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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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Wang N, Xie Y, Liu X, Zheng Y, Xi Z, Xu W, Deng R, Tang T, Liu X. Safety and clinical efficacy of endoscopic procedures for the treatment of adjacent segmental disease after lumbar fusion: A systematic review and meta-analysis. PLoS One 2023; 18:e0280135. [PMID: 36745653 PMCID: PMC9901788 DOI: 10.1371/journal.pone.0280135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 12/20/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Adjacent segment disease (ASD) is a common complication after lumbar fusion and is still traditionally treated by open surgery. In recent years, with the development of minimally invasive techniques, percutaneous endoscopic surgery(PES) has been used for the treatment of ASD after lumbar fusion due to its unique benefits. Nevertheless, it remains unclear about its significant clinical efficacy and advantages over conventional open surgery. OBJECTIVES To evaluate the clinical efficacy and safety of PES in the treatment of ASD after lumbar fusion. STUDY DESIGN A systematic review and meta-analysis studies about the role of PES in managing ASD after lumbar fusion. METHODS A systematic search review was conducted in PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, VIP, WanFang, and SinoMed databases from the start of their construction to 15 November 2021. Eligible studies included references to clinical trials of PES for ASD after open lumbar fusion. Observations included pain relief, recovery of postoperative function, overall excellent rates, and indicators of the advantages of minimally invasive surgery compared to conventional surgery. Postoperative complications and recurrence rates were also recorded. RESULTS A total of 24 studies, including 20 single-arm studies and 4 clinical control studies, all involving 928 patients were included. A total of 694 patients were included in the single-arm analysis. The results of the single-arm meta-analysis showed that PES could significantly reduce low back and leg pain and improve the functional status of the lumbar spine in patients with ASD after open lumbar fusion compared to preoperatively, and had good clinical efficacy after surgery. A total of 234 patients were included in the four clinically controlled studies, and the results of the meta-analysis showed that PES could clearly reduce pain and improve lumbar function, with no significant difference in efficacy between PES and open surgery. However, PES has a lower surgical incision, less intraoperative bleeding, and shorter operative time and length of hospital stay compared to open surgery. Moreover, it has a lower rate of postoperative recurrence as well as complications and a longer duration of efficacy. CONCLUSIONS On the basis of the available clinical literature and the results of this study, PES could achieve satisfactory clinical effects in ASD treatment after lumbar fusion. Compared with conventional open surgery, PES can not only obtain similar clinical results, but also had the advantages of less trauma and faster recovery. Nevertheless, a randomized controlled study is still needed to validate the findings of this study. TRIAL REGISTRATION Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022298387.
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Affiliation(s)
- Nan Wang
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine for Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Yimin Xie
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine for Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Xiyu Liu
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine for Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Yawei Zheng
- Department of Cardiovascular Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Zhipeng Xi
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine for Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Wenqiang Xu
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine for Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Rongrong Deng
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine for Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
| | - Tian Tang
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine for Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
- * E-mail: (TT); (XL)
| | - Xin Liu
- Department of Spine Surgery, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine for Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, P.R. China
- * E-mail: (TT); (XL)
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Joiner A, Gomez G, Vatsia SK, Ellett T, Pahl D. Location variance of the great vessels while undergoing side-bend positioning changes during lateral interbody fusion. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:71-75. [PMID: 37213583 PMCID: PMC10198204 DOI: 10.4103/jcvjs.jcvjs_8_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 02/04/2023] [Indexed: 03/18/2023] Open
Abstract
Background Minimally invasive lateral lumbar interbody fusion (LLIF) is an increasingly popular surgical technique that facilitates minimally invasive exposure, attenuated blood loss, and potentially improved arthrodesis rates. However, there is a paucity of evidence elucidating the risk of vascular injury associated with LLIF, and no previous studies have evaluated the distance from the lumbar intervertebral space (IVS) to the abdominal vascular structures in a side-bend lateral decubitus position. Therefore, the purpose of this study is to evaluate the average distance, and changes in distance, from the lumbar IVS to the major vessels from supine to side-bend right and left lateral decubitus (RLD and LLD) positions simulating operating room positioning utilizing magnetic resonance imaging (MRI). Methods We independently evaluated lumbar MRI scans of 10 adult patients in the supine, RLD, and LLD positions, calculating the distance from each lumbar IVS to adjacent major vascular structures. Results At the cephalad lumbar levels (L1-L3), the aorta lies in closer proximity to the IVS in the RLD position, in contrast to the inferior vena cava (IVC), which is further from the IVS in the RLD. At the L3-S1 vertebral levels, the right and left common iliac arteries (CIA) are both further from the IVS in the LLD position, with the notable exception of the right CIA, which lies further from the IVS in the RLD at the L5-S1 level. At both the L4-5 and L5-S1 levels, the right common iliac vein (CIV) is further from the IVS in the RLD. In contrast, the left CIV is further from the IVS at the L4-5 and L5-S1 levels. Conclusion Our results suggest that RLD positioning may be safer for LLIF as it affords greater distance away from critical venous structures, however, surgical positioning should be assessed at the discretion of the spine surgeon on a patient-specific basis.
