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Dias Pereira Filho AR, Baptista VS, Valadares Bertolini Mussalem MG, Frota Carneiro Júnior FC, de Meldau Benites V, Desideri AV, Uehara MK, Colaço Aguiar NR, Baston AC. Analysis of the Frequency of Intraoperative Complications in Anterior Lumbar Interbody Fusion: A Systematic Review. World Neurosurg 2024; 184:165-174. [PMID: 38266992 DOI: 10.1016/j.wneu.2024.01.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE We assessed the frequency of intraoperative complication rates related to access surgery, operating time, and intraoperative bleeding rates described in the literature for patients undergoing anterior lumbar interbody fusion (ALIF) to evaluate the adverse effects and, thus, help in therapeutic decision making and contribute to future clinical trials. METHODS A systematic review was conducted of MEDLINE and Embase databases in March 2023. The main inclusion criteria were adult patients aged >18 years, with no maximum age limit; the use of ALIF; the presence of quantitative data on intraoperative complications; and randomized controlled trials and cohort studies. Vascular and peritoneal injuries were considered primary endpoints. The operative time and intraoperative bleeding rate were secondary endpoints. Reports and case series, case-control series, systematic reviews, and meta-analyses were excluded. RESULTS Eight studies were included with a total of 2395 patients. We found important quantitative data for future randomized clinical studies involving ALIF surgery, including the rate of vascular lesions (2.79%) and peritoneal lesions (0.37%). In addition to these factors, only 4 of the 8 studies addressed the average surgery time, with a total average of 145.61 minutes. Furthermore, 6 of the 8 articles reported the mean rate of intraoperative bleeding, with a total mean blood loss of 272.75 mL. CONCLUSIONS ALIF is a lumbar spine access technique with low intraoperative complications. Patients with contraindications have a higher risk of complications. Randomized clinical trials are needed to assess the efficacy and safety of the procedure.
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Affiliation(s)
| | - Vinicius Santos Baptista
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | | | | | - Vinicius de Meldau Benites
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
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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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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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Zheng B, Leary OP, Liu DD, Nuss S, Barrios-Anderson A, Darveau S, Syed S, Gokaslan ZL, Telfeian AE, Fridley JS, Oyelese AA. Radiographic analysis of neuroforaminal and central canal decompression following lateral lumbar interbody fusion. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 10:100110. [PMID: 35345481 PMCID: PMC8957056 DOI: 10.1016/j.xnsj.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/28/2022] [Indexed: 11/20/2022]
Abstract
Background Lateral lumbar interbody fusion (LLIF) is a minimally invasive surgical option for treating symptomatic degenerative lumbar spinal stenosis (DLSS) in select patients. However, the efficacy of LLIF for indirectly decompressing the lumbar spine in DLSS, as well as the best radiographic metrics for evaluating such changes, are incompletely understood. Methods A single-institutional cohort of patients who underwent LLIF for DLSS between 5/2015 – 12/2019 was retrospectively reviewed. Diameter, area, and stenosis grades were measured for the central canal (CC) and neural foramina (NF) at each LLIF level based on preoperative and postoperative T2-weighted MRI. Baseline facet joint (FJ) space, degree of FJ osteoarthritis, presence of spondylolisthesis, interbody graft position, and posterior disc height were analyzed as potential predictors of radiographic outcomes. Changes to all metrics after LLIF were analyzed and compared across lumbar levels. Preoperative and intraoperative predictors of decompression were then assessed using multivariate linear regression. Results A total of 102 patients comprising 153 fused levels were analyzed. Pairwise linear regression of stenosis grade to diameter and area revealed significant correlations for both the CC and NF. All metrics except CC area were significantly improved after LLIF (p < 0.05, 2-tailed t-test). Worse FJ osteoarthritis ipsilateral to the surgical approach was predictive of greater post-operative CC and NF stenosis grade (p < 0.05, univariate and multivariate ordinary least squares linear regression). Lumbar levels L3-5 had significantly higher absolute postoperative CC stenosis grades while relative change in CC stenosis at the L2-3 was significantly greater than other lumbar levels (p < 0.05, one-way ANOVA). There were no baseline or postoperative differences in NF stenosis grade across lumbar levels. Conclusions Radiographically, LLIF is effective at indirect compression of the CC and NF at all lumbar levels, though worse FJ osteoarthritis predicted higher degrees of post-operative stenosis.
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Griffith MS, Shaw KA, Burke BK, Jackson KL, Gloystein DM. Post-operative radiculitis following one or two level anterior lumbar surgery with or without posterior instrumentation. J Orthop 2021; 25:45-52. [PMID: 33927508 DOI: 10.1016/j.jor.2021.03.023] [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: 02/09/2021] [Accepted: 03/28/2021] [Indexed: 11/27/2022] Open
Abstract
The purpose of this study was to define risk factors for non-compression radiculitis following anterior lumbar surgery with or without posterior instrumentation and to define a time to resolution. In this study, we followed 58 consecutive patients who had anterior lumbar surgery with or without posterior instrumentation. We identified those with and without post-operative radiculitis. There as a 36.5% rate of postoperative radiculitis. We found that there was a moderate to strong correlation with height change and radiculitis (p = 0.044). Additionally patients treated with rh-BMP2 had a higher risk of developing symptoms. In all of the patients who developed postoperative radiculitis, symptoms resolved by 3 months. In conclusion 36.5% of patients developed post operative radiculitis. This was associated with the use of rh-BMP2, as well as increasing disc height through surgery. All symptoms resolved by 3 months posoperatively.
