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Souslian FG, Patel PD. Review and analysis of modern lumbar spinal fusion techniques. Br J Neurosurg 2024; 38:61-67. [PMID: 34263676 DOI: 10.1080/02688697.2021.1881041] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 01/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE A variety of different lumbar spinal fusion techniques have been developed. In this study, we review published medical literature highlighting the differences between lumbar interbody fusion techniques with regard to their surgical technique, clinical outcomes, and complications. MATERIALS AND METHODS PubMed, ScienceDirect, and Google Scholar searches were performed for studies published between January 1990 to April 2018 reporting spinal fusion surgery clinical outcomes of at least one fusion technique. Clinical outcomes were extracted and pooled by surgical technique. Chi-squared analyses and Fisher Exact Tests were used to determine differences in rates between groups. RESULTS PLIF had the highest rate of successful fusion (97% [155/159]) and the lowest rate of complications (4% [6/131]). A chi square analysis revealed a significant difference in fusion success in PLIF compared to PLF (84% [278/330], p < .001). PLIF also had significantly fewer complications compared to PSF (14.7% [251/1709], p = .001), PLF (13.4% [47/351], p = .008), ALIF (14.2% [22/155], p = .008), and LIC (13.9% [47/339], p = .005). Additionally, there were significant differences in the rate of successful fusion when comparing lateral interbody cage (LIC) techniques (p = .041), which include OLIF (100% [63/63]), DLIF (92% [24/26]), and XLIF (87% [67/77]). LIC techniques overall had higher fusion success rates (93.0% [154/166] compared to PLF (p = .01), but a higher rate of complications (14% [47/339]) compared to PLIF (p = .005) and TLIF (6% [17/259], p = .005). CONCLUSIONS Overall, PLF and XLIF have the lowest fusion success rates, and OLIF demonstrated a trend of higher fusion rates among LIC. Techniques that utilized interbody fusion tended to increase the rate of fusion. While interbody fusion techniques offer higher rates of fusion, complication rates also tend to rise with the increase in complexity of the surgical technique, as with OLIF which notably has the highest fusion rate and complication rate.
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Affiliation(s)
- Fotis G Souslian
- Department of Neurologic Surgery, Regions Hospital, St Paul, Minnesota, USA
| | - Puja D Patel
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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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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Meade MH, Lee Y, Brush PL, Lambrechts MJ, Jenkins EH, Desimone CA, Mccurdy MA, Mangan JJ, Canseco JA, Kurd MF, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. Lateral approach to the lumbar spine: The utility of an access surgeon. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:281-287. [PMID: 37860021 PMCID: PMC10583800 DOI: 10.4103/jcvjs.jcvjs_78_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/05/2023] [Indexed: 10/21/2023] Open
Abstract
Background Lateral lumbar interbody fusions (LLIFs) utilize a retroperitoneal approach that avoids the intraperitoneal organs and manipulation of the anterior vasculature encountered in anterior approaches to the lumbar spine. The approach was championed by spinal surgeons; however, general/vasculature surgeons may be more comfortable with the approach. Objective The objective of this study was to compare short-term outcomes following LLIF procedures based on whether a spine surgeon or access surgeon performed the approach. Materials and Methods We retrospectively identified all one- to two-level LLIFs at a tertiary care center from 2011 to 2021 for degenerative spine disease. Patients were divided into groups based on whether a spine surgeon or general surgeon performed the surgical approach. The electronic medical record was reviewed for hospital readmissions and complication rates. Results We identified 239 patients; of which 177 had approaches performed by spine surgeons and 62 by general surgeons. The spine surgeon group had fewer levels with posterior instrumentation (1.40 vs. 2.00; P < 0.001) and decompressed (0.94 vs. 1.25, P = 0.046); however, the two groups had a similar amount of two-level LLIFs (29.9% vs. 27.4%, P = 0.831). This spine surgeon approach group was found to have shorter surgeries (281 vs. 328 min, P = 0.002) and shorter hospital stays Length of Stay (LOS) (3.1 vs. 3.6 days, P = 0.019); however, these differences were largely attributed to the shorter posterior fusion construct. On regression analysis, there was no statistical difference in postoperative complication rates whether or not an access surgeon was utilized (P = 0.226). Conclusion Similar outcomes may be seen regardless of whether a spine or access surgeon performs the approach for an LLIF.