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Affiliation(s)
- Aaron Joiner
- Jack Hughston Memorial Hospital Orthopedic Surgery Residency Program, Jack Hughston Memorial Hospital, Phenix City, Alabama, USA
- Hughston Clinic, Columbus, Georgia, USA
| | | | | | - Tyler Ellett
- Edward Via College of Osteopathic Medicine – Auburn Campus, Auburn, Alabama, USA
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Quack V, Eschweiler J, Prechtel C, Migliorini F, Betsch M, Maffulli N, Gutteck N, Tingart M, Kobbe P, Pishnamaz M, Hildebrand F, Arbab D. L4/5 accessibility for extreme lateral interbody fusion (XLIF): a radiological study. J Orthop Surg Res 2022; 17:483. [PMID: 36369101 PMCID: PMC9652979 DOI: 10.1186/s13018-022-03320-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Potential advantages of the Extreme Lateral Interbody Fusion (XLIF) approach are smaller incisions, preserving anterior and posterior longitudinal ligaments, lower blood loss, shorter operative time, avoiding vascular and visceral complications, and shorter length of stay. We hypothesize that not every patient can be safely treated at the L4/5 level using the XLIF approach. The objective of this study was to radiographically (CT-scan) evaluate the accessibility of the L4/5 level using a lateral approach, considering defined safe working zones and taking into account the anatomy of the superior iliac crest. Methods Hundred CT examinations of 34 female and 66 male patients were retrospectively evaluated. Disc height, lower vertebral endplate (sagittal and transversal), and psoas muscle diameter were quantified. Accessibility to intervertebral space L4/5 was investigated by simulating instrumentation in the transverse and sagittal planes using defined safe zones. Results The endplate L5 in the frontal plane considering defined safe zones in the sagittal and transverse plane (Zone IV) could be reached in 85 patients from the right and in 83 from the left side. Through psoas split, the safe zone could be reached through psoas zone II in 82 patients from the right and 91 patients from the left side. Access through psoas zone III could be performed in 28 patients from the right and 32 patients from the left side. Safe access and sufficient instrumentation of L4/5 through an extreme lateral approach could be performed in 76 patients of patients from the right and 70 patients from the left side. Conclusion XLIF is not possible and safe in every patient at the L4/5 level. The angle of access for instrumentation, access of the intervertebral disc space, and accessibility of the safe zone should be taken into account. Preoperative imaging planning is important to identify patients who are not suitable for this procedure.