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Affiliation(s)
- Matthew S Griffith
- Winn Army Community Hospital, Fort Stewart, Georgia.,Department of Orthopaedic Surgery, Georgia
| | - K Aaron Shaw
- Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
| | - Brian K Burke
- Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
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Lee DH, Lee DG, Hwang JS, Jang JW, Maeng DH, Park CK. Clinical and radiological results of indirect decompression after anterior lumbar interbody fusion in central spinal canal stenosis. J Neurosurg Spine 2021; 34:564-572. [PMID: 33450734 DOI: 10.3171/2020.7.spine191335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 07/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Whereas the benefits of indirect decompression after lateral lumbar interbody fusion are well known, the effects of anterior lumbar interbody fusion (ALIF) have not yet been verified. The purpose of this study was to evaluate the clinical and radiological effects of indirect decompression after ALIF for central spinal canal stenosis. In this report, along with the many advantages of the anterior approach, the authors share cases with good outcomes that they have encountered. METHODS The authors performed a retrospective analysis of 64 consecutive patients who underwent ALIF for central spinal canal stenosis with instability and mixed foraminal stenosis between January 2015 and December 2018 at their hospital. Clinical assessments were performed using the visual analog scale score, the Oswestry Disability Index, and the modified Macnab criteria. The radiographic parameters were determined from pre- and postoperative cross-sectional MRI scans of the spinal canal and were compared to evaluate neural decompression after ALIF. The average follow-up period was 23.3 ± 1.3 months. RESULTS All clinical parameters, including the visual analog scale score, Oswestry Disability Index, and modified Macnab criteria, improved significantly. The mean operative duration was 254.8 ± 60.8 minutes, and the intraoperative bleeding volume was 179.8 ± 119.3 ml. In the radiological evaluation, radiological parameters of the cross-sections of the spinal canal showed substantial development. The spinal canal size improved by an average of 43.3% (p < 0.001) after surgery. No major complications occurred; however, aspiration guided by ultrasonography was performed in 2 patients because of a pseudocyst and fluid collection. CONCLUSIONS ALIF can serve as a suitable alternative to extensive posterior approaches. The authors suggest that ALIF can be used for decompression in central spinal canal stenosis as well as restoration of the foraminal dimensions, thus allowing decompression of the nerve roots.
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Affiliation(s)
- Dong Hyun Lee
- 1Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital; and
| | - Dong-Geun Lee
- 1Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital; and
| | - Jin Sub Hwang
- 1Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital; and
| | - Jae-Won Jang
- 1Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital; and
| | - Dae Hyeon Maeng
- 2Department of Cardiovascular Surgery, The Leon Wiltse Memorial Hospital, Suwon, Gyeonggi-do, South Korea
| | - Choon Keun Park
- 1Department of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital; and
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Li HM, Zhang RJ, Shen CL. Differences in radiographic and clinical outcomes of oblique lateral interbody fusion and lateral lumbar interbody fusion for degenerative lumbar disease: a meta-analysis. BMC Musculoskelet Disord 2019; 20:582. [PMID: 31801508 PMCID: PMC6894220 DOI: 10.1186/s12891-019-2972-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 11/26/2019] [Indexed: 12/26/2022] Open
Abstract
Background In the current surgical therapeutic regimen for the degenerative lumbar disease, both oblique lateral interbody fusion (OLIF) and lateral lumbar interbody fusion (LLIF) are gradually accepted. Thus, the objective of this study is to compare the radiographic and clinical outcomes of OLIF and LLIF for the degenerative lumbar disease. Methods We conducted an exhaustive literature search of MEDLINE, EMBASE, and the Cochrane Library to find the relevant studies about OLIF and LLIF for the degenerative lumbar disease. Random-effects model was performed to pool the outcomes about disc height (DH), fusion, operative blood loss, operative time, length of hospital stays, complications, visual analog scale (VAS), and Oswestry disability index (ODI). Results 56 studies were included in this study. The two groups of patients had similar changes in terms of DH, operative blood loss, operative time, hospital stay and the fusion rate (over 90%). The OLIF group showed slightly better VAS and ODI scores improvement. The incidence of perioperative complications of OLIF and LLIF was 26.7 and 27.8% respectively. Higher rates of nerve injury and psoas weakness (21.2%) were reported for LLIF, while higher rates of cage subsidence (5.1%), endplate damage (5.2%) and vascular injury (1.7%) were reported for OLIF. Conclusions The two groups are similar in terms of radiographic outcomes, operative blood loss, operative time and the length of hospital stay. The OLIF group shows advantages in VAS and ODI scores improvement. Though the incidence of perioperative complications of OLIF and LLIF is similar, the incidence of main complications is significantly different.
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Affiliation(s)
- Hui-Min Li
- Department of Orthopedics & Spine Surgery, the First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China
| | - Ren-Jie Zhang
- Department of Orthopedics & Spine Surgery, the First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China
| | - Cai-Liang Shen
- Department of Orthopedics & Spine Surgery, the First Affiliated Hospital of Anhui Medical University, 210 Jixi Road, Hefei, 230022, Anhui, China.