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Affiliation(s)
- Matthew H. Meade
- Department of Orthopaedic Surgery, Jefferson Health – New Jersey, Washington Township, NJ, USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Parker L. Brush
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark J. Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Eleanor H. Jenkins
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Cristian A. Desimone
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael A. Mccurdy
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - John J. Mangan
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose A. Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark F. Kurd
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan S. Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Bamps S, Raymaekers V, Roosen G, Put E, Vanvolsem S, Achahbar SE, Meeuws S, Wissels M, Plazier M. Lateral Lumbar Interbody Fusion (Direct Lateral Interbody Fusion/Extreme Lateral Interbody Fusion) versus Posterior Lumbar Interbody Fusion Surgery in Spinal Degenerative Disease: A Systematic Review. World Neurosurg 2023; 171:10-18. [PMID: 36521760 DOI: 10.1016/j.wneu.2022.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Degenerative diseases of the lumbar spine are often treated with posterior interbody fusion surgery (posterior lumbar interbody fusion [PLIF]) for spinal instability or intractable back pain with neurologic impairment. Several lateral, less invasive procedures have recently been described (lateral lumbar interbody fusion [LLIF]/direct lateral interbody fusion/extreme lateral interbody fusion [XLIF]). The aim of this systematic review is to compare structural and functional outcomes of lateral surgical approaches to PLIF. METHODS We conducted a MEDLINE (PubMed), Web of Science, ScienceDirect, and Cochrane Library search for studies focusing on outcomes and complications comparing LLIF (direct lateral interbody fusion/XLIF) and PLIF. The systematic review was reported using the PRISMA criteria. RESULTS In total, 1000 research articles were identified, of which 5 studies were included comparing the outcomes and complications between the lateral and posterior approach. Three studies found significantly less perioperative blood loss with a lateral approach. Average hospital stay was shorter in populations who underwent the lateral approach compared with PLIF. Functional outcomes (visual analog scale score/Oswestry Disability Index) were similar or better with LLIF. In most of the included studies, complication rates did not differ between the posterior and lateral approach. Most of the neurologic deficits with XLIF/LLIF were temporary and healed completely within 1 year follow-up. CONCLUSIONS A lateral approach (XLIF/LLIF) is a good and safe alternative for PLIF in single-level degenerative lumbar diseases, with comparable functional outcomes, shorter hospital stays, and less blood loss. Future prospective studies are needed to establish the role of lateral minimally invasive approaches in spinal degenerative surgery.
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Affiliation(s)
- Sven Bamps
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium; Department of Neurosurgery, St. Trudo Hospital, Sint-Truiden, Belgium; Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium; Study and Training Center Neurosurgery, Virga Jesse, Hasselt, Belgium; Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium.
| | - Vincent Raymaekers
- Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium; Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Gert Roosen
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium; Department of Neurosurgery, St. Trudo Hospital, Sint-Truiden, Belgium; Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium; Study and Training Center Neurosurgery, Virga Jesse, Hasselt, Belgium
| | - Eric Put
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium; Department of Neurosurgery, St. Trudo Hospital, Sint-Truiden, Belgium; Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium; Study and Training Center Neurosurgery, Virga Jesse, Hasselt, Belgium
| | - Steven Vanvolsem
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium; Department of Neurosurgery, St. Trudo Hospital, Sint-Truiden, Belgium; Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium; Study and Training Center Neurosurgery, Virga Jesse, Hasselt, Belgium
| | - Salah-Eddine Achahbar
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium; Department of Neurosurgery, St. Trudo Hospital, Sint-Truiden, Belgium; Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium; Study and Training Center Neurosurgery, Virga Jesse, Hasselt, Belgium
| | - Sacha Meeuws
- Study and Training Center Neurosurgery, Virga Jesse, Hasselt, Belgium; Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium; Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Maarten Wissels
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium; Department of Neurosurgery, St. Trudo Hospital, Sint-Truiden, Belgium; Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium; Study and Training Center Neurosurgery, Virga Jesse, Hasselt, Belgium
| | - Mark Plazier
- Department of Neurosurgery, Jessa Hospital, Hasselt, Belgium; Department of Neurosurgery, St. Trudo Hospital, Sint-Truiden, Belgium; Department of Neurosurgery, St. Franciscus Hospital, Heusden-Zolder, Belgium; Study and Training Center Neurosurgery, Virga Jesse, Hasselt, Belgium; Faculty of Medicine and Life Science, Hasselt University, Hasselt, Belgium
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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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Wang X, Liu H, Wang W, Sun Y, Zhang F, Guo L, Li J, Zhang W. Comparison of Posterior Pedicle Screw Fixation and Lateral Fixation in the Extreme Lateral Interbody Fusion in Lumbar Degenerative Disease Patients with Osteopenia or Osteoporosis. Orthop Surg 2022; 14:3283-3292. [PMID: 36274218 PMCID: PMC9732588 DOI: 10.1111/os.13540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Nowadays, with the increasing proportion of osteoporosis in patients with lumbar degenerative diseases, doctors are facing the choice of intraoperative internal fixation methods. The purpose of this study was to compare and assess the clinical results of posterior bilateral pedicle screw fixation and lateral fixation in the extreme lateral interbody fusion (XLIF) in patients with osteopenia or osteoporosis. METHODS The retrospective review was performed on 67 degenerative lumbar diseases patients with osteopenia or osteoporosis who underwent XLIF in our hospital from January 2018 to July 2021. Patients in this study were classified into lateral screw (LS) group, lateral self-locking plate (LP) group, and bilateral pedicle screw (BPS) group. The functional evaluation factors containing Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) of leg pain, and VAS of low back pain, radiological factors such as disc height (DH), lumbar lordotic (LL) angle, segmental lordotic (SL) angle, cage subsidence degree and interbody fusion degree were compared. RESULTS Primary outcomes: no differences were observed with regards to the incidence of complications among LS, LP and BS group (P < 0.05). The JOA and leg pain VAS were significantly improved after operation (P < 0.05) and all groups demonstrated similar improvements in the leg pain VAS and JOA score (P > 0.05). When comparing VAS of leg pain and JOA scores, no differences were identified among LS, LP and BPS groups (P > 0.05). There are four thigh sensory complaint, one hip flexor weakness and one thigh pain occurred and no death was observed. There were significantly better DH, LL angle, SL angle, cage subsidence degree and interbody fusion degree in the BPS group than in LS and LP groups 1 year after surgery (P < 0.05). The DH loss ratio, LL angle loss ratio, SL angle loss ratio in the BPS group was significantly lower than in the LP and LS groups (P < 0.05). The 12-month SL angle improvement rate in the BPS group was significantly higher than in the LP and LS groups (20.20 ± 14.69, 0.73 ± 4.68, 6.20 ± 12.31, P < 0.05). SECONDARY OUTCOMES the BPS patients had significantly worse intraoperative blood loss and operation time than LS and LP patients (P < 0.05). CONCLUSION In lumbar diseases patients with osteopenia or osteoporosis, the bilateral pedicle screw fixation has better orthopedic effect than lateral internal fixation, and can better maintain the stability of the spine in the long-term follow-up, which is a better choice in XLIF surgery.
