ring bilaterally1,2. The original 2-incision LLIF technique described by Ozgur et al., in 2006, had some inherent limitations3. First, it substantially limited direct visualization of the surgical field and may have endangered nerve and vascular structures. Additionally, it often required multiple separated incisions for multilevel pathologies. Finally, for surgeons with experience in traditional open retroperitoneal surgery, utilization of their previously acquired skills may have been difficult with this approach. To overcome these limitations, we adopted the mini-open lateral approach, which allows for visualization, palpation, and electrophysiologic neurologic confirmation during the procedure4. Description As detailed below, the patient is positioned in the lateral decubitus position and a single incision is carried out centered between the target discs. For single-level LLIF, the incision spans approximately 3 cm and can be lengthened in small increments for multilevel procedures. After blunt dissection, the retroperitoneal space is entered. The psoas muscle is split under direct visualization, carefully avoiding the traversing nerves with neurosurveillance5. A self-retaining retractor is used, and after thorough discectomy, the disc space is sized with trial components. The implant is filled with bone graft materials and is introduced using intraoperative fluoroscopy. Alternatives The 2-incision LLIF technique or traditional anterior or posterior lumbar spine interbody fusion techniques might be used instead. Rationale LLIF offers the reported advantages of minimally invasive surgery, such as reduced tissue trauma during the approach, low blood loss, shorter length of stay, decreased recovery time, and less postoperative pain. LLIF allows for the placement of a relatively larger interbody cage spanning the dense apophyseal ring bilaterally. The lateral approach preserves the anterior longitudinal ligament and posterior longitudinal ligament. These structures allow for powerful ligamentotaxis and provide extra stability for the construct. Compared with other approaches, LLIF has a reduced risk of visceral and vascular injuries, incidental dural tears, and perioperative infections. Although associated with approach-related complications such as motor and sensory deficits, LLIF can be a safe and versatile procedure1,2.
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Affiliation(s)
- Stephan N Salzmann
- Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Gary A Fantini
- Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Ichiro Okano
- Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Andrew A Sama
- Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Alexander P Hughes
- Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
| | - Federico P Girardi
- Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY
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Nojiri H, Miyagawa K, Yamaguchi H, Koike M, Iwase Y, Okuda T, Kaneko K. Intraoperative ultrasound visualization of paravertebral anatomy in the retroperitoneal space during lateral lumbar spine surgery. J Neurosurg Spine 2019; 31:334-337. [DOI: 10.3171/2019.3.spine181210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVELumbar surgery via a lateral approach is a minimally invasive and highly useful procedure. However, care must be taken to avoid its potentially fatal complications of intestinal and vascular injuries. The object of this study was to evaluate the usefulness of intraoperative ultrasound in improving the safety of lateral lumbar spine surgery.METHODSA transvaginal ultrasound probe was inserted into the operative field, and the intestinal tract, kidney, psoas muscle, and vertebral body were identified using B-mode ultrasound. The aorta, vena cava, common iliac vessels, and lumbar arteries and their associated branches were identified using the color Doppler mode.RESULTSThe study cohort comprised 100 patients who underwent lateral lumbar spine surgery, 92 via a left-sided approach. The intestinal tract and kidney lateral to the psoas muscle on the anatomical approach pathway were visualized in 36 and 26 patients, respectively. A detachment maneuver displaced the intestinal tract and kidneys in an anteroinferior direction, enabling confirmation of the absence of organ tissues above the psoas. In all patients, the major vessels anterior to the vertebral bodies and the lumbar arteries and associated branches in the psoas on the approach path were clearly visualized in the Doppler mode, and their orientation, location, and positional relationship with regard to the vertebral bodies, intervertebral discs, and psoas were determined.CONCLUSIONSWhen approaching the lateral side of the lumbar spine in the retroperitoneal space, intraoperative ultrasound allows real-time identification of the blood vessels surrounding the lumbar spine, intestinal tract, and kidney in the approach path and improves the safety of surgery without increasing invasiveness.
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Affiliation(s)
- Hidetoshi Nojiri
- 1Department of Orthopedic Surgery, Juntendo University; and
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kei Miyagawa
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Hiroto Yamaguchi
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Masato Koike
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Yoshiyuki Iwase
- 2Department of Orthopedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | | | - Kazuo Kaneko
- 1Department of Orthopedic Surgery, Juntendo University; and
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Hah R, Kang HP. Lateral and Oblique Lumbar Interbody Fusion-Current Concepts and a Review of Recent Literature. Curr Rev Musculoskelet Med 2019; 12:305-310. [PMID: 31230190 PMCID: PMC6684701 DOI: 10.1007/s12178-019-09562-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To review the relevant recent literature regarding minimally invasive, lateral, and oblique approaches to the anterior lumbar spine, with a particular focus on the operative and postoperative complications. METHODS A literature search was performed on Pubmed and Web of Science using combinations of the following keywords and their acronyms: lateral lumbar interbody fusion (LLIF), oblique lateral interbody fusion (OLIF), anterior-to-psoas approach (ATP), direct lateral interbody fusion (DLIF), extreme lateral interbody fusion (XLIF), and minimally invasive surgery (MIS). All results from January 2016 through January 2019 were evaluated and all studies evaluating complications and/or outcomes were included in the review. RECENT FINDINGS Transient neurological deficit, particularly sensorimotor symptoms of the ipsilateral thigh, remains the most common complication seen in LLIF. Best available current literature demonstrates that approximately 30-40% of patients have postoperative deficits, primarily of the proximal leg. Permanent symptoms are less common, affecting 4-5% of cases. Newer techniques to reduce this rate include different retractors, direct visualization of the nerves, and intraoperative neuromonitoring. OLIF may have lower deficit rates, but the available literature is limited. Subsidence rates in both LLIF and OLIF are comparable to ALIF (anterior lumbar interbody fusion), but further study is required. Supplemental posterior fixation is an active area of investigation that shows favorable biomechanical results, but additional clinical studies are needed. Minimally invasive lumbar interbody fusion techniques continue to advance rapidly. As these techniques continue to mature, evidence-based risk-stratification systems are required to better guide both the patient and clinician in the joint decision-making process for the optimal surgical approach.
