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Liu F, Liu Y, Gu Z, Zhao Z, Gao Y, Lu K, Sun X. How to Choose Surgical Corridor in Left Oblique Approach Lumbar Interbody Fusion at the L5-S1 Segment: A Prospective Cohort Study. World Neurosurg 2024; 183:e730-e737. [PMID: 38195028 DOI: 10.1016/j.wneu.2024.01.016] [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: 11/20/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/11/2024]
Abstract
OBJECTIVE There are 2 surgical corridors to L5-S1 lumbar interbody fusion via the left oblique approach: anterior to psoas-oblique lateral interbody fusion (ATP-OLIF) and oblique-anterior lumbar interbody fusion (O-ALIF). The aim of this study was to evaluate criteria to guide the selection of surgical corridors for L5-S1 lumbar interbody fusion via the left oblique approach. METHODS According to the structure of L5-S1 segment left common iliac vein (LCIV) in axial magnetic resonance image, the LCIV was divided into 6 types. O-ALIF was performed for type I and type II. ATP-OLIF was performed for type A and type B. For sexually active men, ATP-OLIF was chosen. Between April 2020 and April 2022, 22 patients were assigned to ATP-OLIF or O-ALIF based on the type of LCIV. Clinical outcomes and radiographic outcomes were assessed. RESULTS There were 11 cases in O-ALIF group (type I, n = 10; type II, n = 1) and 11 cases in ATP-OLIF group (type A, n = 8; type B, n = 3). No differences were observed in clinical outcomes (Oswestry Disability Index, VAS, and complication rate); radiographic outcomes (mean disk height and segmental lordosis angle); length of hospital stay; operation time; and blood loss. No vascular injury occurred in either group. CONCLUSIONS This may be an appropriate criterion to guide the selection of surgical corridor for L5-S1 lumbar interbody fusion through the left oblique approach. O-ALIF was performed for type I and type II. ATP-OLIF was performed for type A and type B. For sexually active men, ATP-OLIF was chosen. According to this standard, the operation can be performed safely and with good clinical results.
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Affiliation(s)
- Fengyu Liu
- Department of Spine Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, China
| | - Yanbing Liu
- Department of Spine Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, China
| | - Zhenfang Gu
- Department of Spine Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, China
| | - Zhengqi Zhao
- Department of Spine Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, China
| | - Yuan Gao
- Department of Spine Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, China
| | - Kuan Lu
- Department of Spine Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, China
| | - Xianze Sun
- Department of Spine Surgery, The Third Hospital of Shijiazhuang, Shijiazhuang, China.
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Limthongkul W, Praisarnti P, Tanasansomboon T, Prasertkul N, Kotheeranurak V, Yingsakmongkol W, Singhatanadgige W. An Expanded Surgical Corridor of Oblique Lateral Interbody Fusion at L4-5: A Magnetic Resonance Imaging Study. Neurospine 2023; 20:1450-1456. [PMID: 38171311 PMCID: PMC10762402 DOI: 10.14245/ns.2346678.339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/01/2023] [Accepted: 09/01/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE We introduced a new preoperative method, the "expanded surgical corridor," to evaluate the actual safety corridor, which may expand the possibility of performing oblique lateral interbody fusion (OLIF). METHODS Axial T2-weighted magnetic resonance images at the L4-5 disc level of 511 lumbar degenerative disease patients was evaluated. The distance between the medial edge of the left-sided psoas muscle and the major artery was measured as the conventional surgical corridor (CSc). The distance between the major vein and lumbar plexus was measured as the expanded surgical corridor (ESc). RESULTS The mean CSc and ESc were 13.9 ± 8.20 and 37.43 ± 10.1 mm, respectively. No surgical corridor was found in 7.05% of CSc and 1.76% of ESc, small corridor ( ≤ 1 cm) was found in 27.40% of CSc and 0.59% of ESc, moderate corridor (1-2 cm) was found in 42.07% of CSc and 1.96% of ESc, and large corridor ( > 2 cm) was found in 23.48% of CSc and 95.69% of ESc. A total of 33.83% (45 of 133) of whom were preoperatively categorized as having a limited surgical corridor by conventional measurement, underwent OLIF L4-5 successfully. CONCLUSION By using the ESc, only 2.35% were categorized as having a limited surgical corridor. The other 97.65% of the patients had an approachable corridor that could be successfully operated by experienced spine surgeons who employ meticulous surgical dissection and thorough understanding of the anatomical structures. The ESc may represent true accessibility to the disc space for OLIF, particularly at the L4-5 level.