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Affiliation(s)
- Xianzheng Wang
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Huanan Liu
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Weijian Wang
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Yapeng Sun
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Fei Zhang
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Lei Guo
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Jiaqi Li
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Wei Zhang
- Department of Spinal SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
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Rates of Postoperative Complications and Approach-related Neurological Symptoms After L4-L5 Lateral Transpsoas Lumbar Interbody Fusion Compared With Upper Lumbar Levels. Clin Spine Surg 2022:01933606-990000000-00058. [PMID: 35945666 DOI: 10.1097/bsd.0000000000001367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective comparative study. OBJECTIVE To compare the likelihood of approach-related complications for patients undergoing single-level lateral lumbar interbody fusion (LLIF) at L4-L5 to those undergoing the procedure at upper lumbar levels. SUMMARY OF BACKGROUND DATA LLIF has been associated with a number of advantages when compared with traditional interbody fusion techniques. However, potential risks with the approach include vascular or visceral injury, thigh dysesthesias, and lumbar plexus injury. There are concerns of a higher risk of these complications at the L4-L5 level compared with upper lumbar levels. MATERIALS AND METHODS A retrospective cohort review was completed for consecutive patients undergoing single-level LLIF between 2004 and 2019 by a single surgeon. Indication for surgery was symptomatic degenerative lumbar stenosis and/or spondylolisthesis. Patients were divided into 2 cohorts: LLIF at L4-L5 versus a single level between L1 and L4. Baseline characteristics, intraoperative complications, postoperative approach-related neurological symptoms, and patient-reported outcomes were compared and analyzed between the cohorts. RESULTS A total of 122 were included in analysis, of which 58 underwent LLIF at L4-L5 and 64 underwent LLIF between L1 and L4. There were no visceral or vascular injuries or lumbar plexus injuries in either cohort. There was no significant difference in the rate of postoperative hip pain, anterior thigh dysesthesias, and/or hip flexor weakness between the cohorts (53.5% L4-L5 vs. 37.5% L1-L4; P=0.102). All patients reported complete resolution of these symptoms by 6-month postoperative follow-up. DISCUSSION LLIF surgery at the L4-L5 level is associated with a similar infrequent likelihood of approach-related complications and postoperative hip pain, thigh dysesthesias, and hip flexor weakness when compared with upper lumbar level LLIF. Careful patient selection, meticulous use of real-time neuromonitoring, and an understanding of the anatomic location of the lumbar plexus to the working corridor are critical to success.
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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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Tan MWP, Sayampanathan AA, Jiang L, Guo CM. Comparison of Outcomes Between Single-level Lateral Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion: A Meta-analysis and Systematic Review. Clin Spine Surg 2021; 34:395-405. [PMID: 33298799 DOI: 10.1097/bsd.0000000000001107] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a meta-analysis and systematic review of the available literature. OBJECTIVE This study aims to compare the clinical and radiologic outcomes of single-level lateral lumbar interbody fusion (LLIF) with single-level transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA In the treatment of adult spinal deformity, LLIF allows interbody fusion while avoiding complications associated with an anterior or transforaminal approach, although the clinical outcomes of LLIF compared with other approaches have not been well established. METHODS We searched PubMed, Embase, and Scopus for 385 unique studies. On the basis of our exclusion criteria, 8 studies remained for our systematic review. Data were analyzed using Review Manager 5.3 using Mantel-Haenszel statistics and random effect models. This study identified self-reported Visual Analog Scale (VAS), Oswestry Disability Index, length of stay, blood loss, complication rate, and radiologic parameters (disk height, lumbar lordosis, segmental lordosis). RESULTS Our meta-analysis showed that LLIF contributed to decreased blood loss [mean difference (MD)=-67.62 mL, 95% confidence interval (CI): -104 to -30.90, P<0.001], superior restoration of segmental lordosis (MD=1.91 degrees, 95% CI: 0.71-3.10, P=0.002), lumbar lordosis (MD=1.95 degrees, 95% CI: 0.15-3.74, P=0.03), and disk height (MD=2.18 mm, 95% CI: 1.18-3.17, P<0.001) when compared with TLIF. However, current data suggests no significant difference in clinical outcomes between LLIF and TLIF based on overall complication rates (P=0.22), length of hospital stay (P=0.65), postoperative Oswestry Disability Index (P=0.13), postoperative VAS Back Pain (P=0.47) and VAS Leg Pain (P=0.16). CONCLUSIONS LLIF is an increasingly popular option for single-level anterior column reconstruction. When compared with single-level TLIF, single-level LLIF is associated with greater changes in lumbar lordosis and disk height. The single-level LLIF is a viable alternative to TLIF, demonstrating comparable clinical outcomes and better restoration of spinopelvic parameters. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Marcus Wei Ping Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
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10