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Affiliation(s)
- Raymond Hah
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Suite 5400, Los Angeles, CA 90033 USA
| | - H. Paco Kang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Suite 5400, Los Angeles, CA 90033 USA
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Rentenberger C, Shue J, Soffin EM, Stiles BM, Craig CM, Hughes AP. Intercostal artery hemorrhage with hemothorax following combined lateral and posterior lumbar interbody fusion: a case report. Spinal Cord Ser Cases 2019; 5:60. [PMID: 31632718 PMCID: PMC6786361 DOI: 10.1038/s41394-019-0205-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/22/2019] [Accepted: 05/27/2019] [Indexed: 11/09/2022] Open
Abstract
Introduction Lateral lumbar interbody fusion (LLIF) is a safe treatment for degenerative spine conditions. However, risk of complications such as vascular injuries remains. We report a unique case of an intercostal artery (ICA) hemorrhage with hemothorax following LLIF. Case presentation One hour after a right-sided LLIF L3-4 with posterior decompression L2-4 and L3-5 instrumentation, the patient became hypotensive, anemic and required vasopressor support. Evaluation revealed a right-sided hemothorax, which was caused by a bleeding intercostal artery, laterally at the 10th intercostal space. A lateral thoracotomy was performed to stop the bleeding. After vessel ligation and placement of two chest tubes, the patients' hemodynamics improved. The patient remained intubated overnight and was extubated on the first postoperative day. Discussion Vascular injury is a rare complication of LLIF procedures. Most vascular injuries are segmental vessel lacerations, which resolve postoperatively. This is the first case description of ICA bleeding associated with LLIF surgery. Spontaneous ICA bleeding exists, but surgeons should be aware of careful handling in patients with vascular risk factors, especially with regard to patient positioning required in certain spinal surgical approaches. Timely vascular injury identification is critical for hemostasis and clinical management.
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Affiliation(s)
- Colleen Rentenberger
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY USA
| | - Ellen M. Soffin
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY USA
| | - Brendon M. Stiles
- Weill Cornell Brain and Spine Center, Division of Thoracic Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY USA
| | - Chad M. Craig
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY USA
| | - Alexander P. Hughes
- Spine Care Institute, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY USA
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Anatomic Considerations in the Lateral Transpsoas Interbody Fusion: The Impact of Age, Sex, BMI, and Scoliosis. Clin Spine Surg 2019; 32:215-221. [PMID: 30520767 DOI: 10.1097/bsd.0000000000000760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This is a retrospective case series. OBJECTIVE Define the anatomic variations and the risk factors for such within the operative corridor of the transpsoas lateral interbody fusion. SUMMARY OF BACKGROUND DATA The lateral interbody fusion approach has recently been associated with devastating complications such as injury to the lumbosacral plexus, surrounding vasculature, and bowel. A more comprehensive understanding of anatomic structures in relation to this approach using preoperative imaging would help surgeons identify high-risk patients potentially minimizing these complications. MATERIALS AND METHODS Age-sex distributed, naive lumbar spine magnetic resonance imagings (n=180) were used to identify the corridor for the lateral lumbar interbody approach using axial images. Bilateral measurements were taken from L1-S1 to determine the locations of critical vascular, intraperitoneal, and muscular structures. In addition, a subcohort of scoliosis patients (n=39) with a Cobb angle >10 degrees were identified and compared. RESULTS Right-sided vascular anatomy was significantly more variant than left (9.9% vs. 5.7%; P=0.001). There were 9 instances of "at-risk" vasculature on the right side compared with 0 on the left (P=0.004). Age increased vascular anatomy variance bilaterally, particularly in the more caudal levels (P≤0.001). A "rising-psoas sign" was observed in 26.1% of patients. Bowel was identified within the corridor in 30.5% of patients and correlated positively with body mass index (P<0.001). Scoliosis increased variant anatomy of left-sided vasculature at L2-3/L3-4. Nearly all variant anatomy in this group was found on the convex side of the curvature (94.2%). CONCLUSIONS Given the risks and complications associated with this approach, careful planning must be taken with an understanding of vulnerable anatomic structures. Our analysis suggests that approaching the intervertebral space from the patient's left may reduce the risk of encountering critical vascular structures. Similarly, in the setting of scoliosis, an approach toward the concave side may have a more predictable course for surrounding anatomy. LEVEL OF EVIDENCE Level 3-study.
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Kyoh Y. Minimally Invasive Endoscopic-Assisted Lateral Lumbar Interbody Fusion: Technical Report and Preliminary Results. Neurospine 2019; 16:72-81. [PMID: 31618808 PMCID: PMC6449819 DOI: 10.14245/ns.1938024.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/05/2019] [Accepted: 03/08/2019] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Lateral lumbar interbody fusion (LLIF) is a highly useful lumbar fusion surgical technique for degenerative spinal disease. However, many complications have already been reported. The purpose of this study is to report the concept, surgical technique, and clinical results of the first 70 consecutive cases treated with a safer and minimally invasive endoscopic-assisted LLIF (ELLIF). METHODS This retrospective study included 70 cases involving 106 segments in which ELLIF was used to treat degenerative spinal disease. We examined the clinical progress, complications and analyzed radiographic images. Regarding the fusion rate, 49 cases involving 72 segments whose follow-up period was more than 7 months were evaluated. RESULTS The mean of preoperative Numerical Rating Scale (NRS) was 7.0 and postoperative NRS was 1.4. Postoperative NRS had a significant correlation with the number of fusion segments (p = 0.028). The mean of preoperative disc space height, foraminal height, sagittal rotation angle, whole lumbar lordosis and sagittal translation distance were 3.3 mm, 14.3 mm, 2.4°, 9.7°, and 3.2 mm, respectively. Postoperative values were 9.4 mm, 17.9 mm, -4.9°, 36.3°, and 0.7 mm. The fusion rate was 79.2%. Complications included, transient psoas muscle weakness 1, sensory disturbance in the thigh 2, retroperitoneal injury 1, postoperative ileus possibly involving a retroperitoneal injury 1, and cage migration 4. CONCLUSION Using the ELLIF in the degenerative spinal disease, we obtained good radiological reduction and good clinical results. Our study confirms that ELLIF is safer and provides better results for degenerative spinal disease. However, the issue of cage migration remains to be resolved.