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Affiliation(s)
- Worawat Limthongkul
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Pakawas Praisarnti
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Teerachat Tanasansomboon
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Natavut Prasertkul
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Vit Kotheeranurak
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Wicharn Yingsakmongkol
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Weerasak Singhatanadgige
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
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Zhang Z, Zhao Q, Cheng L, Zheng Z, Chen J, Liu Z, Gao Y, Wang G, Li Q. Position of lumbar plexus nerves in the psoas major: Application to transpsoas approaches to the lumbar spine. Clin Anat 2023; 36:1075-1080. [PMID: 36942892 DOI: 10.1002/ca.24016] [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: 10/24/2022] [Revised: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 03/23/2023]
Abstract
Far lateral interbody fusion is a minimally invasive operating technique. However, the incidence of postoperative neurological complications is high, and some scholars question its safety. This study describes the neuroanatomical features and spatial orientation within the psoas major. Ten embalmed male cadavers were selected and the left psoas major was dissected. Subsequently, the area between the anterior and the posterior edges of the vertebral body was divided into three equal zones. The nerves' distribution, number, and spatial orientation of the L1/2 to L4/5 intervertebral discs were examined. A caliper was used to measure the diameter of the nerve. The safety zone of the L1/2 intervertebral disc level is located in zone I and II, the relative safe zones of the L2/3 and L4/5 intervertebral discs are located in zone II, and the safety zone of the L3/4 intervertebral disc level is located in the caudal side of zone II. The genitofemoral nerve exits the psoas major in a co-trunk or two-branch pattern, and its exit point was distributed between the L3 and L4 vertebral bodies, mainly at the L3/4 intervertebral disc level. The sympathetic ganglia in the psoas major appeared only in zone I at the L2/3 intervertebral disc level. This is a systematic anatomical study that describes the nerves of the psoas major. Spine surgeons can use this study-which consists of important clinical implications-for preoperative planning, and thus, reduce the risk of nerve injury during surgery.
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Affiliation(s)
- Zhenfeng Zhang
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, No. 183, Zhongshan Road West, Guangzhou, 510630, China
- Department of Orthopedics, Guangzhou Development District Hospital, No. 196 Youyi Road, Huangpu District, Guangzhou, 510730, China
| | - Qinghao Zhao
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, No. 183, Zhongshan Road West, Guangzhou, 510630, China
| | - Liang Cheng
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, No. 183, Zhongshan Road West, Guangzhou, 510630, China
| | - Zhiyang Zheng
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, No. 183, Zhongshan Road West, Guangzhou, 510630, China
| | - Junjie Chen
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, No. 183, Zhongshan Road West, Guangzhou, 510630, China
| | - Zexian Liu
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, No. 183, Zhongshan Road West, Guangzhou, 510630, China
| | - Yuan Gao
- Department of the Institute of Trauma Surgery, The Second Hospital of Tangshan, No. 21 Jianshe North Road, Lubei District, Tangshan, 063015, China
| | - Guoliang Wang
- Department of Orthopedics, Guangzhou Development District Hospital, No. 196 Youyi Road, Huangpu District, Guangzhou, 510730, China
| | - Qingchu Li
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, No. 183, Zhongshan Road West, Guangzhou, 510630, China
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CreveCoeur TS, Sperring CP, DiGiorgio AM, Chou D, Chan AK. Antepsoas Approaches to the Lumbar Spine. Neurosurg Clin N Am 2023; 34:619-632. [PMID: 37718108 DOI: 10.1016/j.nec.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Lumbar interbody fusion (LIF) is a well-established approach in treating spinal deformity and degenerative conditions of the spine. Since its inception in the 20th century, LIF has continued to evolve, allowing for minimally invasive approaches, high fusion rates, and improving disability scores with favorable complication rates. The anterior to the psoas (ATP) approach utilizes a retroperitoneal pathway medial to the psoas muscle to access the L1-S1intervertebral disc spaces. In contrast to the transpsoas arppoach, its primary advantage is avoiding transgressing the psoas muscle and the contained lumbar plexus, which potentially decreases the risk of injury to the lumbar plexus. Avoiding transgression of the psoas may minimize the risk of transient or permanent neurological deficits secondary to lumbar plexus injury. Indications for ATP approaches may expand as it is shown to be a safe and effective method of achieving spinal arthrodesis.
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Affiliation(s)
- Travis S CreveCoeur
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, NY 10033, USA
| | - Colin P Sperring
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, NY 10033, USA
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Dean Chou
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 5141 Broadway, New York, NY 10034, USA
| | - Andrew K Chan
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 5141 Broadway, 3FW, Room 20, New York, NY 10034, USA.
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Alluri R, Clark N, Sheha E, Shafi K, Geiselmann M, Kim HJ, Qureshi S, Dowdell J. Location of the Femoral Nerve in the Lateral Decubitus Versus Prone Position. Global Spine J 2023; 13:1765-1770. [PMID: 34617812 PMCID: PMC10556917 DOI: 10.1177/21925682211049170] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Cadaveric study. OBJECTIVE To compare the position of the femoral nerve within the lumbar plexus at the L4-L5 disc space in the lateral decubitus vs prone position. METHODS Seven lumbar plexus specimens were dissected and the femoral nerve within the psoas muscle was identified and marked with radiopaque paint. Lateral fluoroscopic images of the cadaveric specimens in the lateral decubitus vs prone position were obtained. The location of the radiopaque femoral nerve at the L4-L5 disc space was normalized as a percentage of the L5 vertebral body (0% indicates posterior location and 100% indicates anterior location at the L4-L5 disc space). The location of the femoral nerve at L4-L5 in the lateral decubitus vs prone position was compared using a paired t test. RESULTS In the lateral decubitus position, the femoral nerve was located 28% anteriorly from the posterior edge of the L4-L5 disc space, and in the prone position, the femoral nerve was relatively more posterior, located 18% from the posterior edge of the L4-L5 disc space (P = .037). CONCLUSIONS The femoral nerve was on average more posteriorly located at the L4-L5 disc space in the prone position compared to lateral decubitus. This more posterior location allows for a larger safe zone at the L4-L5 disc space, which may decrease the incidence of neurologic complications associated with Lateral lumbar interbody fusion in the prone vs lateral decubitus position; however, further studies are needed to evaluate this possible clinical correlation.