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Pojskić M, Bopp M, Saß B, Kirschbaum A, Nimsky C, Carl B. Intraoperative Computed Tomography-Based Navigation with Augmented Reality for Lateral Approaches to the Spine. Brain Sci 2021; 11:brainsci11050646. [PMID: 34063546 PMCID: PMC8156391 DOI: 10.3390/brainsci11050646] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background. Lateral approaches to the spine have gained increased popularity due to enabling minimally invasive access to the spine, less blood loss, decreased operative time, and less postoperative pain. The objective of the study was to analyze the use of intraoperative computed tomography with navigation and the implementation of augmented reality in facilitating a lateral approach to the spine. Methods. We prospectively analyzed all patients who underwent surgery with a lateral approach to the spine from September 2016 to January 2021 using intraoperative CT applying a 32-slice movable CT scanner, which was used for automatic navigation registration. Sixteen patients, with a median age of 64.3 years, were operated on using a lateral approach to the thoracic and lumbar spine and using intraoperative CT with navigation. Indications included a herniated disc (six patients), tumors (seven), instability following the fracture of the thoracic or lumbar vertebra (two), and spondylodiscitis (one). Results. Automatic registration, applying intraoperative CT, resulted in high accuracy (target registration error: 0.84 ± 0.10 mm). The effective radiation dose of the registration CT scans was 6.16 ± 3.91 mSv. In seven patients, a control iCT scan was performed for resection and implant control, with an ED of 4.51 ± 2.48 mSv. Augmented reality (AR) was used to support surgery in 11 cases, by visualizing the tumor outline, pedicle screws, herniated discs, and surrounding structures. Of the 16 patients, corpectomy was performed in six patients with the implantation of an expandable cage, and one patient underwent discectomy using the XLIF technique. One patient experienced perioperative complications. One patient died in the early postoperative course due to severe cardiorespiratory failure. Ten patients had improved and five had unchanged neurological status at the 3-month follow up. Conclusions. Intraoperative computed tomography with navigation facilitates the application of lateral approaches to the spine for a variety of indications, including fusion procedures, tumor resection, and herniated disc surgery.
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Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
- Correspondence: ; Tel.: +49-64215869848
| | - Miriam Bopp
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 35043 Marburg, Germany
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
| | - Andreas Kirschbaum
- Department of Visceral, Thoracic and Vascular Surgery, University of Marburg, 35043 Marburg, Germany;
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 35043 Marburg, Germany
| | - Barbara Carl
- Department of Neurosurgery, University of Marburg, Baldingerstraße, 35043 Marburg, Germany; (M.B.); (B.S.); (C.N.); (B.C.)
- Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, 65199 Wiesbaden, Germany
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11
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Clinical Outcomes of Biportal Endoscopic Interlaminar Decompression with Oblique Lumbar Interbody Fusion (OLIF): Comparative Analysis with TLIF. Brain Sci 2021; 11:brainsci11050630. [PMID: 34068334 PMCID: PMC8153266 DOI: 10.3390/brainsci11050630] [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: 04/05/2021] [Revised: 05/03/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022] Open
Abstract
Oblique lumbar interbody fusion (OLIF) improves the spinal canal, with favorable clinical outcomes. However, it may not be useful for treating concurrent, severe central canal stenosis (SCCS). Therefore, we added biportal endoscopic spinal surgery (BESS) after OLIF, evaluated the combined procedure for one-segment fusion with clinical outcomes, and compared it to open conventional TLIF. Patients were divided into two groups: Group A underwent BESS with OLIF, and Group B were treated via TLIF. The length of hospital stay (LOS), follow-up period, operative time, estimated blood loss (EBL), fusion segment, complications, and clinical outcomes were evaluated. Clinical outcomes were measured using Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified Macnab criteria. All the clinical parameters improved significantly after the operation in Group A. The only significant between-group difference was that the EBL was significantly lower in Group A. At the final follow-up, no clinical parameter differed significantly between the groups. No complications developed in either group. We suggest that our combination technique is a useful, alternative, minimally invasive procedure for the treatment of one-segment lumbar SCCS associated with foraminal stenosis or segmental instability.
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12
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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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13
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Pimenta L, Pokorny G, Amaral R, Ditty B, Batista M, Moriguchi R, Filho FM, Taylor WR. Single-Position Prone Transpsoas Lateral Interbody Fusion Including L4L5: Early Postoperative Outcomes. World Neurosurg 2021; 149:e664-e668. [PMID: 33548532 DOI: 10.1016/j.wneu.2021.01.118] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The lateral lumbar interbody fusion (LLIF) was a revolutionary approach devised by Luiz Pimenta that allowed the surgeon to access the lumbar spine through the major psoas muscle. Although the traditional LLIF had enabled enormous advances, the technique has its drawbacks. A new concept to perform the traditional LLIF has been proposed, with the patient being prone to decubitus with slightly extended legs. Our study aims to analyze the early outcomes of patients who had undergone the prone transpsoas (PTP) for degenerative spine pathologies including the L4/5 level. METHODS This study was multicentric, retrospective, nonrandomized, noncomparative, and observational. Only participants who received PTP in L4/5, with no more than 3 levels of intersomatics and fixation no further than S1, were included. The primary outcomes were the onset of new neurologic deficits and postoperative complications. Also, surgery details, such as blood loss and surgery duration, were measured. Neurologic deficits were accessed at the postoperative visit, which ranged from 7 to 14 days after surgery. RESULTS Twenty-seven patients fulfilled the inclusion and exclusion criteria, with the majority receiving PTP only in L4/5 (66.6%). The mean surgery time was 182, with 29 minutes of mean transpsoas time. Of the patients, only 1 presented the onset of a motor deficit, while 3 patients presented a new sensory deficit. Five complications occurred, none intraoperative and 5 postoperative, with only 1 directly correlated with the access. CONCLUSIONS The prone transpsoas is safe and feasible for approaching the L4/5 disk, presenting with a low rate of complication and new-onset neurologic deficits.