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Affiliation(s)
- Yoshinori Kyoh
- Kyoh Orthopaedics & Neurosurgery Clinic, Amagasaki, Japan
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Ruchirawan S, Fujita N, Yagi M, Tsuji O, Okada E, Nagoshi N, Ishii K, Nakamura M, Matsumoto M, Watanabe K. Acute Paraparesis Due to Protrusion of a Disc Following Lateral Interbody Fusion for Degenerative Kyphoscoliosis: A Case Report. JBJS Case Connect 2019; 9:e8. [PMID: 30676346 DOI: 10.2106/jbjs.cc.18.00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 74-year-old woman presented with severe trunk deformity. Radiographs revealed severe sagittal and coronal imbalance with spinal canal stenosis at L4 to L5. Anterior cages were placed at L2 to L3, L3 to L4, and L4 to L5. Three days later, posterior correction surgery from T5 to the ilium with decompression at L4 to L5 was performed. At 30 minutes after surgery, leg muscle strength severely deteriorated. Emergency surgery revealed disc fragments protruding into the spinal canal at L2 to L3. CONCLUSION Because posteriorly placed extreme lateral interbody fusion (XLIF) cages can be a risk factor for disc protrusion into the spinal canal, computed tomographic evaluation or prophylactic posterior decompression should be considered before the correction procedure.
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Affiliation(s)
| | - Nobuyuki Fujita
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Eijiro Okada
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ken Ishii
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Masaya Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
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Kanter AS, Tempel ZJ, Agarwal N, Hamilton DK, Zavatsky JM, Mundis GM, Tran S, Chou D, Park P, Uribe JS, Wang MY, Anand N, Eastlack R, Mummaneni PV, Okonkwo DO. Curve Laterality for Lateral Lumbar Interbody Fusion in Adult Scoliosis Surgery: The Concave Versus Convex Controversy. Neurosurgery 2018; 83:1219-1225. [PMID: 29361052 DOI: 10.1093/neuros/nyx612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 12/07/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Minimally invasive lateral lumbar interbody fusion (LLIF) is an effective adjunct in adult degenerative scoliosis (ADS) surgery. LLIF approaches performed from the concavity or convexity have inherent approach-related risks and benefits. OBJECTIVE To analyze LLIF approach-related complications and radiographic and clinical outcomes in patients with ADS. METHODS A multicenter retrospective review of a minimally invasive adult spinal deformity database was queried with a minimum of 2-yr follow-up. Patients were divided into 2 groups as determined by the side of the curve from which the LLIF was performed: concave or convex. RESULTS No differences between groups were noted in demographic, and preoperative or postoperative radiographic parameters (all P > .05). There were 8 total complications in the convex group (34.8%) and 21 complications in the concave group (52.5%; P = .17). A subgroup analysis was performed in 49 patients in whom L4-5 was in the primary curve and not in the fractional curve. In this subset of patients, there were 6 complications in the convex group (31.6%) compared to 19 in the concave group (63.3%; P < .05) and both groups experienced significant improvements in coronal Cobb angle, Oswestry Disability Index, and Visual Analog Scale score with no difference between groups. CONCLUSION Patients undergoing LLIF for ADS had no statistically significant clinical or operative complication rates regardless of a concave or convex approach to the curve. Clinical outcomes and coronal plane deformity improved regardless of approach side. However, in cases wherein L4-5 is in the primary curve, approaching the fractional curve at L4-5 from the concavity may be associated with a higher complication rate compared to a convex approach.
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Affiliation(s)
- Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zachary J Tempel
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Stacie Tran
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Dean Chou
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Paul Park
- Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Juan S Uribe
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida
| | | | - Neel Anand
- Department of Neurological Surgery, Cedars-Sanai Medical Center, Los Angeles, California
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Anatomic evaluation of retroperitoneal organs for lateral approach surgery: a prospective imaging study using computed tomography in the 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 2018; 28:835-841. [PMID: 30377807 DOI: 10.1007/s00586-018-5803-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 10/20/2018] [Indexed: 10/28/2022]
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Huang C, Xu Z, Li F, Chen Q. Does the Access Angle Change the Risk of Approach-Related Complications in Minimally Invasive Lateral Lumbar Interbody Fusion? An MRI Study. J Korean Neurosurg Soc 2018; 61:707-715. [PMID: 29940723 PMCID: PMC6280061 DOI: 10.3340/jkns.2017.0296] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/17/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To investigate the potential risk of approach-related complications at different access angles in minimally invasive lateral lumbar interbody fusion. METHODS Eighty-six axial magnetic resonance images were obtained to analyze the risk of approach-related complications. The access corridor were simulated at different access angles and the potential risk of neurovascular structure injury was evaluated when the access corridor touching or overlapping the corresponding structures at each angle. Furthermore, the safe corridor length was measured when the corridor width was 18 and 22 mm. RESULTS When access angle was 0°, the potential risk of ipsilateral nerve roots injury was 54.7% at L4-L5. When access angle was 45°, the potential risk of abdominal aorta, contralateral nerve roots or central canal injury at L4-L5 was 79.1%, 74.4%, and 30.2%, respectively. The length of the 18mm-wide access corridor was largest at 0° and it could reach 44.5 mm at L3-L4 and 46.4 mm at L4-L5. While the length of the 22 mm-wide access corridor was 42.3 mm at L3-L4 and 44.1 mm at L4-L5 at 0°. CONCLUSION Changes in the access angle would not only affect the ipsilateral neurovascular structures, but also might adversely influence the contralateral neural elements. It should be also noted to surgeons that alteration of the access angle changed the corridor length.