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Affiliation(s)
- Ram Alluri
- Hospital for Special Surgery, New York, NY, USA
| | | | - Evan Sheha
- Hospital for Special Surgery, New York, NY, USA
| | - Karim Shafi
- Hospital for Special Surgery, New York, NY, USA
| | - Matthew Geiselmann
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
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Bobinski L, Liv P, Meyer B, Krieg SM. Lateral interbody fusion without intraoperative neuromonitoring in addition to posterior instrumented fusion in geriatric patients: A single center consecutive series of 108 surgeries. BRAIN & SPINE 2023; 3:101782. [PMID: 38021016 PMCID: PMC10668059 DOI: 10.1016/j.bas.2023.101782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/10/2023] [Accepted: 07/10/2023] [Indexed: 12/01/2023]
Abstract
Introduction Lateral lumbar interbody fusion (LLIF) and lateral thoracic interbody fusion (LTIF), supported by intraoperative neuromonitoring (IONM), gained popularity as a mini-invasive alternatives for standard interbody fusion. The objective of this study was to investigate the clinical outcome in a large elderly patient cohort who underwent LTIF/LLIF without IONM. Methods This retrospective, single-center study enrolled elderly patients (≥70 years old) operated during the period from 2010 to 2016. Anterior lumbar interbody fusion (ALIF) in the L5/S1 segment was excluded from the analysis. Results The study enrolled 108 patients (63 males, 58.3%) with a mean age of 76.5 y/o. The mean follow-up was 14.4 ± 11.3 months. The mean time of the surgery was 92 ± 34.2 min. The mean blood loss was 62.2 ml. There were no vascular or visceral surgical complications. 39 medical complications were encountered in 24 (22%) patients. Less than 5% of patients presented with a new onset of motor weakness and less than 2% of the patients developed a new sensory deficit at the discharge. 46% of patients were lost in follow-up at 12 months. Conclusions IONM is not mandatory for LLIF/LTIF surgery in geriatric patients and has a low frequency of approach-related complications as well as neurological deterioration. Our results are comparable to the available literature. Regardless of the utilization of these mini-invasive, anterior approaches, in patients of advanced aged, the risk for major medical complications is high and is responsible for contributing to prolonged hospitalization.
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Affiliation(s)
| | - Per Liv
- Section of Sustainable Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Nie JW, Hartman TJ, Zheng E, MacGregor KR, Oyetayo OO, Massel DH, Sayari AJ, Singh K. Postoperative clinical outcomes in patients undergoing MIS-TLIF versus LLIF for adjacent segment disease. Acta Neurochir (Wien) 2023; 165:1907-1914. [PMID: 37261504 DOI: 10.1007/s00701-023-05629-z] [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: 01/30/2023] [Accepted: 04/29/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Few studies examine the clinical outcomes in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) versus lateral lumbar interbody fusion (LLIF) for adjacent segment disease (ASD). We aim to compare the postoperative clinical trajectory through patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID) in patients undergoing MIS-TLIF versus LLIF for ASD. METHODS Patients were stratified into two cohorts based on surgical technique for ASD: MIS-TLIF versus LLIF. PROMs of 12-Item Short Form Physical Component Score (SF-12 PCS), visual analog scale (VAS) back, VAS leg, and Oswestry Disability Index (ODI) were collected at preoperative and postoperative 6-week/12-week/6-month/1-year time points. MCID attainment was calculated through comparison to established thresholds. Cohorts were compared through nonparametric inferential statistics. RESULTS Fifty-four patients were identified, with 22 patients undergoing MIS-TLIF after propensity score matching. Patients undergoing MIS-TLIF for ASD demonstrated significant postoperative improvement up to 1-year VAS back, up to 1-year VAS leg, and 6-month through 1-year ODI (p ≤ 0.035, all). Patients undergoing LLIF demonstrated significant postoperative improvement in 6-month SF-12 PCS, 6-month through 1-year VAS back, 12-week through 6-month VAS leg, and 6-month to 1-year ODI (p ≤ 0.035, all). No significant differences were calculated between surgical techniques for PROMs or MCID achievement rates. CONCLUSION Patients undergoing either MIS-TLIF or LLIF for adjacent segment disease demonstrated significant postoperative improvement in pain and disability outcomes. Additionally, patients undergoing LLIF reported significant improvement in physical function. Both MIS-TLIF and LLIF are effective for the treatment of adjacent segment disease.