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Affiliation(s)
- Luiz Pimenta
- Institute of Spinal Pathology, São Paulo, Brazil; Department of Neurosurgery, University of California, San Diego, California, USA
| | | | | | - Benjamin Ditty
- Department of Neurosurgery, University of Alabama, Birmingham, Alabama, USA
| | | | | | | | - William R Taylor
- Department of Neurosurgery, University of California, San Diego, California, USA
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14
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Guiroy AJ, Duarte MP, Cabrera JP, Coombes N, Gagliardi M, Gotfryd A, Carazzo C, Taboada N, Falavigna A. Neurosurgery versus orthopedic surgery: Who has better access to minimally invasive spinal technology? Surg Neurol Int 2020; 11:385. [PMID: 33408919 PMCID: PMC7771484 DOI: 10.25259/sni_600_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/02/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Our aim was to evaluate differences in neurosurgeons versus orthopedists access to technologies needed to perform minimally invasive spine surgeries (MISS) in Latin America. Methods: We sent a survey to members of AO Spine Latin America (January 2020), and assessed the following variables; nationality, level of hospital (primary, secondary, and tertiary), number of spinal operations performed per year, spinal pathologies addressed, the number of minimally invasive spine operations performed/year, and differences in access to MISS spinal technology between neurosurgeons and orthopedists. Results: Responses were returned from 306 (25.6) members of AO Spine Latin America representing 20 different countries; 57.8% of respondents were orthopedic surgeons and 42.4% had over 10 years of experience. Although both specialties reported a lack of access to most of the technologies, the main difference between the two was greater utilization/access of neurosurgeons to operating microscope (e.g., 84% of the neurosurgeons vs. 39% of orthopedic spine surgeons). Conclusion: Although both specialties have limited access to MISS spinal technologies, orthopedic spine surgeons reported significantly lower access to operating microscopes versus neurosurgeons (P < 0.01).
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Affiliation(s)
| | - Matias Pereira Duarte
- Department of Orthopedic, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pablo Cabrera
- Department of Neurosurgery, Hospital Clínico Regional de Concepción, Concepción, Chile
| | - Nicolás Coombes
- Department of Orthopedics, Axial Medical Group, Buenos Aires, Argentina
| | | | - Alberto Gotfryd
- Department of Orthopedic, Hospital Israelita Albert Einstein, Sao Paulo, Brasil
| | - Charles Carazzo
- Department of Neurosurgery, University of Passo Fundo, Passo Fundo, Brasil
| | - Nestor Taboada
- Department of Neurosurgery, Clinica Portoazul, Barranquilla, Colombia
| | - Asdrubal Falavigna
- Department of Medicine, University of Caxias do Sul, Rio Grande do Sul, Brasil
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15
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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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16
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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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17
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Boghani Z, Steele WI, Barber SM, Lee JJ, Sokunbi O, Blacklock JB, Trask T, Holman P. Variability in the size of the retroperitoneal oblique corridor: A magnetic resonance imaging-based analysis. Surg Neurol Int 2020; 11:54. [PMID: 32363049 PMCID: PMC7193205 DOI: 10.25259/sni_438_2019] [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: 07/31/2019] [Accepted: 12/16/2019] [Indexed: 11/16/2022] Open
Abstract
Background: A minimally invasive approach to the L2-S1 disc spaces through a single, left-sided, retroperitoneal oblique corridor has been previously described. However, the size of this corridor varies, limiting access to the disc space in certain patients. Here, the authors retrospectively reviewed lumbar spine magnetic resonance imaging (MRI) in 300 patients to better define the size and variability of the retroperitoneal oblique corridor. Methods: Lumbar spine MRI from 300 patients was reviewed. The size of the retroperitoneal oblique corridor from L2-S1 was measured. It was defined as the (1) distance between the medial aspect of the aorta and the lateral aspect of the psoas muscle from L2-L5 and (2) the distance between the midpoint of the L5-S1 disc and the medial aspect of the nearest major vessel on the left at L5-S1. In addition, the rostral-caudal location of the iliac bifurcation was measured. Results: The size of the retroperitoneal oblique corridor at L2/3, L3/4, L4/5, and L5/S1 was, respectively, 17.3 ± 6.4 mm, 16.2 ± 6.3 mm, 14.8 ± 7.8 cm, and 13.0 ± 8.3 mm. The incidence of corridor size <1 cm at L2/3, L3/4, L4/5, and L5/S1 was 10.3%, 16.0%, 30.0%, and 39.3%, respectively. The iliac bifurcation was most commonly found behind the L4 vertebral body (n = 158, 52.67%) followed by the L4/5 disc space (n = 74, 24.67%). Conclusion: The size of the retroperitoneal oblique corridor diminishes in a rostral-caudal direction, often limiting access to the L4/5 and L5/S1 disc spaces.