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Affiliation(s)
- Chunneng Huang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Zhengkuan Xu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Fangcai Li
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Qixin Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Safaee MM, Zarkowsky D, Eichler CM, Pekmezci M, Clark AJ. Management of aortic injury during minimally invasive 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 2018; 27:538-543. [PMID: 29736802 DOI: 10.1007/s00586-018-5620-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/02/2018] [Accepted: 04/29/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Minimally invasive lateral approaches to the lumbar spine allow for interbody fusion with good visualization of the disk space, minimal blood loss, and decreased length of stay. Major neurologic, vascular, and visceral complications are rare with this approach; however, the steps in management for severe vascular injuries are not well defined. We present a case report of aortic injury during lateral interbody fusion and discuss the use of endovascular repair. METHODS This study is a case report of an intraoperative aortic injury. RESULTS A 59-year-old male with ankylosing spondylitis suffered an acute L1 Chance fracture after mechanical fall. He was taken to the operating room for a T10-L4 posterior instrumented fusion followed by a minimally invasive L1-L2 lateral interbody fusion for anterior column support. During the discectomy, brisk arterial bleeding was encountered due to an aortic injury. The vascular surgery team expanded the incision in an attempt to control the bleeding but with limited success. The patient underwent intraoperative angiogram with placement of stent grafts at the level of the injury followed by completion of the interbody fusion. Despite the potentially catastrophic nature of this injury, the patient made a good recovery and was discharged home in stable condition with no new neurologic deficits. CONCLUSIONS This case highlights the importance of immediate recognition and imaging of any potential vascular injury during minimally invasive lateral interbody fusion. Given the poor outcomes associated with attempted open repair, endovascular techniques provide a valuable tool for the treatment of these complex injuries with significantly less morbidity.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave. Room M779, San Francisco, CA, 94143, USA
| | - Devin Zarkowsky
- Division of Vascular and Endovascular Surgery, Department of General Surgery, University of California, San Francisco, 400 Parnassus Ave. Suite 501, San Francisco, CA, 94143, USA
| | - Charles M Eichler
- Division of Vascular and Endovascular Surgery, Department of General Surgery, University of California, San Francisco, 400 Parnassus Ave. Suite 501, San Francisco, CA, 94143, USA
| | - Murat Pekmezci
- Department of Orthopedic Surgery, University of California, San Francisco, 1500 Owens St., San Francisco, CA, 94158, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Ave. Room M779, San Francisco, CA, 94143, USA.
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Comparison of Clinical and Radiologic Results of Mini-Open Transforaminal Lumbar Interbody Fusion and Extreme Lateral Interbody Fusion Indirect Decompression for Degenerative Lumbar Spondylolisthesis. Asian Spine J 2018; 12:356-364. [PMID: 29713419 PMCID: PMC5913029 DOI: 10.4184/asj.2018.12.2.356] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 06/13/2017] [Accepted: 06/29/2017] [Indexed: 11/08/2022] Open
Abstract
Study Design Retrospective study. Purpose In this study, we compared the postoperative outcomes of extreme lateral interbody fusion (XLIF) indirect decompression with that of mini-open transforaminal lumbar interbody fusion (TLIF) in patients with lumbar degenerative spondylolisthesis. Overview of Literature There are very few reports examining postoperative results of XLIF and minimally invasive TLIF for degenerative lumbar spondylolisthesis, and no reports comparing XLIF and mini-open TLIF. Methods Forty patients who underwent 1-level spinal fusion, either by XLIF indirect decompression (X group, 20 patients) or by mini-open TLIF (T group, 20 patients), for treatment of lumbar degenerative spondylolisthesis were included in this study. Invasiveness of surgery was evaluated on the basis of surgery time, blood loss, hospitalization period, and perioperative complications. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), disc angle (DA), disc height (DH), and slipping length (SL) were evaluated before surgery, immediately after surgery, and at 12 months after surgery. Cross-sectional spinal canal area (CSA) was also measured before surgery and at 1 month after surgery. Results There was no significant difference between the groups in terms of surgery time or hospitalization period; however, X group showed a significant decrease in blood loss (p<0.001). Serious complications were not observed in either group. In clinical assessment, no significant differences were observed between the groups with regard to the JOABPEQ results. The change in DH at 12 months after surgery increased significantly in the X group (p<0.05), and the changes in DA and SL were not significantly different between the two groups. The change in CSA was significantly greater in the T group (p<0.001). Conclusions Postoperative clinical results were equally favorable for both procedures; however, in comparison with mini-open TLIF, less blood loss and greater correction of DH were observed in XLIF.
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Kanemura T, Satake K, Nakashima H, Segi N, Ouchida J, Yamaguchi H, Imagama S. Understanding Retroperitoneal Anatomy for Lateral Approach Spine Surgery. Spine Surg Relat Res 2017; 1:107-120. [PMID: 31440621 PMCID: PMC6698495 DOI: 10.22603/ssrr.1.2017-0008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/31/2017] [Indexed: 01/10/2023] Open
Abstract
Lateral approach spine surgery provides effective interbody stabilization, and correction and indirect neural decompression with minimal-incision and less invasive surgery compared with conventional open anterior lumbar fusion. It may also avoid the trauma to paraspinal muscles or facet joints found with transforaminal lumbar interbody fusion and posterior lumbar interbody fusion. However, because lateral approach surgery is fundamentally retroperitoneal approach surgery, it carries potential risk to intra- and retroperitoneal structures, as seen in a conventional open anterior approach. There is an innovative lateral approach technique that reveals different anatomical views; however, it requires reconsideration of the traditional surgical anatomy in more detail than a traditional open anterior approach. The retroperitoneum is the compartmentalized space bounded anteriorly by the posterior parietal peritoneum and posteriorly by the transversalis fascia. The retroperitoneum is divided into three compartments by fascial planes: anterior and posterior pararenal spaces and the perirenal space. Lateral approach surgery requires mobilization of the peritoneum and its content and accurate exposure to the posterior pararenal space. The posterior pararenal space is confined anteriorly by the posterior renal fascia, anteromedially by the lateroconal fascia, and posteriorly by the transversalis fascia. The posterior renal fascia, the lateroconal fascia or the peritoneum should be detached from the transversalis fascia and the psoas fascia to allow exposure to the posterior pararenal space. The posterior pararenal space, however, does not allow a clear view and identification of these fasciae as this relationship is variable and the medial extent of the posterior pararenal space varies among patients. Correct anatomical recognition of the retroperitoneum is essential to success in lateral approach surgery. Spine surgeons must be aware that the retroperitoneal membrane and fascia is multilayered and more complex than is commonly understood. Preoperative abdominal images would facilitate more efficient surgical considerations of retroperitoneal membrane and fascia in lateral approach surgery.