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Affiliation(s)
- James W Nie
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Timothy J Hartman
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Eileen Zheng
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Keith R MacGregor
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Omolabake O Oyetayo
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Dustin H Massel
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St. Suite #300, Chicago, IL, 60612, USA
| | - Arash J Sayari
- 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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Lumbosacral plexus 3D printing with dissection validation - a baseline study with regards to lateral spine surgery. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Alluri RK, Vaishnav AS, Sivaganesan A, Ricci L, Sheha E, Qureshi SA. Multimodality Intraoperative Neuromonitoring in Lateral Lumbar Interbody Fusion: A Review of Alerts in 628 Patients. Global Spine J 2023; 13:466-471. [PMID: 33733881 PMCID: PMC9972257 DOI: 10.1177/21925682211000321] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective review of private neuromonitoring databases. OBJECTIVES To review neuromonitoring alerts in a large series of patients undergoing lateral lumbar interbody fusion (LLIF) and determine whether alerts occurred more frequently when more lumbar levels were accessed or more frequently at particular lumbar levels. METHODS Intraoperative neuromonitoring (IONM) databases were reviewed and patients were identified undergoing LLIF between L1 and L5. All cases in which at least one IONM modality was used (motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), evoked electromyography (EMG)) were included in this study. The type of IONM used and incidence of alerts were collected from each IONM report and analyzed. The incidence of alerts for each IONM modality based on number of levels at which at LLIF was performed and the specific level an LLIF was performed were compared. RESULTS A total of 628 patients undergoing LLIF across 934 levels were reviewed. EMG was used in 611 (97%) cases, SSEP in 561 (89%), MEP in 144 (23%). The frequency of IONM alerts for EMG, SSEP and MEPs did not significantly increase as the number of LLIF levels accessed increased. No EMG, SSEP, or MEP alerts occurred at L1-L2. EMG alerts occurred in 2-5% of patients at L2-L3, L3-L4, and L4-L5 and did not significantly vary by level (P = .34). SSEP and MEP alerts occurred more frequently at L4-L5 versus L2-L3 and L3-L4 (P < .03). CONCLUSIONS IONM may provide the greatest utility at L4-L5, particularly MEPs, and may not be necessary for more cephalad LLIF procedures such as at L1-L2.
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Affiliation(s)
| | | | | | - Luke Ricci
- Hospital for Special Surgery, New York, NY, USA
| | - Evan Sheha
- Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medical College, New York, NY,
USA
| | - Sheeraz A. Qureshi
- Hospital for Special Surgery, New York, NY, USA,Weill Cornell Medical College, New York, NY,
USA,Sheeraz A Qureshi, Hospital for Special Surgery,
535 E. 70th St, New York, NY, 10021, USA.
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Degulmadi D, Parmar V, Dave B, Krishnan A, Mayi S, Rai RR, Bali S, Amin P, Agrawal P. A comparative morphometric analysis of operative windows for performing OLIF among normal and deformity group in lower lumbar spine. Spine Deform 2023; 11:455-462. [PMID: 36180669 DOI: 10.1007/s43390-022-00594-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/17/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the radiological morphometric parameters of OLIF surgical technique in lower lumbar spine among normal and in patients with adult degenerative spine (levoscoliosis and dextroscoliosis). METHOD Standing AP radiographs and MRI in supine position were taken. Patients were divided into 3 groups based on Cobbs' angle into normal, levo and dextro scoliosis. Moros classification was used to calculate bare window (BW), vascular window (VW), Psoas window (PW), psoas major height (pmh) and width (pmw) at lower lumbar levels and measurements were done on PACS. RESULTS Seventy five patients (25 in each group) were assessed. BW has trend from L2-L3 > L3-L4 > L4-L5 in dextro and levoscoliosis. PW has trend from L3-L4 > L2-L3 > L4-L5 in levoscoliosis and normal group. VW has trend from L4-L5 > L3-L4 > L2-L3 in dextro and levoscoliosis; pmw has trend from L4-L5 > L3-L4 > L2-L3 in Levo and dextroscoliosis; pmh has trend from L4-L5 > L3-L4 > L2-L3 in levoscoliosis and normal group. CONCLUSION BW was noted to be highest at L3-4, lowest at L4-5 in normal group. VW was constant, BW showed a reverse trend with PW across all the levels. Though levoscoliosis group of patients had significantly higher BW, psoas retraction issues are to be kept in mind in view of anatomically taught psoas.
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Affiliation(s)
- Devanand Degulmadi
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India.
| | - Vatsal Parmar
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India
| | - Bharat Dave
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India
| | - Ajay Krishnan
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India
| | - Shivanand Mayi
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India
| | - Ravi Ranjan Rai
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India
| | - Shiv Bali
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India
| | - Prarthan Amin
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India
| | - Pritesh Agrawal
- Stavya Spine Hospital and Research Institute, Ahmedabad, 380006, Gujarat, India
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Song Z, Chen X, Zhou Z, Chen W, Zhu G, Jiang R, Zhang P, Lin S, Wang X, Yu X, Ren H, Liang D, Cui J, Tang J, Jiang X. Different Moro Zones of Psoas Major Affect the Clinical Outcomes after Oblique Lumbar Interbody Fusion: A Retrospective Study of 94 Patients. J Clin Med 2023; 12:jcm12030989. [PMID: 36769637 PMCID: PMC9917587 DOI: 10.3390/jcm12030989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Oblique lumbar interbody fusion (OLIF) has been driven to the maturity stage in recent years. However, postoperative symptoms such as thigh paresthesia resulting from intraoperative retraction of the psoas major (PM) have sometimes occurred. The aim of this study was to assess the different positions and morphology of PM muscles and their relationship with clinical outcomes after OLIF by introducing the Moro zones. Patients who underwent L4-5 OLIF at our institution between April 2019 and June 2021 were reviewed and all data were recorded. All patients were grouped by Moro zones into a Moro A cohort and a Moro I and II cohort based on the front edges of their left PM muscles. A total of 94 patients were recruited, including 57 in the Moro A group and 37 in the Moro I and II group. Postoperative thigh pain or numbness occurred in 12 (21.1%) and 2 (5.4%) patients in the Moro A group and the Moro I and II group, respectively. There was no difference in the psoas major transverse diameter (PMTD) between groups preoperatively, while longer PMTD was revealed postoperatively in the Moro A group. The operating window (OW) and psoas major sagittal diameter (PMSD) showed significant differences within and between groups. Thirteen patients had teardrop-shaped PM muscles, with 92.3% in the Moro A group showing significantly worse clinical scores at 1-week follow-up. The Moro zones of the PM affected the short-term outcomes after OLIF. Preoperative measurements and analysis of OW, PMSD and PM morphology should be performed as necessary to predict short-term outcomes.