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Yilmaz E, von Glinski A, Ishak B, Abdul-Jabbar A, Blecher R, O'Lynnger T, Alonso F, Benca E, Chapman JR, Oskouian RJ. Outcome After Extreme Lateral Transpsoas Approach: Corpectomies Versus Interbody Fusion. World Neurosurg 2019; 131:e170-e175. [PMID: 31330334 DOI: 10.1016/j.wneu.2019.07.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The lateral transpsoas approach (LTPA) has gained popularity in thoracolumbar spine surgery procedures; however, there is an insufficient amount of data pertaining to motor and sensory complications that arise when a corpectomy is performed through the LTPA approach. METHODS Patients who underwent a corpectomy through a LTPA at a single institution between 2006 and 2016 were analyzed. Demographics, neurological outcomes, and complications were recorded. The minimum follow-up was 6 months. Univariate analysis was performed to compare demographics, surgical characteristics, complications, and outcome scores. To compare categorical variables, the χ2 test was used. For continuous outcomes, simple linear regression was used. Statistical significance was set at P < 0.05. RESULTS A total of 166 patients were included. The patients were divided into 2 groups; LTPA without corpectomy (n = 112) versus LTPA with corpectomy (n = 54). Patients without corpectomy showed a significantly lower rate of postoperative infections compared with patients with corpectomy (3.6% vs. 22.2%; P < 0.000). A higher percentage of postoperative complications was found in patients with corpectomy (31.5% vs. 13.4%; P = 0.006). The rate of neurologic complications at the 6-month follow-up and the reoperation rate (22.7% vs. 32.4%; P = 0.256) were higher in the corpectomy group (8.9% vs. 7.4%; P = 0.741), no significant difference was found between the groups. CONCLUSION Patients who underwent an LTPA corpectomy have a higher risk to suffer from postoperative complications. The results at the 6-month follow-up did not significantly differ between the groups.
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Affiliation(s)
- Emre Yilmaz
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA; Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, Bochum, Germany
| | - Alexander von Glinski
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA; Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, Bochum, Germany; Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, USA.
| | - Basem Ishak
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA; Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Amir Abdul-Jabbar
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Ronan Blecher
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Thomas O'Lynnger
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Fernando Alonso
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Eric Benca
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA; Seattle Science Foundation, Seattle, Washington, USA
| | - Jens R Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Rod J Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
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The Effects of Preoperative Steroid Therapy on Perioperative Complications After Elective Anterior Lumbar Fusion. World Neurosurg 2019; 126:e314-e322. [DOI: 10.1016/j.wneu.2019.02.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 01/10/2023]
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Goodnough LH, Koltsov J, Wang T, Xiong G, Nathan K, Cheng I. Decreased estimated blood loss in lateral trans-psoas versus anterior approach to lumbar interbody fusion for degenerative spondylolisthesis. JOURNAL OF SPINE SURGERY 2019; 5:185-193. [PMID: 31380471 DOI: 10.21037/jss.2019.05.08] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The goal of the current study was to compare the perioperative and post-operative outcomes of eXtreme lateral trans-psoas approach (XLIF) versus anterior lumbar interbody fusion (ALIF) for single level degenerative spondylolisthesis. The ideal approach for degenerative spondylolisthesis remains controversial. Methods Consecutive patients undergoing single level XLIF (n=21) or ALIF (n=54) for L4-5 degenerative spondylolisthesis between 2008-2012 from a single academic center were retrospectively reviewed. Groups were compared for peri-operative data (estimated blood loss, operative time, adjunct procedures or additional implants), radiographic measurements (L1-S1 cobb angle, disc height, fusion grade, subsidence), 30-day complications (infection, DVT/PE, weakness/paresthesia, etc.), and patient reported outcomes (leg and back Numerical Rating Scale, and Oswestry Disability Index). Results Estimated blood loss was significantly lower for XLIF [median 100; interquartile range (IQR), 50-100 mL] than for ALIF (median 250; IQR, 150-400 mL; P<0.001), including after adjusting for significantly higher rates of posterior decompression in the ALIF group. There were no significant differences in rates of complications within 30 days, radiographic outcomes, or in re-operation rates. Both groups experienced significant pain relief post-operatively. Conclusions The lateral trans-psoas approach is associated with diminished blood loss compared to the anterior approach in the treatment of degenerative spondylolisthesis. We were unable to detect differences in radiographic outcomes, complication rates, or patient reported outcomes. Continued efforts to directly compare approaches for specific indications will minimize complications and improve outcomes. Further studies will continue to define indications for lateral versus anterior approach to lumbar spine for degenerative spondylolisthesis.
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Affiliation(s)
- L Henry Goodnough
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Jayme Koltsov
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Tianyi Wang
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Grace Xiong
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Karthik Nathan
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
| | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA
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Bronheim RS, Cheung ZB, Phan K, White SJW, Kim JS, Cho SK. Anterior Lumbar Fusion: Differences in Patient Selection and Surgical Outcomes Between Neurosurgeons and Orthopaedic Surgeons. World Neurosurg 2018; 120:e221-e226. [PMID: 30121412 DOI: 10.1016/j.wneu.2018.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/04/2018] [Accepted: 08/06/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Anterior lumbar fusion (ALF) is performed by both neurosurgeons and orthopaedic surgeons. The aim of this study was to determine differences between the 2 surgical subspecialties in terms of patient selection and postoperative outcomes after ALF. METHODS A retrospective cohort study of adult patients undergoing ALF in the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014 was performed. Univariate analyses were performed to identify differences in baseline patient demographics, comorbidities, operative characteristics, and 30-day postoperative outcomes between neurosurgery and orthopaedic surgery patients. Multivariate logistic regression analysis was used to determine whether surgical subspecialty was an independent risk factor for postoperative complications. RESULTS The study included 3182 patients, with 1629 (51.2%) neurosurgery patients and 1553 (48.8%) orthopaedic surgery patients. A greater proportion of neurosurgery patients were >65 years old, were being treated with preoperative steroids, had cardiac or pulmonary comorbidities, and had an American Society of Anesthesiologists classification III or higher. ALF procedures performed by neurosurgeons more frequently involved use of intervertebral devices and bone graft. On multivariate logistic regression analysis, ALF procedures performed by neurosurgeons were independently associated with a higher risk of reoperation (odds ratio = 1.61; 95% confidence interval, 1.02-2.56; P = 0.042) and urinary tract infection (odds ratio = 1.94; 95% confidence interval, 1.02-3.68; P = 0.043). CONCLUSIONS In addition to differences in baseline patient demographics and comorbidities and operative characteristics, ALF performed by neurosurgeons had a higher risk of 30-day reoperation and urinary tract infection compared with ALF performed by orthopaedic surgeons.