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Affiliation(s)
- Tokumi Kanemura
- Department of Orthopedic Surgery, Spine Center, Konan Kosei Hospital, Aichi, Japan
| | - Kotaro Satake
- Department of Orthopedic Surgery, Spine Center, Konan Kosei Hospital, Aichi, Japan
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Spine Center, Konan Kosei Hospital, Aichi, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Spine Center, Konan Kosei Hospital, Aichi, Japan
| | - Jun Ouchida
- Department of Orthopedic Surgery, Spine Center, Konan Kosei Hospital, Aichi, Japan
| | - Hidetoshi Yamaguchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
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Abstract
PURPOSE OF REVIEW Lateral lumbar interbody fusion (LLIF) is a relatively new, minimally invasive technique for interbody fusion. The goal of this review is to provide a general overview of LLIF with a special focus on outcomes and complications. RECENT FINDINGS Since the first description of the technique in 2006, the indications for LLIF have expanded and the rate of LLIF procedures performed in the USA has increased. LLIF has several theoretical advantages compared to other approaches including the preservation of the anterior and posterior annular/ligamentous structures, insertion of wide cages resting on the dense apophyseal ring bilaterally, and augmentation of disc height with indirect decompression of neural elements. Favorable long-term outcomes and a reduced risk of visceral/vascular injuries, incidental dural tears, and perioperative infections have been reported. However, approach-related complications such as motor and sensory deficits remain a concern. In well-indicated patients, LLIF can be a safe procedure used for a variety of indications.
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Affiliation(s)
- Stephan N Salzmann
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA.
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Complications Associated With Lateral Interbody Fusion: Nationwide Survey of 2998 Cases During the First 2 Years of Its Use in Japan. Spine (Phila Pa 1976) 2017; 42:1478-1484. [PMID: 28252557 DOI: 10.1097/brs.0000000000002139] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective nationwide questionnaire-based survey of complications. OBJECTIVE To elucidate the incidence of complications and risk factors associated with lateral interbody fusion (LIF). SUMMARY OF BACKGROUND DATA After its introduction to Japan in February 2013, the numbers of LIF cases have increased substantially because of the advantages of this minimally invasive procedure. However, LIF has the potential risk of several complications unique to the procedure. Although there are many reports of complications, no nationwide survey has been conducted. METHODS Questionnaires were sent to all Japanese Society for Spine Surgery and Related Research (JSSR) members. Questionnaires requested information about surgical procedures (XLIF or OLIF), patient characteristics, preoperative diagnosis, complications, salvage procedures, final outcomes, and the surgeon's experience of LIF. The data from replies received between March 2013 and April 2015 were recorded on a web site and the details of complications were analyzed by a JSSR research team. RESULTS Seventy-one institutions (12.3%) answered "yes" to LIF experience and 2998 cases (1995 XLIF and 1003 OLIF) were enrolled in this study. The response rate was 86.1%. A total of 540 complications were reported, of which 474 (84.8%) could be further analyzed. The overall complication rate was 18.0%. The most frequent complications were sensory nerve injury (5.1%) and psoas weakness (4.3%) and the majority resolved spontaneously. The rates of major vascular injury, bowel injury, and surgical site infection were 0.03%, 0.03%, and 0.7%, respectively. The overall reoperation rate was 2.2%. Higher rates of sensory nerve injury and psoas weakness were reported for XLIF and higher rates of peritoneal laceration and ureteral injury were reported for OLIF. CONCLUSION A nationwide survey of complications associated with LIF was conducted. Although the majority of complications were minor, a relatively high rate of complications was reported. Approach-related specific features of the two procedures were identified. LEVEL OF EVIDENCE 4.
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Hijji FY, Narain AS, Bohl DD, Ahn J, Long WW, DiBattista JV, Kudaravalli KT, Singh K. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J 2017; 17:1412-1419. [PMID: 28456671 DOI: 10.1016/j.spinee.2017.04.022] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 02/24/2017] [Accepted: 04/21/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lateral lumbar interbody fusion (LLIF) is a frequently used technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach. PURPOSE To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF. STUDY DESIGN Systematic review. PATIENT SAMPLE 6,819 patients who underwent LLIF reported in clinical studies through June 2016. OUTCOME MEASURES Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and spine (MSK) categories. METHODS This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and MSK categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work. RESULTS A total of 2,232 articles were identified. Following screening of title, abstract, and full-text availability, 63 articles were included in the review. A total of 6,819 patients had 11,325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval [CI]=1.00%-1.85%), cardiac (1.86%; CI=1.33%-2.52%), vascular (0.81%; CI=0.44%-1.36%), pulmonary (1.47; CI=0.95%-2.16%), gastrointestinal (1.38%; CI=1.00%-1.87%), urologic (0.93%; CI=0.55%-1.47%), transient neurologic (36.07%; CI=34.74%-37.41%), persistent neurologic (3.98%; CI=3.42%-4.60%), and MSK or spine (9.22%; CI=8.28%-10.23%). CONCLUSIONS The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks to and expectations for patients following LLIF procedures.
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Affiliation(s)
- Fady Y Hijji
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Ankur S Narain
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - William W Long
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Jacob V DiBattista
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Krishna T Kudaravalli
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA.