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Epstein NE. Perspective on the true incidence of bowel perforations occurring with extreme lateral lumbar interbody fusions. How should they be treated? Surg Neurol Int 2021; 12:576. [PMID: 34877062 PMCID: PMC8645470 DOI: 10.25259/sni_1003_2021] [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] [Received: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/04/2022] Open
Abstract
Background What is the risk of bowel perforation (BP) with open or minimally invasive (MI) extreme lateral lumbar interbody fusion (XLIF)? What is the truth? Further, if peritoneal symptoms/signs arise following XLIF/MI XLIF, it is critical to obtain an emergent consultation with general surgery who can diagnose and treat a potential BP. Literature Review In multiple series, the frequency of BP ranged markedly from 0.03% (i.e. 1 of 2998 patients), to 0.08% (11/13,004), to 0.5%, to 8.3% (1 in 12 patients), up to 12.5% (1 in 8 patients). BPs attributed to different causes carry high mortality rates varying from 11.1% to 23%. For the 11 (0.08%) BP occurring out of 13,004 patients undergoing XLIF in one series, there was one (9.09%) death due to uncontrolled sepsis. In another series, where 31 BP were identified for multiple lumbar surgical procedures identified through PubMed (1960-2016), including 10 (32.2%) for lateral lumbar surgery including XLIF, the overall mortality rate was 12.9% (4/31). Conclusion The incidence of BPs occurring following XLIF/MI XLIF procedures ranged from 0.03% to 12.5% in various reports. What is the true incidence of these errors? Certainly, it is more critical that when spine surgeons' patients develop acute peritoneal symptoms/signs following these procedures, they immediately consult general surgery to both diagnose, and treat potential BP in a timely fashion to avoid the high morbidity (87.1%) and mortality rates (12.9%) attributed to these perforations.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurosurgery, Schoold of Medicine, State University of New York at Stony Brook, and % Dr. Marc Agulnick, 1122 Franklin Avenue Suite 106, Garden City, NY 11530, USA
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Kapetanakis S, Gkantsinikoudis N, Gkasdaris G, Charitoudis G. Treatment of adjacent segment disease with percutaneous transforaminal endoscopic discectomy: Early experience and results. J Orthop Surg (Hong Kong) 2021; 28:2309499020960560. [PMID: 32990158 DOI: 10.1177/2309499020960560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Adjacent segment disease (ASD) constitutes a long-term complication of instrumented spinal fusion. Aim of this study is to analyze the utilization of percutaneous transforaminal endoscopic discectomy (PTED) for the treatment of symptomatic ASD, emphasizing basically in the postoperative course. METHODS A prospective study with 35 patients was designed. Patients enrolled in our study were distributed in two different groups. Group A constituted of 15 patients featuring ASD as a complication of a previously conducted lumbar spinal fusion. Group B was composed of 20 patients, presenting simple lumbar disc herniation (LDH). All patients were subjected to successful PTED for LDH. Patients were evaluated at regular intervals in 6-week and 3-, 6-, and 12-month postoperatively. Visual analog scale was utilized for leg (VAS-LP) and low back pain (VAS-BP) evaluation. Health-related quality of life was assessed with short-form 36 health survey questionnaire (SF-36). RESULTS VAS-BP scores were statistically significantly differentiated between the two groups in all intervals of follow-up. In contrast, VAS-LP scores demonstrated statistically significant differentiation in none of follow-up intervals, indicating similar results between the two groups. Maximal improvement was in both cases for all patients observed in 6-week postoperatively, with subsequent stabilization. SF-36 preoperative evaluation denoted a statistically significant differentiation in bodily pain and role emotional parameters, which was continually until the end of follow-up observed. The other SF-36 parameters featured similar values between the two groups preoperatively as well as during the follow-up intervals. CONCLUSION PTED is capable of successfully dealing with LDH and furthermore with complications of fusion as ASD.