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Affiliation(s)
- Rachel S Bronheim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kevin Phan
- NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, Australia; Department of Neurosurgery, Prince of Wales Hospital, Randwick, Sydney, Australia
| | - Samuel J W White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Dufault CA. Patient Care During Minimally Invasive Lateral Spine Surgery: 1.7 www.aornjournal.org/content/cme. AORN J 2018; 108:127-139. [PMID: 30117551 DOI: 10.1002/aorn.12303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Perioperative nurses care for patients undergoing a wide range of surgical procedures. One fast-growing surgical specialty is spine surgery performed using minimally invasive techniques. Patients may be candidates for minimally invasive spine surgery based on their presenting signs and symptoms and medical imaging test results. Open anterior and posterior surgical approaches to spine surgery are how surgeons traditionally have performed these procedures. However, new technology has enabled a minimally invasive lateral approach to the spine. This approach minimizes many of the risks and challenges associated with both the anterior and posterior approaches. Minimally invasive lateral interbody fusion requires the perioperative nurse to have a thorough understanding of the necessary patient positioning, spinal anatomy, and OR suite setup to ensure a safe and successful surgical experience for the patient.
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Derman PB, Albert TJ. Interbody Fusion Techniques in the Surgical Management of Degenerative Lumbar Spondylolisthesis. Curr Rev Musculoskelet Med 2017; 10:530-538. [PMID: 29076042 PMCID: PMC5685965 DOI: 10.1007/s12178-017-9443-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The various lumbar interbody fusion (IBF) techniques and the evidence for their use in the treatment of degenerative lumbar spondylolisthesis (DLS) are described in this review. RECENT FINDINGS The existing evidence is mixed regarding the indications for and utility of IBF in DLS, but its use in the setting of pre-operative instability is most strongly supported. Anterior (ALIF), lateral (LLIF), posterior (PLIF), transforaminal (TLIF), and axial (AxiaLIF) lumbar IBF approaches have been described. While the current data are limited, TLIF may be a better option than PLIF in DLS due the increased operative morbidity and peri-operative complications observed with the latter. LLIF also appears superior to PLIF in light of improved radiologic outcomes, fewer intra-operative complications, and potentially greater improvements in disability. The data comparing LLIF to TLIF are less conclusive. No studies specifically comparing ALIF or AxiaLIF to other IBF techniques could be identified. Instability may be the strongest indication for IBF in DLS. When IBF is employed, the authors' preferred technique is TLIF with posterior segmental spinal instrumentation. Further research is needed.
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Affiliation(s)
- Peter B Derman
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL, 60612, USA
| | - Todd J Albert
- Hospital for Special Surgery, 535 East 71st St., New York, NY, 10021, USA.
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Bronheim RS, Kim JS, Di Capua J, Lee NJ, Kothari P, Somani S, Phan K, Cho SK. High-Risk Subgroup Membership Is a Predictor of 30-Day Morbidity Following Anterior Lumbar Fusion. Global Spine J 2017; 7:762-769. [PMID: 29238640 PMCID: PMC5721989 DOI: 10.1177/2192568217696691] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine if membership in a high-risk subgroup is predictive of morbidity and mortality following anterior lumbar fusion (ALF). METHODS The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify patients undergoing ALF between 2010 and 2014. Multivariate analysis was utilized to identify high-risk subgroup membership as an independent predictor of postoperative complications. RESULTS Members of the elderly (≥65 years) (OR = 1.3, P = .02) and non-Caucasian (black, Hispanic, other) (OR = 1.7, P < .0001) subgroups were at greater risk for a LOS ≥5 days. Obese patients (≥30 kg/m2 ) were at greater risk for an operative time ≥4 hours (OR = 1.3, P = .005), and wound complications (OR = 1.8, P = .024) compared with nonobese patients. Emergent procedures had a significantly increased risk for LOS ≥5 days (OR = 4.9, P = .021), sepsis (OR = 14.8, P = .018), and reoperation (OR = 13.4, P < .0001) compared with nonemergent procedures. Disseminated cancer was an independent risk factor for operative time ≥4 hours (OR = 8.4, P < .0001), LOS ≥5 days (OR = 15.2, P < .0001), pulmonary complications (OR = 7.4, P = .019), and postoperative blood transfusion (OR = 3.1, P = .040). CONCLUSIONS High-risk subgroup membership is an independent risk factor for morbidity following ALF. These groups should be targets for aggressive preoperative optimization, and quality improvement initiatives.
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Affiliation(s)
| | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Di Capua
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathan J. Lee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parth Kothari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Kevin Phan
- Prince of Wales Private Hospital, Sydney, Australia,University of New South Wales, Sydney, Australia
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1188, New York, NY 10029, USA.