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Segawa T, Inanami H, Koga H. Clinical evaluation of microendoscopy-assisted extreme lateral interbody fusion. JOURNAL OF SPINE SURGERY 2017; 3:398-402. [PMID: 29057349 DOI: 10.21037/jss.2017.08.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Extreme lateral interbody fusion (XLIF) has rapidly become a popular operative procedure for lumbar canal stenosis and scoliosis. This approach provides direct access to the lateral aspect of the disc with minimal disruption of spinal structures, including ligaments and muscles. However, it involves risk of injuries to the lumbar nerve plexus, segmental artery and intestinal tract because of the limited surgical field. This study aimed to clarify the benefit of using a microendoscope to prevent these injuries. METHODS A total of 96 consecutive patients treated by a single surgeon were retrospectively analyzed. The basic approach via the psoas muscle was performed in accordance with the conventional XLIF procedure. Operative manipulations, such as insertion of the shim, discectomy, endplate preparation and intervertebral spacer placement, were performed with the assistance of a microendoscope. Preoperative and postoperative neurological status were evaluated using the Japanese Orthopedic Association (JOA) scores and the Oswestry Disability Index (ODI). RESULTS Eighty-four patients underwent surgery for a single vertebral level, nine patients underwent surgery for 2 levels and three patients underwent surgery for 3 levels (average, 1.2 levels). The average age of patients was 61 years (range, 22-83 years); the mean follow-up period was 18 months (range, 3-36 months). Average preoperative and postoperative JOA scores were 11.9 and 15.6, with a mean recovery rate of 33%. Average preoperative and postoperative ODI scores were 38.6 and 19.1. There were 3 (3.1%) complications: 2 end-plate fractures and 1 deep surgical site infection. There were no bowel perforations or vascular injuries. CONCLUSIONS Microendoscopy assistance is one solution for severe visceral and vascular injuries related to XLIF.
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Affiliation(s)
- Tomohide Segawa
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Hirohiko Inanami
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Hisashi Koga
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, Tokyo, Japan
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Morphometric Analysis of the Retroperitoneal Vessels With Respect to Lateral Access Surgery in Adult Scoliosis. Clin Spine Surg 2017; 30:E1010-E1014. [PMID: 28266959 DOI: 10.1097/bsd.0000000000000524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Cross-sectional study reviewing 62 magnetic resonance imaging or computed tomography scans from consecutive adult patients with scoliotic spinal deformity in the thoracolumbar spine. OBJECTIVE To investigate the variation in anatomic position of retroperitoneal vessels in relationship to curve direction, location, magnitude, and axial rotation of curves in adult scoliosis. SUMMARY OF BACKGROUND DATA The minimally invasive lateral approach to the thoracolumbar spine avoids manipulation of abdominal and retroperitoneal structures and decreases risk of injury to paraspinal musculature. In adult patients with scoliosis, the varying anatomic relationship between retroperitoneal vessels and intervertebral disk spaces can increase the risk of vascular injury. MATERIALS AND METHODS Axial images were used to measure the anterior-posterior diameter of the inferior vertebral endplate with respect to the disk space perpendicular to the widest length of the disk. The overlap of the retroperitoneal vessels with the endplate were measured at the cephalad end vertebra, apex, and caudad end vertebra of each curve. Overlap and accessible disk space for individual disk spaces were also measured. RESULTS There was a significant difference in percentage overlap of the apex and cephalad vertebral endplate and inferior vena cava in right versus left-sided curves (P=0.002). Overlap between the inferior vertebral endplate and inferior vena cava at the cephalad, apex, and caudad end of the curve was significantly different between thoracolumbar and lumbar curves (P<0.05). Axial rotation significantly affected vessel overlap at multiple curve locations. There was a statistically significant difference in accessible disk space when approaching the curve from the concavity versus convexity. CONCLUSIONS Overlap between retroperitoneal vessels and inferior vertebral endplates at the disk level in scoliotic spines varies significantly with direction of the curvature, level of the deformity, and degree of axial rotation. There is decreased accessible disk space and increased vessel overlap on the concavity of the curve. Surgeons, as usual, will take an individualized case by case approach to avoid approach-related vascular complications, but the general relationships reported in this study can guide side of approach.
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Josiah DT, Boo S, Tarabishy A, Bhatia S. Anatomical differences in patients with lumbosacral transitional vertebrae and implications for minimally invasive spine surgery. J Neurosurg Spine 2017; 26:137-143. [PMID: 27661564 DOI: 10.3171/2016.6.spine1691] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The objective of this study was to investigate the neurovascular and anatomical differences in patients with lumbosacral transitional vertebrae (LSTV) and the associated risk of neurovascular injury in minimally invasive spine surgery.
METHODS
The authors performed a retrospective study of CT and MR images of the lumbar spine obtained at their institution between 2010 and 2014. The following characteristics were evaluated: level of the iliac crest in relation to the L4–5 disc space, union level of the iliac veins and arteries in relation to the L4–5 disc space, distribution of the iliac veins and inferior vena cava according to the different Moro zones (A, I, II, III, IV, P) at the L4–5 disc space, and the location of the psoas muscle at the L4–5 disc space. The findings were compared with findings on images obtained in 28 age- and sex-matched patients without LSTV who underwent imaging studies during the same time period.
RESULTS
Twenty-eight patients (12 male, 16 female) with LSTV and the required imaging studies were identified; 28 age- and sex-matched patients who had undergone CT and MRI studies of the thoracic and lumbar spine imaging but did not have LSTV were selected for comparison (control group). The mean ages of the patients in the LSTV group and the control group were 52 and 49 years, respectively. The iliac crest was located at a mean distance of 12 mm above the L4–5 disc space in the LSTV group and 4 mm below the L4–5 disc space in the controls. The iliac vein union was located at a mean distance of 8 mm above the L4–5 disc space in the LSTV group and 2.7 mm below the L4–5 disc space in the controls. The iliac artery bifurcation was located at a mean distance of 23 mm above the L4–5 disc space in the LSTV group and 11 mm below the L4–5 disc space in controls. In patients with LSTV, the distribution of iliac vein locations was as follows: Zone A, 7.1%; Zone I only, 78.6%; Zone I encroaching into Zone II, 7.1%; and Zone II only, 7.1%. In the control group, the distribution was as follows: Zone A only, 17.9%; Zone A encroaching into Zone I, 75%; and Zone I only, 7.1%. There were no iliac vessels in Zone II in the control group. The psoas muscle was found to be rising away laterally and anteriorly from the vertebral body more often in patients with LSTV, resulting in the iliac veins being found in the “safe zone” only 14% of the time, greatly increasing the risk of vascular injury.