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Affiliation(s)
- Zefeng Song
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Xingda Chen
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Zelin Zhou
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Wanyan Chen
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Guangye Zhu
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Rueishiuan Jiang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Peng Zhang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Shaohao Lin
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Xiaowen Wang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Xiang Yu
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
| | - Hui Ren
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
| | - De Liang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
| | - Jianchao Cui
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
| | - Jingjing Tang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
- Correspondence: (J.T.); (X.J.); Tel.: +86-15914305386 (J.T.); +86-13632494486 (X.J.)
| | - Xiaobing Jiang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
- Correspondence: (J.T.); (X.J.); Tel.: +86-15914305386 (J.T.); +86-13632494486 (X.J.)
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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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Kramer DE, Woodhouse C, Kerolus MG, Yu A. Lumbar plexus safe working zones with lateral lumbar interbody fusion: a systematic review and meta-analysis. 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 2022; 31:2527-2535. [PMID: 35984508 DOI: 10.1007/s00586-022-07352-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 06/20/2022] [Accepted: 08/10/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Significant risk of injury to the lumbar plexus and its departing motor and sensory nerves exists with lateral lumbar interbody fusion (LLIF). Several cadaveric and imaging studies have investigated the lumbar plexus position with respect to the vertebral body anteroposterior plane. To date, no systematic review and meta-analysis of the lumbar plexus safe working zones for LLIF has been performed. METHODS This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Relevant studies reporting on the position of the lumbar plexus with relation to the vertebral body in the anteroposterior plane were identified from a PubMed database query. Quantitative analysis was performed using Welch's t test. RESULTS Eighteen studies were included, encompassing 1005 subjects and 2472 intervertebral levels. Eleven studies used supine magnetic resonance imaging (MRI) with in vivo subjects. Seven studies used cadavers, five of which performed dissection in the left lateral decubitus position. A significant correlation (p < 0.001) existed between anterior lumbar plexus displacement and evaluation with in vivo MRI at all levels between L1-L5 compared with cadaveric measurement. Supine position was also associated with significant (p < 0.001) anterior shift of the lumbar plexus at all levels between L1-L5. CONCLUSIONS This is the first comprehensive systematic review and meta-analysis of the lumbar neural components and safe working zones for LLIF. Our analysis suggests that the lumbar plexus is significantly displaced ventrally with the supine compared to lateral decubitus position, and that MRI may overestimate ventral encroachment of lumbar plexus.
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Affiliation(s)
- Dallas E Kramer
- Department of Neurosurgery, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA, 15212, USA.
| | - Cody Woodhouse
- Department of Neurosurgery, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA, 15212, USA
| | - Mena G Kerolus
- Department of Neurological Surgery, Rush University Medical Center, 1725 West Harrison Street, Suite 855, Chicago, IL, 60612, USA
| | - Alexander Yu
- Department of Neurosurgery, Allegheny Health Network, 320 East North Avenue, Pittsburgh, PA, 15212, USA
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Neuromonitoring in Lateral Interbody Fusion: A Systematic Review. World Neurosurg 2022; 168:268-277.e1. [DOI: 10.1016/j.wneu.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/07/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022]
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15
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Single-position anterior and lateral lumbar fusion in the supine position: a novel technique for multi-level arthrodesis. World Neurosurg 2022; 168:4-10. [PMID: 36096381 DOI: 10.1016/j.wneu.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) are common techniques that typically require staged procedures when performed in combination. Interest is emerging in single-position surgery to increase operative efficiency. We report a novel surgical technique, supine extended reach (SupER) lateral fusion, to perform ALIF and LLIF with the patient in a single supine position. METHODS A man in his fifties presented with degenerative levoscoliosis, spondylolisthesis, sagittal-plane deformity, and progressive low back pain. He was offered L3-S1 anterolateral fusion. RESULTS With the patient supine, a left abdominal paramedian incision was performed to gain anterior retroperitoneal access, and standard L5-S1 and L4-5 ALIFs were performed. The anterior incision was used for direct visualization, retraction, and bimanual dissection. A left lateral incision was then made to perform an L3-4 LLIF. The patient subsequently underwent a second-stage L3-S1 posterior percutaneous fixation. The patient tolerated the procedures well, without complications. Postoperative radiograph findings confirmed acceptable implant positioning. The patient was discharged home in stable condition and was doing well at follow-up. CONCLUSION This case description is the first report of the SupER technique, which allows incorporation of anterior and lateral fusion constructs at adjacent levels without changing patient positioning. Many surgeons believe the ALIF to be the most powerful technique for achieving lordosis, and this technique enables concomitant lateral access in a supine position. It can also be used as an alternative strategy when anterior access to the disc space is unobtainable. Further clinical investigation of this technique is warranted.