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Hijji FY, Narain AS, Bohl DD, Ahn J, Long WW, DiBattista JV, Kudaravalli KT, Singh K. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J 2017; 17:1412-1419. [PMID: 28456671 DOI: 10.1016/j.spinee.2017.04.022] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 02/24/2017] [Accepted: 04/21/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lateral lumbar interbody fusion (LLIF) is a frequently used technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach. PURPOSE To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF. STUDY DESIGN Systematic review. PATIENT SAMPLE 6,819 patients who underwent LLIF reported in clinical studies through June 2016. OUTCOME MEASURES Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and spine (MSK) categories. METHODS This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and MSK categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work. RESULTS A total of 2,232 articles were identified. Following screening of title, abstract, and full-text availability, 63 articles were included in the review. A total of 6,819 patients had 11,325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval [CI]=1.00%-1.85%), cardiac (1.86%; CI=1.33%-2.52%), vascular (0.81%; CI=0.44%-1.36%), pulmonary (1.47; CI=0.95%-2.16%), gastrointestinal (1.38%; CI=1.00%-1.87%), urologic (0.93%; CI=0.55%-1.47%), transient neurologic (36.07%; CI=34.74%-37.41%), persistent neurologic (3.98%; CI=3.42%-4.60%), and MSK or spine (9.22%; CI=8.28%-10.23%). CONCLUSIONS The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks to and expectations for patients following LLIF procedures.
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Affiliation(s)
- Fady Y Hijji
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Ankur S Narain
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - William W Long
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Jacob V DiBattista
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Krishna T Kudaravalli
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite #300, Chicago, IL 60612, USA.
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Cheah J, Zhang AL, Tay B. Intraoperative Use of Neuromonitoring in Multilevel Thoracolumbar Spine Instrumentation and the Effects on Postoperative Neurological Injuries. Clin Spine Surg 2017; 30:321-327. [PMID: 27404856 DOI: 10.1097/bsd.0000000000000420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective cohort analysis of a national database between 2005 and 2011. OBJECTIVE To investigate the current usage of neuromonitoring in patients undergoing multilevel thoracolumbar spine surgery. We hypothesize that the use of neuromonitoring would be associated with a reduced incidence of postoperative neurological injuries. SUMMARY OF BACKGROUND DATA Intraoperative neuromonitoring is a common technique utilized in spine surgery to improve safety and reduce neurological injuries. However, the literature remains unclear in defining the populations that benefit from the use of neuromonitoring. METHODS The PearlDiver Medicare database was queried to identify patients undergoing multilevel thoracolumbar spine instrumentation (defined as >3 thoracolumbar levels) from 2005 to 2011. The use of neuromonitoring was identified by Current Procedural Terminology codes. Neurological injuries were identified by codes from the International Classification of Diseases, Ninth Revision. RESULTS Within 15,032 patients, the postoperative rate of neurological injury diagnosis was higher when neuromonitoring was used at both 1 week (1.3% vs. 1.0%, P=0.06) and 6 months (5.9% vs. 4.6%, P=0.0005). However, a lower incidence of neurological injury was associated with neuromonitoring in patients undergoing specifically anterior fusion of 4-7 levels, posterior fusion of 7-12 levels, and in adults below 65 years old (P=0.0266, 0.0458, 0.032). CONCLUSION Within the total Medicare cohort, the use of neuromonitoring was not associated with a decreased rate of neurological injury in multilevel thoracolumbar instrumentation procedures. This is likely due to the possible selection and detection bias of utilizing neuromonitoring when there is an increased risk of neurological injury based on patient-specific pathology and/or surgical procedure. However, despite the overall potential bias, it was appreciated that in subgroups: age below 65 years old, anterior fusion of 4-7 segments, and posterior fusion of 7-12 segments, there was a statistically significant reduction in the incidence of neurological injuries with neuromonitoring. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jonathan Cheah
- Departments of *Orthopedic Surgery †Anesthesia and Perioperative Care, San Francisco Medical Center, University of California, San Francisco, CA
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Blizzard DJ, Gallizzi MA, Isaacs RE, Brown CR. Renal artery injury during lateral transpsoas interbody fusion: case report. J Neurosurg Spine 2016; 25:464-466. [DOI: 10.3171/2016.2.spine15785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lateral interbody fusion (LIF) via the retroperitoneal transpsoas approach is an increasingly popular, minimally invasive technique for interbody fusion in the thoracolumbar spine that avoids many of the complications of traditional anterior and transforaminal approaches. Renal vascular injury has been cited as a potential risk in LIF, but little has been documented in the literature regarding the etiology of this injury. The authors discuss a case of an intraoperative complication of renal artery injury during LIF. A 42-year-old woman underwent staged T12–L5 LIF in the left lateral decubitus position, and L5–S1 anterior lumbar interbody fusion, followed 3 days later by T12–S1 posterior instrumentation for idiopathic scoliosis with radiculopathy refractory to conservative management. After placement of the T12–L1 cage, the retractor was released and significant bleeding was encountered during its removal. Immediate consultation with the vascular team was obtained, and hemostasis was achieved with vascular clips. The patient was stabilized, and the remainder of the procedure was performed without complication. On postoperative CT imaging, the patient was found to have a supernumerary left renal artery with complete occlusion of the superior left renal artery, causing infarction of approximately 75% of the kidney. There was no increase in creatinine level immediately postoperatively or at the 3-month follow-up. Renal visceral and vascular injuries are known risks with LIF, with potentially devastating consequences. The retroperitoneal transpsoas approach for LIF in the superior lumbar spine requires a thorough knowledge of renal visceral and vascular anatomy. Supernumerary renal arteries occur in 25%–40% of the population and occur most frequently on the left and superior to the usual renal artery trunk. These arteries can vary in number, position, and course from the aorta and position relative to the usual renal artery trunk. Understanding of renal anatomy and the potential variability of the renal vasculature is essential to prevent iatrogenic injury.