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Affiliation(s)
- Zain Boghani
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - William Iii Steele
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Jonathan J Lee
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Olumide Sokunbi
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - J Bob Blacklock
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Todd Trask
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Paul Holman
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA
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18
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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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19
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Epstein NE. Many Intraoperative Monitoring Modalities Have Been Developed To Limit Injury During Extreme Lateral Interbody Fusion (XLIF/MIS XLIF): Does That Mean XLIF/MIS XLIF Are Unsafe? Surg Neurol Int 2019; 10:233. [PMID: 31893134 PMCID: PMC6911673 DOI: 10.25259/sni_563_2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/26/2022] Open
Abstract
Background: Extreme lateral interbody fusions (XLIF) and Minimally Invasive (MIS) XLIF pose significant risks of neural injury to the; lumbar plexus, ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, and subcostal nerves. To limit these injuries, many intraoperative neural monitoring (IONM) modalities have been proposed. Methods: Multiple studies document various frequencies of neural injuries occurring during MIS XLIF/XLIF: plexus injuries (13.28%); sensory deficits (0-75%; permanent 62.5%); motor deficits (0.7-33.6%; most typically iliopsoas weakness (14.3%-31%)), and anterior thigh/groin pain (12.5-25%.-34%). To avoid/limit these injuries, multiple IONM techniques have been proposed. These include; using finger electrodes during operative dissection, employing motor evoked potentials (MEP), eliminating (no) muscle relaxants (NMR), and using “triggered” EMGs. Results: In one study, finger electrodes for XLIF at L4-L5 level for degenerative spondylolisthesis reduced transient postoperative neurological symptoms from 7 [38%] of 18 cases (e.g. without IONM) to 5 [14%] of 36 cases (with IONM). Two series showed that motor evoked potential monitoring (MEP) for XLIF reduced postoperative motor deficits; they, therefore, recommended their routine use for XLIF. Another study demonstrated that eliminating muscle relaxants during XLIF markedly reduced postoperative neurological deficits/thigh pain by allowing for better continuous EMG monitoring (e.g. NMR no muscle relaxants). Finally, a “triggered” EMG study” reduced postoperative motor neuropraxia, largely by limiting retraction time. Conclusion: Multiple studies have offered different IONM techniques to avert neurological injuries following MIS XLIF/XLIF. Does this mean that these procedures (e.g. XLIF/MIS XLIF) are unsafe?
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook, New York, and Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience/Neurosurgery, Mineola, New York 11501, United States
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20
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Campbell PG, Nunley PD, Cavanaugh D, Kerr E, Utter PA, Frank K, Stone M. Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4-5. Neurosurg Focus 2019; 44:E6. [PMID: 29290128 DOI: 10.3171/2017.10.focus17566] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recently, authors have called into question the utility and complication index of the lateral lumbar interbody fusion procedure at the L4-5 level. Furthermore, the need for direct decompression has also been debated. Here, the authors report the clinical and radiographic outcomes of transpsoas lumbar interbody fusion, relying only on indirect decompression to treat patients with neurogenic claudication secondary to Grade 1 and 2 spondylolisthesis at the L4-5 level. METHODS The authors conducted a retrospective evaluation of 18 consecutive patients with Grade 1 or 2 spondylolisthesis from a prospectively maintained database. All patients underwent a transpsoas approach, followed by posterior percutaneous instrumentation without decompression. The Oswestry Disability Index (ODI) and SF-12 were administered during the clinical evaluations. Radiographic evaluation was also performed. The mean follow-up was 6.2 months. RESULTS Fifteen patients with Grade 1 and 3 patients with Grade 2 spondylolisthesis were identified and underwent fusion at a total of 20 levels. The mean operative time was 165 minutes for the combined anterior and posterior phases of the operation. The estimated blood loss was 113 ml. The most common cage width in the anteroposterior dimension was 22 mm (78%). Anterior thigh dysesthesia was identified on detailed sensory evaluation in 6 of 18 patients (33%); all patients experienced resolution within 6 months postoperatively. No patient had lasting sensory loss or motor deficit. The average ODI score improved 26 points by the 6-month follow-up. At the 6-month follow-up, the SF-12 mean Physical and Mental Component Summary scores improved by 11.9% and 9.6%, respectively. No patient required additional decompression postoperatively. CONCLUSIONS This study offers clinical results to establish lateral lumbar interbody fusion as an effective technique for the treatment of Grade 1 or 2 degenerative spondylolisthesis at L4-5. The use of this surgical approach provides a minimally invasive solution that offers excellent arthrodesis rates as well as favorable clinical and radiological outcomes, with low rates of postoperative complications. However, adhering to the techniques of transpsoas lateral surgery, such as minimal table break, an initial look-and-see approach to the psoas, clear identification of the plexus, minimal cranial caudal expansion of the retractor, mobilization of any traversing sensory nerves, and total psoas dilation times less than 20 minutes, ensures the lowest possible complication profile for both visceral and neural injuries even in the narrow safe zones when accessing the L4-5 disc space in patients with degenerative spondylolisthesis.