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Tannoury C, Das A, Saade A, Bhale R, Chen K, Tannoury T. The Antepsoas (ATP) Surgical Corridor for Lumbar and Lumbosacral Arthrodesis: A Radiographic, Anatomic, and Surgical Investigation. Spine (Phila Pa 1976) 2022; 47:1084-1092. [PMID: 35834370 DOI: 10.1097/brs.0000000000004360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 03/12/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To investigate the size of prepsoas surgical corridors, developed between the iliopsoas and prespinal vessels, at all disk levels between L1 and S1 granted by left and right lateral antepsoas (ATP) approaches. Secondary aims include evaluation of presurgery radiographic prepsoas windows between L1 and S1 with respect to the intraoperative findings. SUMMARY OF BACKGROUND DATA The ATP technique is an evolving alternative to the transpsoas and direct anterior exposures for lumbar fusion. However, the vascular morphometric data of the ATP approach remain underexplored, especially at L5-S1. MATERIALS AND METHODS Patients indicated for ATP lumbar-lumbosacral fusion between September 2018 and February 2020 were enrolled (n=121). Data were collected prospectively, including the following (in mm): intraoperative manual measurements of the premobilization psoas-vessel (pre-PV) window, the final postmobilization psoas-vessel (post-PV) window, and the preoperative radiographic psoas-to-vessel distance at the respective studied disk levels. RESULTS A total of 121 patients (75 female, mean age: 55.3 yr, 81.8% right-sided approach) underwent a total of 279 levels of spinal fusion. Irrespective of the ATP access laterality, we noted ample postmobilization psoas-vessel (post-PV differential) corridors: largest at L4-L5 (36-38 mm) followed by L5-S1 (31-35 mm), L3-L4 (32-33 mm), L2-L3 (28-30 mm), and L1-L2 (20-24 mm). Similarly, the relative increases of the psoas-vessel corridors (post-PV and pre-PV differentials, averaged: 31 mm at L5-S1, 32 mm at L4-L5, 26 mm at L3-L4, 25 mm at L2-L3, and 14 mm at L1-L2) were also significant in both lateral approaches. In right flank approaches, the right vascular structures projected more dorsally compared with left-sided vasculature ( P <0.05). CONCLUSION The ATP access offers generous bilateral prepsoas surgical windows to L1-S1 intervertebral disks, allowing for a safe anterior column release, decompression, instrumentation, and fusion.
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Affiliation(s)
- Chadi Tannoury
- Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston University, Boston, MA
| | - Avilash Das
- Boston University School of Medicine, Boston University, Boston, MA
| | | | - Rahul Bhale
- Boston University School of Medicine, Boston University, Boston, MA
| | - Kathleen Chen
- Boston University School of Medicine, Boston University, Boston, MA
| | - Tony Tannoury
- Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston University, Boston, MA
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Gandhi SV, Dugan R, Farber SH, Godzik J, Alhilali L, Uribe JS. Anatomical positional changes in the lateral lumbar interbody fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2220-2226. [PMID: 35428915 DOI: 10.1007/s00586-022-07195-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 01/13/2022] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION ALIFs and LLIFs are now becoming more utilized for adult spinal disease. As technologies advance, so do surgical techniques, with surgeons now modifying traditional supine-ALIF and lateral-LLIF to lateral-ALIF and prone-LLIF approaches to allow for more efficient surgeries. The objective of this study is to characterize the anatomical changes in the surgical corridor that occur with changes in patient positioning. METHODS MRIs of ten healthy volunteers were evaluated in five positions: supine, prone with hips flexed, prone with hips extended, lateral with hips flexed, and lateral with hips extended. All lateral scans were in the left lateral decubitus position. The anatomical changes of the psoas muscles, inferior vena cava, aorta, iliac vessels were assessed with relation to fixed landmarks on the disc spaces from L1 to S1. RESULTS The most anteriorly elongated ipsilateral to approach psoas when compared to supine was seen in lateral-flexed position (- 5.82 mm, p < 0.001), followed by lateral-extended (- 2.23 mm, p < 0.001), then prone-flexed (- 1.40 mm, p = 0.014), and finally supine and prone-extended (- 0.21 mm, p = 0.643). The most laterally extending or "thickest" psoas was seen in prone-flexed (- 1.40 mm, p = 0.004) and prone-extended (- 1.17 mm, p = 0.002). The psoas was "thinnest" in lateral-extended (2.03 mm, p < 0.001) followed by lateral-flexed (1.11 mm, p = 0.239). The contralateral psoas did not move as anteriorly as the ipsilateral. 3D volumetric analysis showed that the greatest changes in the psoas occur at its proximal and distal poles near T12-L1 and L4-S1. In lateral-flexed compared to prone-extended, the IVC moves medially to the left (p < 0.001). The aorta moves laterally to the left (p = 0.005). The venous structures appeared more full and open in the lateral positions and flattened in the supine and prone positions. The arteries remain in full calibre. CONCLUSION The MRI anatomical evaluation shows that the psoas, and therefore lumbar plexus, and vasculature move significantly with changes in positioning. This is important for preoperative planning for proper intraoperative execution from preoperative supine MRI. Understanding that the psoas and vessels move the most anteriorly in the lateral-flexed position and to a least degree in the prone-extended is essential for safe and efficient utilization of techniques such as the traditional LLIF, traditional ALIF, prone-LLIF.