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Affiliation(s)
| | | | - Robert E. Isaacs
- 2Division of Neurological Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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18
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Epstein NE. High neurological complication rates for extreme lateral lumbar interbody fusion and related techniques: A review of safety concerns. Surg Neurol Int 2016; 7:S652-S655. [PMID: 27843679 PMCID: PMC5054635 DOI: 10.4103/2152-7806.191070] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 06/14/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There are frequent reports of lumbosacral plexus and other neurological injuries occurring with extreme lateral interbody fusions (XLIF) and other related lateral lumbar techniques. METHODS This review focuses on the new neurological deficits (e.g. lumbosacral plexus, root injuries) that occur following minimally invasive surgery (MIS) XLIF and other related lateral lumbar techniques. RESULTS A review of multiple articles revealed the following ranges of new postoperative neurological complications for XLIF procedures: plexus injuries 13.28%; sensory deficits 0-75% (permanent in 62.5%); motor deficits 0.7-33.6%; anterior thigh pain 12.5-25%. Of interest, in a study by Lykissas et al., the frequency of long-term neural injury following lateral lumber interbody fusion (LLIF) with BMP-2 (72 patients) was much higher than for LLIF performed with autograft/allograft (72 patients). The addition of bone morphogenetic protein led to persistent sensory deficits in 29 vs. 20 without BMP; persistent motor deficits in 35 with vs. 17 without BMP; and persistent anterior thigh/groin pain in 8 with vs. 0 without BMP. They should also have noted the unacceptably high incidence of neural injury occurring with LLIF alone without BMP. CONCLUSION This review highlights the high risk of neural injury (up to 75% for sensory, 33.6% for motor, and an overall plexus injury rate of 13.28%) utilizing the XLIF and other similar lateral lumbar approaches. With such extensive neurological injuries, is the XLIF really safe, and should it still be performed?
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Affiliation(s)
- Nancy E Epstein
- Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
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19
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Vasiliadis HS, Teuscher R, Kleinschmidt M, Marrè S, Heini P. Temporary liver and stomach necrosis after lateral approach for interbody fusion and deformity correction of lumbar spine: report of two cases and review of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25 Suppl 1:257-66. [DOI: 10.1007/s00586-016-4562-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/31/2016] [Accepted: 04/01/2016] [Indexed: 12/01/2022]
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20
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Winder MJ, Gambhir S. Comparison of ALIF vs. XLIF for L4/5 interbody fusion: pros, cons, and literature review. JOURNAL OF SPINE SURGERY (HONG KONG) 2016; 2:2-8. [PMID: 27683688 PMCID: PMC5039845 DOI: 10.21037/jss.2015.12.01] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 12/15/2015] [Indexed: 11/06/2022]
Abstract
The incidence of lumbar fusion for the treatment of various degenerative lumbar spine diseases has increased dramatically over the last twenty years. Many lumbar fusion techniques have been developed and popularized, each with its own advantages and disadvantages. Anterior lumbar interbody fusion (ALIF) initially introduced in the 1930's, has become a common and widely accepted technique for lumbar fusions over the last decade offering several advantages over standard posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF). More recently, the lateral trans-psoas approach termed extreme, direct or lateral lumbar interbody fusion (XLIF, DLIF, LLIF) is gaining widespread popularity. The aim of this paper is to compare the approaches, advantages and disadvantages of ALIF and XLIF for L4/5 interbody fusion based on relevant literature.
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Affiliation(s)
- Mark J Winder
- St Vincent's Public and Private Hospitals, Sydney, Australia
| | - Shanu Gambhir
- St Vincent's Public and Private Hospitals, Sydney, Australia
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21
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Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery: Let's tell someone. Surg Neurol Int 2016; 7:S96-S101. [PMID: 26904373 PMCID: PMC4743264 DOI: 10.4103/2152-7806.174896] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 01/23/2023] Open
Abstract
Background: In a recent study entitled: “More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion (XLIF): A review”, Epstein documented that more nerve root injuries occurred utilizing minimally invasive surgery (MIS) versus open lumbar surgery for diskectomy, decompression of stenosis (laminectomy), and/or fusion for instability. Methods: In large multicenter Spine Patient Outcomes Research Trial reviews performed by Desai et al., nerve root injury with open diskectomy occurred in 0.13–0.25% of cases, occurred in 0% of laminectomy/stenosis with/without fusion cases, and just 2% for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion. Results: In another MIS series performed largely for disc disease (often contained nonsurgical disc herniations, therefore unnecessary procedures) or spondylolisthesis, the risk of root injury was 2% for transforaminal lumbar interbody fusion (TLIF) versus 7.8% for posterior lumbar interbody fusion (PLIF). Furthermore, the high frequencies of radiculitis/nerve root/plexus injuries incurring during anterior lumbar interbody fusions (ALIF: 15.8%) versus extreme lumbar interbody fusions (XLIF: 23.8%), addressing disc disease, failed back surgery, and spondylolisthesis, were far from acceptable. Conclusions: The incidence of nerve root injuries following any of the multiple MIS lumbar surgical techniques (TLIF/PLIF/ALIF/XLIF) resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques. Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients?