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Affiliation(s)
- Stylianos Kapetanakis
- Spine Department and Deformities, 69021Interbalkan European Medical Center, Thessaloniki, Greece
| | - Nikolaos Gkantsinikoudis
- Spine Department and Deformities, 69021Interbalkan European Medical Center, Thessaloniki, Greece
| | - Grigorios Gkasdaris
- Spine Department and Deformities, 69021Interbalkan European Medical Center, Thessaloniki, Greece
| | - Georgios Charitoudis
- Spine Department and Deformities, 69021Interbalkan European Medical Center, Thessaloniki, Greece
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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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Epstein NE. Review of Risks and Complications of Extreme Lateral Interbody Fusion (XLIF). Surg Neurol Int 2019; 10:237. [PMID: 31893138 PMCID: PMC6911674 DOI: 10.25259/sni_559_2019] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 11/16/2019] [Indexed: 11/04/2022] Open
Abstract
Background Extreme lateral interbody fusions (XLIF) and Minimally Invasive (MIS) XLIF were developed to limit the vascular injuries associated with anterior lumbar interbody fusion (ALIF), and minimize the muscular/ soft tissue trauma attributed to transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterolateral lumbar fusion (PLF). Methods Nevertheless, XLIF/MIS XLIF pose significant additional risks and complications that include; multiple nerve injuries (e.g. lumbar plexus, ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, and subcostals (to the anterior abdominal muscles: abdominal oblique), and sympathectomy), major vascular injuries, bowel perforations/postoperative ileus, seromas, pseudarthrosis, subsidence, and reoperations. Results The risks of neural injury with XLIF/MIS XLIF (up to 30-40%) are substantially higher than for TLIF, PLIF, PLF, and ALIF. These neural injuries included: lumbar plexus injuries (13.28%); new sensory deficits (0-75% (21.7%-40%); permanent 62.5%); motor deficits (0.7-33.6%-40%); iliopsoas weakness (9%-31%: permanent 5%), anterior thigh/groin pain (12.5-34%), and sympathectomy (4%-12%). Additional non-neurological complications included; subsidence (10.3%-13.8%), major vascular injuries (0.4%), bowel perforations, recurrent seroma, malpositioning of the XLIF cages, a 45% risk of cage-overhang, pseudarthrosis (7.5%), and failure to adequately decompress stenosis. In one study, reviewing 20 publications and involving 1080 XLIF patients, the authors observed "Most (XLIF) studies are limited by study design, sample size, and potential conflicts of interest." Conclusion Many new neurological deficits and other adverse events/complications are attributed to MIS XLIF/ XLIF. Shouldn't these significant risk factors be carefully taken into consideration before choosing to perform MIS XLIF/XLIF?
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, New York, and Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience/Neurosurgery, Mineola, New York 11501, United States
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Delayed Fatal Lumbar Artery Bleeding Following Less Invasive Posterolateral Decompression and Fusion. Spine (Phila Pa 1976) 2018; 43:E976-E979. [PMID: 29419718 DOI: 10.1097/brs.0000000000002587] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report. OBJECTIVE The aim of this study was to outline the potential risks of late bleeding from the segmental vessels following less invasively dorsolateral approaches to the thoracolumbar spine. SUMMARY OF BACKGROUND DATA A low risk of major intraoperative bleeding, associated traditional dorsolateral approach to the lumbar spine is reported, but segmental arteries and great vessels may be rarely damaged. Spine surgeons who are involved with these approaches should be aware of this rare but potential dangerous vascular complication because it could be life-threatening, particularly in elderly patients with increased morbidity, and/or metastatic disease to the spine. METHODS A 76-year-old white woman with a comminuted osteoporotic fracture of the L1-vertebrae with spinal canal encroachment underwent a corpectomy and a 360° fusion with the use of a titanium mesh cage, through a less invasively dorsolateral approach. RESULTS Despite the lack of visible intraoperative bleeding and uneventful postoperative period, the patient died on the seventh postoperative day as a result of massive bleeding from a segmental artery at the level of L3 vertebrae body, two levels below our intervention area. CONCLUSION This article describes a rare complication of delayed and fatal bleeding of the segmental L3 left vertebral artery following less invasively L1 corpectomy, mesh cage insertion, and pedicle screw fixation in a elderly female patient with history of two malignancies. Although injury to large vessels must always be prevented during these procedures, an injury to the segmental vessels occurs more frequently. The dorsolateral approach and other retroperitoneal approaches to the thoracolumbar region are established methods for the surgical stabilization of comminuted vertebral body fractures, especially on the hands of experienced spine surgeons. Great care should be given postoperatively for signs of bleeding and hematoma and the surgeon should be aware for these life-threatening complications. LEVEL OF EVIDENCE 5.