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Affiliation(s)
- Shashank V Gandhi
- Texas Back Institute, 6020 W. Parker Road, Suite 200, Plano, TX, 75093, USA.
| | - Robert Dugan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Samuel H Farber
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Lea Alhilali
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
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Qin Y, Zhao B, Yuan J, Xu C, Su J, Hao J, Lv J, Wang Y. Does cage position affect the risk of cage subsidence after oblique lumbar interbody fusion in the osteoporotic lumbar spine: a finite element analysis. World Neurosurg 2022; 161:e220-e228. [PMID: 35123023 DOI: 10.1016/j.wneu.2022.01.107] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to evaluate the biomechanical effects of different cage positions with stand-alone (SA) methods and bilateral pedicle screw fixation (BPSF) in the osteoporotic lumbar spine after OLIF. METHODS A finite element (FE) model of an intact L3-L5 lumbar spine was constructed. After validation, an osteoporosis model (OP) was constructed by assigning osteoporotic material properties. SA models (SA1, SA2, SA3) and BPSF models (BPSF1, BPSF2, BPSF3) in which a cage was placed in the anterior, middle and posterior third of the L5 superior endplate (SEP) were constructed at the L4-L5 segment of the OP. The L4-L5 range of motion (ROM), the stress of the L5 SEP, the stress of the cage and the stress of fixation were compared among the different models. RESULTS According to the degree of ROM of L4-L5, the stress of the L5 SEP and the stress of the cage for most physiological motions, the SA and BPSF models were ranked as follows: SA2<SA1<SA3, BPSF2<BPSF1<BPSF3. In BPSF2, the stress of fixation was minimal in most motions. At the same cage position, the ROM of L4-L5, the stress of the L5 SEP and the stress of the cage in the BPSF models were significantly reduced compared with those in SA models; compared with SA2, BPSF2 had a maximum reduction of 83.24%, 70.71% and 73.52% in these parameters, respectively.results CONCLUSIONS: Placing the cage in the middle third of the L5 SEP for OLIF could reduce the maximum stresses of the L5 SEP, the cage and the fixation, which may reduce the risk of postoperative cage subsidence, endplate collapse and fixation fracture in the osteoporotic lumbar spine. Compared with SA OLIF, BPSF could provide sufficient stability for the surgical segment and may reduce the incidence of the aforementioned complications.
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Affiliation(s)
- Yichuan Qin
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi 030001, China
| | - Bin Zhao
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi 030001, China
| | - Jie Yuan
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi 030001, China
| | - Chaojian Xu
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi 030001, China
| | - Junqiang Su
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi 030001, China
| | - Jiaqi Hao
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi 030001, China
| | - Jie Lv
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi 030001, China
| | - Yongfeng Wang
- Department of Orthopaedics, The Second Hospital of Shanxi Medical University, No. 382, Wuyi Road, Taiyuan, Shanxi 030001, China.
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Ji J, Li F, Chen Q. A Crucial But Neglected Anatomical Factor Underneath Psoas Muscle and Its Clinical Value in Lateral Lumbar Interbody Fusion-The Cleft of Psoas Major (CPM). Orthop Surg 2021; 14:323-330. [PMID: 34939336 PMCID: PMC8867435 DOI: 10.1111/os.13180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/17/2021] [Accepted: 10/21/2021] [Indexed: 12/02/2022] Open
Abstract
Objective To describe the anatomical feature positioned beneath the psoas muscle at the lateral aspect of the lower lumbar, and to create a new location system to identify the risk factors of lateral lumbar interbody fusion. Methods Six cadavers were dissected and analyzed. The anatomy and neurovascular distribution beneath the psoas major from L3 to S1 was observed and recorded, with particular focus on the L4/5 disc and below. The psoas major surface was divided homogeneously into four parts, from the anterior border of psoas major to the transverse process. The cranial‐to‐caudal division was from the lower edge of the psoas muscle attachment on the L4 vertebrae to the upper part of the S1 vertebrae, and was divided into five segments. Then a grid system was used to create 20 grids on the psoas major surface, from the anterior border of the muscle to the transverse process and from L4 to superior S1, which was used to determine the anatomical structures' distribution and relationship beneath the psoas major. Results A cleft was identified beneath the psoas major, from the level of L4/5 downwards. It was filled with loose connective tissue and neurovascular structures. We termed it the cleft of psoas major (CPM). The sympathetic trunk, ascending lumbar vein, iliolumbar vessels, obturator nerve, femoral nerve and occasionally the great vessels are contained within the CPM, although there is significant interpersonal variation. The grid system on the psoas major surface helped to identify the anatomical structures in CPM. There was a considerably lower frequency of occurrence of neurovascular structures in the grids of I/II at the L4/5 level where can be considered the “safe zones” for the lateral lumbar interbody fusion. In contrast, the distribution of neurovascular structures at the L5S1 level is dense, where the operation risk is high. Conclusion The CPM exists lateral to the vertebral surface from L4 and below. Although the occurrence and distribution of neurovascular structures within the CPM is complex and varies greatly, it can provide a potential cavity for visualization during lateral lumbar interbody fusion. Using psoas major as a reference, this novel grid system can be used to identify the risk factors in CPM and thus identify a safe entry point for surgery.