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Affiliation(s)
- Nancy E Epstein
- Department of Winthrop NeuroScience, Winthrop University Hospital, Mineola, New York, USA
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Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: A review. Surg Neurol Int 2016; 7:S83-95. [PMID: 26904372 PMCID: PMC4743267 DOI: 10.4103/2152-7806.174895] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/02/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In the lumbar spine, do more nerve root injuries occur utilizing minimally invasive surgery (MIS) techniques versus open lumbar procedures? To answer this question, we compared the frequency of nerve root injuries for multiple open versus MIS operations including diskectomy, laminectomy with/without fusion addressing degenerative disc disease, stenosis, and/or degenerative spondylolisthesis. METHODS Several of Desai et al. large Spine Patient Outcomes Research Trial studies showed the frequency for nerve root injury following an open diskectomy ranged from 0.13% to 0.25%, for open laminectomy/stenosis with/without fusion it was 0%, and for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion it was 2%. RESULTS Alternatively, one study compared the incidence of root injuries utilizing MIS transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) techniques; 7.8% of PLIF versus 2% of TLIF patients sustained root injuries. Furthermore, even higher frequencies of radiculitis and nerve root injuries occurred during anterior lumbar interbody fusions (ALIFs) versus extreme lateral interbody fusions (XLIFs). These high frequencies were far from acceptable; 15.8% following ALIF experienced postoperative radiculitis, while 23.8% undergoing XLIF sustained root/plexus deficits. CONCLUSIONS This review indicates that MIS (TLIF/PLIF/ALIF/XLIF) lumbar surgery resulted in a higher incidence of root injuries, radiculitis, or plexopathy versus open lumbar surgical techniques. Furthermore, even a cursory look at the XLIF data demonstrated the greater danger posed to neural tissue by this newest addition to the MIS lumbar surgical armamentariu. The latter should prompt us as spine surgeons to question why the XLIF procedure is still being offered to our patients?
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Affiliation(s)
- Nancy E Epstein
- Department of Neurousrgery, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
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Skovrlj B, Belton P, Zarzour H, Qureshi SA. Perioperative outcomes in minimally invasive lumbar spine surgery: A systematic review. World J Orthop 2015; 6:996-1005. [PMID: 26716097 PMCID: PMC4686448 DOI: 10.5312/wjo.v6.i11.996] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 07/21/2015] [Accepted: 08/04/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To compare minimally invasive (MIS) and open techniques for MIS lumbar laminectomy, direct lateral and transforaminal lumbar interbody fusion (TLIF) surgeries with respect to length of surgery, estimated blood loss (EBL), neurologic complications, perioperative transfusion, postoperative pain, postoperative narcotic use, and length of stay (LOS). METHODS A systematic review of previously published studies accessible through PubMed was performed. Only articles in English journals or published with English language translations were included. Level of evidence of the selected articles was assessed. Statistical data was calculated with analysis of variance with P < 0.05 considered statistically significant. RESULTS A total of 11 pertinent laminectomy studies, 20 direct lateral studies, and 27 TLIF studies were found. For laminectomy, MIS techniques resulted in a significantly longer length of surgery (177.5 min vs 129.0 min, P = 0.04), shorter LOS (4.3 d vs 5.3 d, P = 0.01) and less perioperative pain (visual analog scale: 16 ± 17 vs 34 ± 31, P = 0.04). There is evidence of decreased narcotic use for MIS patients (postoperative intravenous morphine use: 9.3 mg vs 42.8 mg), however this difference is of unknown significance. Direct lateral approaches have insufficient comparative data to establish relative perioperative outcomes. MIS TLIF had superior EBL (352 mL vs 580 mL, P < 0.0001) and LOS (7.7 d vs 10.4 d, P < 0.0001) and limited data to suggest lower perioperative pain. CONCLUSION Based on perioperative outcomes data, MIS approach is superior to open approach for TLIF. For laminectomy, MIS and open approaches can be chosen based on surgeon preference. For lateral approaches, there is insufficient evidence to find non-inferior perioperative outcomes at this time.
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Adogwa O, Elsamadicy AA, Han J, Cheng J, Bagley C. WITHDRAWN: Outcomes After Anterior Lumbar Interbody Fusion Versus Transforaminal Lumbar Interbody Fusion for the Treatment of Symptomatic L5-S1 Spondylolisthesis: A Prospective, Multi-Institutional Comparative Effectiveness Study. World Neurosurg 2015:S1878-8750(15)01214-0. [PMID: 26409090 DOI: 10.1016/j.wneu.2015.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 09/07/2015] [Accepted: 09/08/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Owoicho Adogwa
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Aladine A Elsamadicy
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jing Han
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph Cheng
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos Bagley
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Multimodality intraoperative neuromonitoring in extreme lateral interbody fusion. Transcranial electrical stimulation as indispensable rearview. 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 2015; 25:1581-1586. [DOI: 10.1007/s00586-015-4182-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 11/29/2022]
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Moisi M, Page J, Paulson D, Oskouian RJ. Technical Note - Lateral Approach to the Lumbar Spine for the Removal of Interbody Cages. Cureus 2015; 7:e268. [PMID: 26180692 PMCID: PMC4494582 DOI: 10.7759/cureus.268] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 05/11/2015] [Indexed: 01/06/2023] Open
Abstract
Revision surgery to address the migration or fracture of a lumbar interbody cage can be technically challenging. Scar tissue and fibrosis, among other anatomic barriers, can make removal of the cage a complicated procedure, potentially increasing postoperative pain as well as the probability of neurologic deficits. Use of the lateral surgical technique for removal of the cage can avoid these potential complications. In this case report, we describe the removal of interbody cages through a lateral approach in three patients without the necessity of additional posterior hardware revision.