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Blecher R, Yilmaz E, Moisi M, Oskouian RJ, Chapman J. Extreme Lateral Interbody Fusion Complicated by Fungal Osteomyelitis: Case Report and Quick Review of the Literature. Cureus 2018; 10:e2719. [PMID: 30079285 PMCID: PMC6067835 DOI: 10.7759/cureus.2719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The authors describe a 67-year-old man with a prior history of alcohol abuse who presented with a complaint of worsening low back pain. Four months prior to his presentation, the patient had undergone extreme lateral interbody fusion (XLIF) of his lumbar 3-4 segment for the treatment of his chronic low back and legs pain. Imaging revealed a loosening of his interbody fusion implant on top of his prior lumbar spine instrumentation. In surgery, the removal of his loose implant was followed by decompression, the stabilization of the collapsed segment, and the implant of antibiotic-impregnated polymethyl-methacrylate (PMMA) spacer and beads. At a later stage, the patient underwent an interbody fusion of the affected segment as well as a segmental fusion from T10 to his pelvis. Whereas all aerobes and anaerobes stains were negative for organisms, multiple fungal smears from the failed segment were positive for yeast, and the patient was placed on oral fluconazole. Infections complicating the surgical site of interbody fusions performed by minimally invasive techniques are rare. To the best of our knowledge and after reviewing the literature, this is the first report of an extreme lateral interbody fusion implant complicated by fungal osteomyelitis.
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Affiliation(s)
- Ronen Blecher
- Orthopedic Department, Assaf Harofeh, Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Emre Yilmaz
- Swedish Medical Center, Swedish Neuroscience Institute, Seattle, USA
| | - Marc Moisi
- Neurosurgery, Wayne State University School of Medicine., Detroit, USA
| | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - Jens Chapman
- Orthopedics Spine Surgery, Swedish Neuroscience Institute, Seattle, USA
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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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Epstein NE. Extreme lateral lumbar interbody fusion: Do the cons outweigh the pros? Surg Neurol Int 2016; 7:S692-S700. [PMID: 27843688 PMCID: PMC5054636 DOI: 10.4103/2152-7806.191079] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/02/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Major factors prompted the development of minimally invasive (MIS) extreme lateral interbody fusion (XLIF; NuVasive Inc., San Diego, CA, USE) for the thoracic/lumbar spine. These include providing interbody stabilization and indirect neural decompression while avoiding major visceral/vessel injury as seen with anterior lumbar interbody fusion (ALIF), and to avert trauma to paraspinal muscles/facet joints found with transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterior-lateral fusion techniques (PLF). Although anticipated pros of MIS XLIF included reduced blood loss, operative time, and length of stay (LOS), they also included, higher fusion, and lower infection rates. Unanticipated cons, however, included increased morbidity/mortality rates. METHODS We assessed the pros and cons (e.g., risks, complications, comparable value/superiority/inferiority, morbidity/mortality) of MIS XLIF vs. ALIF, TLIF, PLIF, and PLF. RESULTS Pros of XLIF included various biomechanical and technical surgical advantages, along with multiple cons vs. ALIF, TLIF, PLIF, and PLF. For example, XLIF correlated with a considerably higher frequency of major neurological deficits vs. other constructs; plexus injuries 13.28%, sensory deficits 0-75% (permanent in 62.5%), motor deficits 0.7-33.6%, and anterior thigh pain 12.5-25%. XLIF also disproportionately contributed to other major morbidity/mortality; sympathectomy, major vascular injuries (some life-ending others life-threatening), bowel perforations, and seromas. Furthermore, multiple studies documented no superiority, and the potential inferiority of XLIF vs. ALIF, TLIF, PLIF, and PLF. CONCLUSION Reviewing the pros of XLIF (e.g. radiographic, technical, biomechanical) vs. the cons (inferiority, increased morbidity/mortality) vs. ALIF, TLIF, PLIF, and PLF, we question whether XLIF should remain part of the lumbar spinal surgical armamentarium.
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Affiliation(s)
- Nancy E. Epstein
- Chief of Neurosurgical Spine and Education, Department of Neurosurgery, Winthrop University Hospital, Mineola, New York – 11501, USA
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