CONCLUSIONS
In patients with LSTV, the iliac crest is more likely to be above the L4–5 disc space, which increases the technical challenges of a lateral approach. The location of the psoas muscle rising away laterally and ventrally in patients with LSTV compared with controls and with the union of the iliac veins occurring more often above the L4–5 disc space increases the risk for iatrogenic vascular injury at the L4–5 level in this patient population.
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Affiliation(s)
| | - SoHyun Boo
- 2Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Abdul Tarabishy
- 2Radiology, West Virginia University School of Medicine, Morgantown, West Virginia
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Epstein NE. Non-neurological major complications of extreme lateral and related lumbar interbody fusion techniques. Surg Neurol Int 2016; 7:S656-S659. [PMID: 27843680 PMCID: PMC5054631 DOI: 10.4103/2152-7806.191071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 06/14/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Complications exclusive of new neurological deficits/injuries that follow extreme lateral interbody fusion (XLIF) and related lateral lumbar interbody techniques should be better recognized to determine the safety of these procedures. Unfortunately, a review of the XLIF literature did not accurately reflect the frequency of these "other complications" as few US surgeons publish such adverse events that may lead to medicolegal suits. METHODS Major complications occurring with XLIF included sympathectomy, major vascular injuries, bowel perforations, sterile seromas, and instrumentation failures. RESULTS The frequency of sympathectomy was 4% for XLIF vs. 15% for anterior lumbar interbody fusion (ALIF). There were three major vascular injuries for XLIF; one fatal intraoperative event, one life-threatening retroperitoneal hematoma, and one iatrogenic lumbar artery pseudoaneurysm that was successfully embolized. Two bowel perforations were reported, whereas a third was a "direct communication." One patient developed a sterile recurrent seroma due to vancomycin powder utilized for an XLIF. One study cited malpositioning of an XLIF cage resulting in a lateral L3-L4 extrusion, whereas the second series looked at the 45% risk of cage-overhang when XLIF devices were placed in the anterior one-third of the vertebral body. CONCLUSION Excluding new neurological deficits, XLIF techniques resulted in multiple other major complications. However, these small numbers likely reflect just the tip of the iceberg (e.g., 10%) and the remaining 90% may never be known as many US-based spine surgeons fail to publish such adverse events as they are discoverable in a court of law and may lead to medicolegal suits.
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Affiliation(s)
- Nancy E Epstein
- Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
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Suratwala SJ, Cronin M, Kondra K, Leone V. Acute Renal Infarction After Lateral Lumbar Interbody Spinal Fusion for Kyphoscoliosis. Spine Deform 2016; 4:385-389. [PMID: 27927497 DOI: 10.1016/j.jspd.2016.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 03/21/2016] [Accepted: 04/03/2016] [Indexed: 01/04/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVES Case report of acute renal infarction following lateral interbody fusion with posterior instrumentation for adult lumbar kyphoscoliosis. SUMMARY OF BACKGROUND DATA This is the first reported renal infarction following minimally invasive lateral interbody fusion and posterior spinal instrumentation. METHODS We report a case of acute renal infarction in a 72-year-old woman following direct lateral interbody fusion (DLIF) with percutaneous pedicle screw and rod fixation from L1 to L5 for correction of kyphoscoliosis. She reported vague abdominal pain on postoperative day (POD) 7. Abdominal ultrasound findings revealed no abnormalities. The patient tolerated a regular diet, improved in rehabilitative modalities, and had stable vital signs. Abdominal computed tomographic (CT) scan on POD 9 for persistent abdominal pain revealed right renal infarction and right renal artery occlusion. The patient was transferred to the ICU for evaluation, where intravenous heparin was administered and no reperfusion was performed. Transesophageal echocardiography on POD 14 revealed moderate diffuse plaque in the descending aorta. RESULTS Surgical correction of kyphoscoliosis through DLIF and posterior spinal instrumentation was performed with improvement of deformity. Subsequent acute renal infarction was noted. The patient was discharged home on POD 21. There were no further adverse events up to the 1-year follow-up. CONCLUSIONS A lateral approach to the anterior lumbar spine may precipitate renal artery occlusion and renal infarction in patients with atherosclerosis. Diagnosis of renal infarction requires a high index of suspicion because the primary complaint may be vague back, flank, and abdominal pain. We emphasize the importance of recognizing potential symptoms early to prevent additional renal injury. Caution should be taken with deformities around the origin of the renal arteries and great vessels, especially in patients with atherosclerosis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sanjeev J Suratwala
- Northwell Health, Glen Cove and Syosset Hospitals, New York Orthopaedic and Spine Center, 833 Northern Boulevard, Suite 220, Great Neck, NY 11021, USA.