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Affiliation(s)
| | | | | | | | | | - Kelly Frank
- 3Clinical Research, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Marcus Stone
- 3Clinical Research, Spine Institute of Louisiana, Shreveport, Louisiana
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21
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Clinical and Radiographic Evaluation of Multilevel Lateral Lumbar Interbody Fusion in Adult Degenerative Scoliosis. Clin Spine Surg 2019; 32:E386-E396. [PMID: 30864972 DOI: 10.1097/bsd.0000000000000812] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective review of prospective data. OBJECTIVE The objective of this study was to describe the clinical, radiographic, and complication-related outcomes through ≥1-year of 27 patients who underwent lateral lumbar interbody fusion (LLIF) with posterior instrumentation to treat ≥3 contiguous levels of degenerative lumbar scoliosis. SUMMARY OF BACKGROUND DATA Multilevel disease has traditionally been treated with open posterior fusion. Literature on multilevel LLIF is limited. We present our experience with utilizing LLIF to treat multilevel degenerative scoliosis. METHODS Clinical outcomes were evaluated using VAS, SF-12, and ODI. Radiographic outcomes included pelvic tilt, pelvic incidence, lumbar lordosis, pelvic incidence-lumbar lordosis mismatch, Cobb angle, and cage subsidence. Perioperative and long-term complications through the ≥1-year final-postoperative visit were reviewed; transient neurological disturbances were assessed independently. Demographic, comorbidity, operative, and recovery variables, including opioid use, were explored for association with primary outcomes. RESULTS Mean time to final-postoperative visit was 22.5 months; levels treated with LLIF per patient, 3.7; age, 66 years; and lateral operative time, 203 minutes. EBL was ≤100 mL in 74% of cases. Clinical outcomes remained significantly improved at ≥1-year. Cobb angle was corrected from 21.1 to 7.9 degrees (P<0.001), lordosis from 47.3 to 52.6 degrees (P<0.001), and mismatch from 11.4 to 6.4 degrees (P=0.003). High-grade subsidence occurred in 3 patients. Subsidence did not significantly impact primary outcomes. In total, 11.1% returned to the operating room for complication-related intervention over nearly 2-years; 37% experienced complications. Experiencing a complication was associated with having an open-posterior portion (P=0.048), but not with number of LLIF levels treated, or with clinical or radiographic outcomes. No patients experienced protracted neurological deficits; psoas weakness was associated with increased lateral operative time (P=0.049) and decreased surgeon experience (P=0.028). CONCLUSIONS Patients who underwent multilevel LLIF with adjunctive posterior surgery had significant clinical and radiographic improvements. Complication rates were similar compared to literature on single-level LLIF. LLIF is a viable treatment for multilevel degenerative scoliosis.
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Nakashima H, Kanemura T, Satake K, Ishikawa Y, Ouchida J, Segi N, Yamaguchi H, Imagama S. Unplanned Second-Stage Decompression for Neurological Deterioration Caused by Central Canal Stenosis after Indirect Lumbar Decompression Surgery. Asian Spine J 2019; 13:584-591. [PMID: 30866617 PMCID: PMC6680044 DOI: 10.31616/asj.2018.0232] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/29/2018] [Indexed: 11/23/2022] Open
Abstract
Study Design Prospective cohort study. Purpose This study aimed to identify risk factors for unplanned second-stage decompression for postoperative neurological deficit after indirect decompression using lateral lumbar interbody fusion (LLIF) with posterior fixation. Overview of Literature Indirect lumbar decompression with LLIF has been used as a minimally invasive alternative to direct decompression to treat degenerative lumbar diseases requiring neural decompression. However, evidence on the prevalence of neurological deficits caused by spinal canal stenosis after indirect decompression is limited. Methods This study included 158 patients (mean age, 71.13±7.98 years; male/female ratio, 67/91) who underwent indirect decompression with LLIF and posterior fixation. Indirect decompression was performed at 271 levels (mean level, 1.71±0.97). Logistic regression analysis was used to identify the risk factors for postoperative neurological deficits. The variables included were age, sex, body mass index, presence of primary diseases, diabetes mellitus, preoperative motor deficit, levels operated on, preoperative severity of lumbar stenosis, and preoperative Japanese Orthopedic Association (JOA) score. Results Postoperative neurological deficit due to spinal canal stenosis occurred in three patients (1.9%). Spinal stenosis due to hemodialysis (p<0.001), ligament ossification (p<0.001), presence of preoperative motor paralysis (p<0.001), low JOA score (p=0.004), and severe canal stenosis (p=0.02) were significantly more frequent in the paralysis group. Conclusions Severe preoperative canal stenosis and neurological deficit were identified as risk factors for postoperative neurological deterioration caused by spinal canal stenosis. Additionally, uncommon diseases, such as spinal stenosis due to hemodialysis and ligament ossification, increased the risk of postoperative neurological deficit; therefore, in such cases, indirect decompression is contraindicated.
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Affiliation(s)
- Hiroaki Nakashima
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Tokumi Kanemura
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Kotaro Satake
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | | | - Jun Ouchida
- Department of Orthopedic Surgery, Konan Kosei Hospital, Konan, Japan
| | - Naoki Segi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetoshi Yamaguchi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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23
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Provaggi E, Capelli C, Leong JJ, Kalaskar DM. A UK-based pilot study of current surgical practice and implant preferences in lumbar fusion surgery. Medicine (Baltimore) 2018; 97:e11169. [PMID: 29952965 PMCID: PMC6039689 DOI: 10.1097/md.0000000000011169] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Lumbar fusion surgery is an established procedure for the treatment of low back pain. Despite the wide set of alternative fusion techniques and existing devices, uniform guidelines are not available yet and common surgical trends are scarcely investigated.The purpose of this UK-based study was to provide a descriptive portrait of current surgeons' practice and implant preferences in lumbar fusion surgery.A UK-based in-person survey was designed for this study and submitted to a group of consultant spinal surgeons (n = 32). Fifteeen queries were addressed based on different aspects of surgeons' practice: lumbar fusion techniques, implant preferences, and bone grafting procedures. Answers were analyzed by means of descriptive statistics.Thirty-two consultant spinal surgeons completed the survey. There was clear consistency on the relevance of a patient-centered management (82.3%), along with a considerable variability of practice on the preferred fusion approach. Fixation surgery was found to be largely adopted (96.0%) and favored over stand-alone cages. With regards to the materials, titanium cages were the most used (54.3%). The geometry of the implants influenced the choice of lumbar cages (81.3%). Specifically, parallel-shape cages were mostly avoided (89.2%) and hyperlordotic cages were preferred at the lower lumbar levels. However, there was no design for lumbar cages which was consistently favored. Autograft bone graft surgeries were the most common (60.0%). Amongst the synthetic options, hydroxyapatite-based bone graft substitutes (76.7%) in injectable paste form (80.8%) were preferred.Current lumbar fusion practice is variable and patient-oriented. Findings from this study highlight the need for large-scale investigative surveys and clinical studies aimed to set specific guidelines for certain pathologies or patient categories.
