Simultaneous Robotic Single-Position Surgery With Oblique Lumbar Interbody Fusion With Software Planning: 2-Dimensional Operative Video

The use of robotic guidance for spinal instrumentation is promising for its ability to offer the advantages of precision, accuracy, and reproducibility. This has become even more important in the era of lateral interbody surgery because spinal robotics opens up the possibility of a straightforward workflow for single-position surgery in the lateral position. We present here a case of a 72-yr-old woman who presented with an L4-5 spondylolisthesis with axial back pain and radiculopathy. She subsequently underwent an L4-5 oblique lumbar interbody fusion with L4-5 bilateral posterior instrumentation in a single lateral position (Mazor X Stealth Edition, Medtronic Sofamor Danek, Medtronic Inc, Dublin, Ireland). Due to the oblique lateral approach and posterior robotic assistance, both surgeons were able to work simultaneously for increased efficiency. To our knowledge, this is the first video demonstrating a two-surgeon simultaneous robotic single-position surgery with oblique lumbar interbody fusion using a spinal robotic platform. There is no identifying information in this video. Patient consent was obtained for the surgical procedure and for publishing of the material included in the video.

Injury to the Lumbar Plexus and its Branches After Lateral Fusion Procedures: A Cadaver Study

INTRODUCTION

Neurologic deficits from lumbar plexus nerve injuries commonly occur in patients undergoing lateral approaches. However, it is not yet clear what types of injury occur, where anatomically they are located, or what mechanism causes them. We aimed to study 1) the topographic anatomy of lumbar plexus nerves and their injuries in human cadavers after lateral transpsoas approaches to the lumbar spine, 2) the structural morphology of those injuries, and 3) the topographic anatomy of the lumbar plexus throughout the mediolateral approach corridor.

METHODS

Fifteen adult fresh frozen cadaveric torsos (26 sides) underwent lateral approaches (L1-L5) by experienced lateral spine surgeons. The cadavers were subsequently opened and the entire plexus dissected and examined for nerve injuries. The topographic anatomy of the lumbar plexus and its branches, their injuries, and the morphology of these injuries were documented.

RESULTS

Fifteen injuries were found with complete or partial nerve transections (Sunderland IV and V). Injuries were found throughout the mediolateral approach corridor. At L1/2, the iliohypogastric, ilioinguinal, and subcostal nerves were injured within the psoas major muscle, the retroperitoneal space, or the outer abdominal muscles and subcutaneous tissues. Genitofemoral nerve injuries were found in the retroperitoneal space. Nerve root injuries occurred within the retroperitoneal space and psoas muscle. Femoral nerve injuries were found only within the psoas major muscle. No obturator nerve injuries occurred.

CONCLUSIONS

Lateral approaches can lead to structural nerve damage. Knowledge of the complex plexus anatomy, specifically its mediolateral course, is critical to avoid approach-related injuries.