| | - MaryAnne Cronin
- Northwell Health, Glen Cove and Syosset Hospitals, Syosset Hospital, 221 Jericho Turnpike, Syosset, NY 11791, USA
| | - Katelyn Kondra
- Hofstra Northwell School of Medicine, 500 Hofstra Blvd, Hempstead, NY 11549, USA
| | - Vincent Leone
- Northwell Health, Glen Cove and Syosset Hospitals, New York Orthopaedic and Spine Center, 833 Northern Boulevard, Suite 220, Great Neck, NY 11021, USA
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Beckman JM, Vincent B, Park MS, Billys JB, Isaacs RE, Pimenta L, Uribe JS. Contralateral psoas hematoma after minimally invasive, lateral retroperitoneal transpsoas lumbar interbody fusion: a multicenter review of 3950 lumbar levels. J Neurosurg Spine 2016; 26:50-54. [PMID: 27494784 DOI: 10.3171/2016.4.spine151040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Minimally invasive lateral lumbar interbody fusion (LLIF) via the retroperitoneal transpsoas approach is a technically demanding procedure with a multitude of potential complications. A relatively unknown complication is the contralateral psoas hematoma. The authors speculate that injury occurs from segmental vessel injury at the time of contralateral annulus release; however, this is not fully understood. In this multicenter retrospective review, the authors report the incidence of this contralateral complication and its neurological sequelae. METHODS This study was a retrospective chart review of all minimally invasive LLIF performed at participating institutions from 2008 to 2014. Exclusion criteria included an underlying diagnosis of trauma or neoplasia as well as lateral corpectomies or anterior column releases. Single-level, multilevel, and stand-alone constructs were included. All patients underwent preoperative MRI. Follow-up was at least 12 months. All complications and clinical outcomes were self-reported by each surgeon. RESULTS There were 3950 lumbar interbody cages placed via the retroperitoneal transpsoas approach, with 7 cases (0.18% incidence) of symptomatic contralateral psoas hematoma, 3 of which required reoperation for hematoma evacuation. Neurological outcome did not improve after reoperation. Reoperation occurred an average of 1 month after the initial operation due to a delay in diagnosis. In 1 case, segmental artery injury was confirmed at the time of surgery; in the others, segmental vessel injury was suspected, although it could not be confirmed. Neurological deficits persisted in 3 patients while the others remained neurologically intact. Two patients were receiving antiplatelet therapy prior to the procedure. CONCLUSIONS The contralateral psoas hematoma is a rare complication suspected to occur from segmental vessel injury during contralateral annulus release. Detailed review of preoperative imaging for aberrant vessel anatomy may prevent injury and subsequent neurological deficit.
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Affiliation(s)
- Joshua M Beckman
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa
| | - Berney Vincent
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa
| | - Michael S Park
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa
| | - James B Billys
- Center for Spinal Disorders, Florida Orthopaedic Institute, Tampa, Florida
| | - Robert E Isaacs
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina; and
| | - Luiz Pimenta
- Instituto de Patologia da Coluna, São Paulo, Brazil
| | - Juan S Uribe
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, Tampa
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Risk Assessment of Lumbar Segmental Artery Injury During Lateral Transpsoas Approach in the Patients With Lumbar Scoliosis. Spine (Phila Pa 1976) 2016; 41:880-4. [PMID: 26656035 DOI: 10.1097/brs.0000000000001362] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study using 27 contrast-enhanced multi-planar computed tomography scans of subjects with lumbar scoliosis. OBJECTIVE To assess the risk of injury of lumbar segmental arteries during transpsoas approach in patients with lumbar scoliosis. SUMMARY OF BACKGROUND DATA Although lumbar interbody fusion using big intervertebral cage through transpsoas approach has a big advantage to correct coronal and sagittal deformity in patients with spinal deformity, the risk for injury of lumbar segmental artery is always concerned. METHODS The abdominal-contrast enhanced multi-planar computed tomography scans of 27 subjects with lumbar scoliosis with over 15° of Cobb angle were retrospectively reviewed. The coronal views through the posterior one third of the intervertebral discs were reviewed. The cranio-caudal intervals of the adjacent segmental arteries at each intervertebral level were measured. The recommended working space for the lateral transpsoas approach using extreme lateral interbody fusion retractor is 24 mm in the cranio-caudal direction. The cutoff value for an intersegmental Cobb angle that would estimate a cranio-caudal interval of less than 24 mm was determined using a receiver operating characteristic curve. RESULTS The average interval between the cranio-caudal lumbar segmental arteries on the concave side was significantly shorter than that on the convex side (29.9 vs. 33.6 mm, P < 0.05). The differences in the intervals between the convex and concave sides were correlated with the corresponding intersegmental Cobb angle (r = 0.65, P < 0.05). Receiver operating characteristic curve analysis revealed that cutoff value for the best prediction of an interval less than 24 mm was 14.5°, with a specificity of 94.3% and sensitivity of 71.4%. CONCLUSION This study demonstrated that female patients with lumbar scoliosis with an intersegmental Cobb angle higher than 14.5° would be at high risk for potential injury to the lumbar artery during a transpsoas approach for extreme lateral interbody fusion from the concave side. LEVEL OF EVIDENCE 4.
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Abstract
STUDY DESIGN A retrospective study using 323 contrast-enhanced, multi-planner three-dimensional computed (3D-CT) scans. OBJECTIVE The aim of this study was to identify risk factors for injury to the major vessels in the lateral transpsoas approach. SUMMARY OF BACKGROUND DATA To avoid critical complications such as major vessel injury, it is essential to examine anatomical information related to preoperative risk management that is specific to the lateral transpsoas approach. METHODS The abdominal contrast-enhanced, multi-planner 3D-CT scans of 323 consecutive subjects (203 males and 120 females, 15-89 years old) were retrospectively reviewed. The true axial views were used for evaluation of the locations of the major vein and artery at L3 to L4 and L4 to L5. According to the Moro system, the axial view was divided into 6 zones from the front side (A, I II, III, IV, P) and the locations of the dorsal tangential line of the major vessels were evaluated. RESULTS At the L3 to L4 level, the dorsal tangential line of the major vein located in zone A was found in 18% of subjects, in zone I in 74%, and in zone II in 8%. The line of the major artery was located in zone A in 92.6% of subjects and in zone I in 7.1%. At the L4 to L5 level, the line of the major vein was located in zone A in 5% of subjects, in zone I in 75%, in zone II in 20%, and in zone III in only 1 subject. The line of the major artery was identified in zone A in 87% of subjects, in zone I in 12%, and in zone II in 1%. Women had significant dorsal-migrated veins and arteries at both spinal levels (P < 0.01). CONCLUSION To avoid critical complications in extreme lateral lumbar interbody fusion, careful preoperative radiological evaluation of the major vessels and intraoperative care are important. LEVEL OF EVIDENCE 3.
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Variations in arterial supply to the lower lumbar spine. 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 2016; 25:4181-4187. [DOI: 10.1007/s00586-016-4427-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/11/2016] [Accepted: 01/27/2016] [Indexed: 11/25/2022]
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Lateral Lumbar Interbody Fusion: A Better, Worse, and Similar Approach to Lumbar Arthrodesis. J Am Acad Orthop Surg 2016; 24:57-9. [PMID: 26803542 DOI: 10.5435/jaaos-d-15-00694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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