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Affiliation(s)
- Elena Provaggi
- UCL Institute of Orthopaedics and Musculoskeletal Science
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science
| | - Claudio Capelli
- Institute of Cardiovascular Science, Great Ormond Street Hospital for Children, University College London (UCL), London, United Kingdom
| | - Julian J.H. Leong
- UCL Institute of Orthopaedics and Musculoskeletal Science
- Royal National Orthopedic Hospital, Brockley Hill, Stanmore, Middlesex, United Kingdom
| | - Deepak M. Kalaskar
- UCL Institute of Orthopaedics and Musculoskeletal Science
- Centre for Nanotechnology and Regenerative Medicine, Division of Surgery & Interventional Science
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24
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Miscusi M, Ramieri A, Forcato S, Giuffrè M, Trungu S, Cimatti M, Pesce A, Familiari P, Piazza A, Carnevali C, Costanzo G, Raco A. Comparison of pure lateral and oblique lateral inter-body fusion for treatment of lumbar degenerative disk disease: a multicentric cohort 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 2018; 27:222-228. [PMID: 29671108 DOI: 10.1007/s00586-018-5596-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/11/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The most effective interbody fusion technique for degenerative disk disease (DDD) is still controversial. The purpose of our study is to compare pure lateral (LLIF) and oblique lateral (OLIF) approaches for the treatment of lumbar DDD from L1-L2 to L4-L5, in terms of clinical and radiological outcomes. MATERIALS AND METHODS 45 patients underwent lumbar interbody fusion for pure lumbar DDD from L1-L2 to L4-L5 through LLIF (n = 31, mean age 62.1 years, range 45-78 years) or OLIF (n = 14, mean age 57.4 years, range 47-77 years). Clinical evaluations were performed with ODI and SF-36 tests. Radiological assessment was based on the modification of coronal segmental Cobb angles and segmental lumbar lordosis (L1-S1). RESULTS On ODI and SF-36, all patients presented good results at follow-up, with 26% the difference between the LIF and OLIF groups on ODI scale in the post-operative period, and 3.9 and 8.8 points difference on physical and mental SF-36 in favor of OLIF. Radiological parameters improved significantly in both groups. The mean correction was 6.25° for cCobb (11.3° in LIF and 1.9° in OLIF), 2.5° for sLL (2° in LLIF and 4° in OLIF). CONCLUSIONS LLIF and OLIF represent safe and effective MIS procedures for the treatment of lumbar DDD. LLIF had some risks of motor deficit and monitoring is mandatory, though it addressed more the coronal deformities. OLIF did not imply risks for motor deficits, but attention should be paid to vascular anatomy. It was more effective in kyphotic segmental deformities. These slides can be retrieved under Electronic Supplementary material.
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Affiliation(s)
- Massimo Miscusi
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Alessandro Ramieri
- Don Gnocchi Foundation ONLUS, Milan, Italy.
- Don Gnocchi Foundation, ONLUS, Via M. Caviglia, 30, Rome, Italy.
| | - Stefano Forcato
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza", University of Rome, Rome, Italy
| | - Mary Giuffrè
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Sokol Trungu
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza", University of Rome, Rome, Italy
| | - Marco Cimatti
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza", University of Rome, Rome, Italy
| | - Alessandro Pesce
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza", University of Rome, Rome, Italy
| | - Pietro Familiari
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza", University of Rome, Rome, Italy
| | - Amedeo Piazza
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Cristina Carnevali
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | | | - Antonino Raco
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza", University of Rome, Rome, Italy
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25
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Quillo-Olvera J, Lin GX, Jo HJ, Kim JS. Complications on minimally invasive oblique lumbar interbody fusion at L2-L5 levels: a review of the literature and surgical strategies. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:101. [PMID: 29707550 DOI: 10.21037/atm.2018.01.22] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fusion is the cornerstone in the treatment of an unstable degenerative lumbar spinal disease. Various techniques have been developed. Amongst these techniques exists the oblique lumbar interbody fusion (OLIF), which is the ante-psoas approach. Adequate restoration of disc height with large cages placed in the intervertebral space, indirect decompression, and correction of sagittal and coronal alignment can be achieved with OLIF procedure with the advantage of minimal risk for the psoas muscle and lumbar plexus. Nevertheless, this technique entails complications directly associated with the anatomical location where the fusion takes place. This surgical area is a window between the left lateral border of the aorta, or the left common iliac artery, and the anterior belly of the left psoas muscle. Vascular complications associated with the injury of the main vessels, segmental artery or iliolumbar vein of the lumbar spine have been reported, as well as urologic lesions due to ureter transgression, amongst others. Although these complications have been described in the literature, an article that complements this information with technical advice for its avoidance is yet to be published. This article is a review of the most frequent complications associated with the OLIF procedure in L2-L5 lumbar levels, as well as a description of technical strategies for the prevention of such complications.
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Affiliation(s)
- Javier Quillo-Olvera
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Guang-Xun Lin
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyun-Jin Jo
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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