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Affiliation(s)
- Marc Moisi
- Neurosurgery, Swedish Neuroscience Institute
| | - Jeni Page
- Department of Neurosurgery, Swedish Neuroscience Institute
| | | | - Rod J Oskouian
- Department of Neurosurgery, Swedish Neuroscience Institute
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Bateman DK, Millhouse PW, Shahi N, Kadam AB, Maltenfort MG, Koerner JD, Vaccaro AR. Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications. Spine J 2015; 15:1118-32. [PMID: 25728552 DOI: 10.1016/j.spinee.2015.02.040] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 12/22/2014] [Accepted: 02/18/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND CONTEXT The anterior approach to the lumbar spine is increasingly used to accomplish various surgical procedures. However, the incidence and risk factors for complications associated with anterior lumbar spine surgery (ALS) have not been fully elucidated. PURPOSE To identify and document types of complications and complication rates associated with ALS, determine risk factors for these events, and evaluate the effect of measures used to decrease complication rates. STUDY DESIGN Systematic review and meta-analysis. METHODS A systematic review of the English-language literature was conducted for articles published between January 1992 and December 2013. A MEDLINE search was conducted to identify articles reporting complications associated with ALS. For each complication, the data were combined using a generalized linear mixed model with a binomial probability distribution and a random effect based on the study. Predictors used were the type of procedure (open, minimally invasive, or laparoscopic), the approach used (transperitoneal vs. retroperitoneal), use of recombinant bone morphogenetic protein-2, use of preoperative computed tomography angiography (CTA), and the utilization of an access surgeon. Open surgery was used as a reference category. RESULTS Seventy-six articles met final inclusion criteria and reported complication rates in 11,410 patients who underwent arthrodesis and/or arthroplasty via laparoscopic, mini-open, and open techniques. The overall complication rate was 14.1%, with intraoperative and postoperative complication rates of 9.1% and 5.2%, respectively. Only 3% of patients required reoperation or revision procedures. The most common complications reported were venous injury (3.2%), retrograde ejaculation (2.7%), neurologic injury (2%), prosthesis related (2%), postoperative ileus (1.4%), superficial infection (1%), and others (1.3%). Laparoscopic and transperitoneal procedures were associated with higher complication rates, whereas lower complication rates were observed in patients receiving mini-open techniques. Our analysis indicated that the use of recombinant bone morphogenetic protein-2 was associated with increased rates of retrograde ejaculation; however, there may be limitations in interpreting these data. Data regarding the use of preoperative CTA and an access surgeon were limited and demonstrated mixed benefit. CONCLUSIONS Overall complication rates with ALS are relatively low, with the most common complications occurring at a rate of 1% to 3%. Complication rates are related to surgical technique, approach, and implant characteristics. Further randomized controlled trials are needed to validate the use of preventative measures including CTA and the use of an access surgeon.
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Affiliation(s)
- Dexter K Bateman
- Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
| | - Paul W Millhouse
- Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Niti Shahi
- Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Abhijeet B Kadam
- Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Mitchell G Maltenfort
- Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - John D Koerner
- Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute/Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
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Uribe JS, Deukmedjian AR. Visceral, vascular, and wound complications following over 13,000 lateral interbody fusions: a survey study and literature review. 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 2015; 24 Suppl 3:386-96. [DOI: 10.1007/s00586-015-3806-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/08/2015] [Accepted: 02/08/2015] [Indexed: 11/29/2022]
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James WS, Rughani AI, Dumont TM. A socioeconomic analysis of intraoperative neurophysiological monitoring during spine surgery: national use, regional variation, and patient outcomes. Neurosurg Focus 2014; 37:E10. [DOI: 10.3171/2014.8.focus14449] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In the United States in recent years, a dramatic increase in the use of intraoperative neurophysiological monitoring (IONM) during spine surgeries has been suspected. Myriad reasons have been proposed, but no clear evidence confirming this trend has been available. In this study, the authors investigated the use of IONM during spine surgery, identified patterns of geographic variation, and analyzed the value of IONM for spine surgery cases.
Methods
In this retrospective analysis, the Nationwide Inpatient Sample was queried for all spine surgeries performed during 2007–2011. Use of IONM (International Classification of Diseases, Ninth Revision, code 00.94) was compared over time and between geographic regions, and its effect on patient independence at discharge and iatrogenic nerve injury was assessed.
Results
A total of 443,194 spine procedures were identified, of which 85% were elective and 15% were not elective. Use of IONM was recorded for 31,680 cases and increased each calendar year from 1% of all cases in 2007 to 12% of all cases in 2011. Regional use of IONM ranged widely, from 8% of cases in the Northeast to 21% of cases in the West in 2011. Iatrogenic nerve and spinal cord injury were rare; they occurred in less than 1% of patients and did not significantly decrease when IONM was used.
Conclusions
As costs of spine surgeries continue to rise, it becomes necessary to examine and justify use of different medical technologies, including IONM, during spine surgery.
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Affiliation(s)
| | | | - Travis M. Dumont
- 1Division of Neurosurgery, University of Arizona, Tucson, Arizona; and
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Assina R, Majmundar NJ, Herschman Y, Heary RF. First report of major vascular injury due to lateral transpsoas approach leading to fatality. J Neurosurg Spine 2014; 21:794-8. [DOI: 10.3171/2014.7.spine131146] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extreme lateral interbody fusion (XLIF) has gained popularity among spine surgeons for treating multiple conditions of the lumbar spine. In contrast to the anterior lumbar interbody fusion (ALIF) approach, the minimally invasive XLIF approach affords wide access to the lumbar disc space without an access surgeon and causes minimal tissue disruption. The XLIF approach offers many advantages over other lumbar spine approaches, with a reportedly low complication profile. The authors describe the first fatality reported in the literature following an XLIF approach. They describe the case of a 50-year-old woman who suffered a fatal intraoperative injury to the great vessels during a lateral transpsoas approach to the L4–5 disc space.
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