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Affiliation(s)
- Jianfei Ji
- Department of Orthopedics, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fangcai Li
- Department of Orthopedics, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qixin Chen
- Department of Orthopedics, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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20
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Revisiting anterior longitudinal ligament release: Are we ready for an endoscopic approach? J Clin Neurosci 2021; 94:166-172. [PMID: 34863432 DOI: 10.1016/j.jocn.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/12/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
Anterior longitudinal ligament release is a proven method for restoring spinopelvic parameters. This technique is mostly described using either lateral or anterior approaches with paucity regarding a posterior method. This paper is the first to provide descriptive analysis of the neurovascular anatomy in the context of planning for a posterior endoscopic ALL release. A retrospective chart review was performed on patients underwent any lumbar surgery by a single surgeon. Anatomical data was obtained from pre-operative CT to describe the location of key neurovascular structures in relation to the ALL with focus on posterior approach. A total of 20 patients were included in data analysis. A posterior approach with endoscopic assistance would be feasible at L4/5 and L5/S1, where the bifurcation of the abdominal aorta has occurred with a vessel window that ranges from 18.85 mm to 33.45 mm with at least 2 mm space between the vessels and the corresponding disc spaces in the anterior-posterior dimension with slight predilection of the left side at the L5/S1 level to avoid any neurovascular structures. Our study confirmed the findings of previous studies examining the vascular anatomy associated with the lumbar spine. Interestingly, we found that direct midline would likely not be the best location for a posterior annulotomy, and that both the window between the iliac vessels as well as the distance in AP dimension between the spine and vessels increases as you descend the lumbar spine. This information will help guide future efforts to fully develop a safe and reproducible posterior endoscopic ALL release.
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21
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Farber SH, Zhou JJ, Smith MA, Porter RW, Chang SW. Supine lateral lumbar interbody fusion: cadaveric proof of principle for simultaneous anterior and lateral approaches. World Neurosurg 2021; 158:e386-e392. [PMID: 34763102 DOI: 10.1016/j.wneu.2021.10.190] [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: 07/07/2021] [Revised: 10/29/2021] [Accepted: 10/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) are commonly performed in separate stages with a change in patient positioning to provide arthrodesis in the lumbar spine. Interest has recently emerged in performing these approaches as a single-stage surgery with the patient in the lateral decubitus position. The objective of this study was to evaluate the technical feasibility of performing minimally invasive anterolateral fixation in a single supine position. METHODS Two fresh-frozen cadavers were used and placed supine. Standard minimally invasive anterior access was obtained by the approach surgeon. An ALIF was performed at L5-S1 using standard techniques. A lateral incision was marked over the L4-5 disc space using fluoroscopy. Direct palpation and bimanual dissection were achieved through the same anterior incision, allowing access to the retroperitoneal space. Dilator and retractor docking was performed under fluoroscopic guidance. Direct visualization of the docking hardware through the anterior incision was used to ensure the safety of peritoneal contents and vasculature. The LLIF was then performed using standard techniques at L4-5. RESULTS Plain radiographs confirmed acceptable positioning of both the ALIF and LLIF grafts. No injury to the cadaveric peritoneum, vasculature, or lumbar plexus was observed. A slightly enlarged anterior incision also permitted retroperitoneal access and visualization of the L3-4 disc space. CONCLUSION This cadaver feasibility study demonstrates that combined minimally invasive ALIF and LLIF procedures may be performed as a single-stage with the patient in the supine position. Clinical consideration and study of this approach are warranted.
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Affiliation(s)
- S Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - James J Zhou
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael A Smith
- Department of Thoracic Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Randall W Porter
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Steve W Chang
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
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Cai Z, Ma R, Zhang J, Liu X, Yang W, Wang Z, Cai B, Xu X, Ge Z. Evaluation of the Stability of a Novel Lateral Plate Internal Fixation: An In Vitro Biomechanical Study. World Neurosurg 2021; 158:e237-e244. [PMID: 34728393 DOI: 10.1016/j.wneu.2021.10.164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND This study aims to evaluate the biomechanical stability of a novel lateral plate (NLP) that can be used in oblique lateral lumbar fusion (OLIF). METHODS In vitro biomechanical tests were performed on 6 fresh calf lumbar vertebrae specimens. The surgical segment was set at L3-L4. Each specimen was tested in the following order: intact state (INT); OLIF cage only/stand-alone (SA); cage supplemented with lateral screw-rod (LSR); cage supplemented with novel lateral plate (NLP); and cage supplemented with unilateral or bilateral pedicle screw-rod (UPS or BPS). A pure moment of ±7.5 Nm was applied to the specimen to produce 6 different motion directions, including flexion and extension, lateral bending, and axial rotation, and the range of motion (ROM) of L3-L4 in each direction was recorded. RESULTS In addition to flexion-extension, NLP reduced the ROM of SA (P < 0.05). In flexion-extension, the ROM of NLP was similar to those of SA and LSR (P > 0.05); compared to pedicle screw-rod (PSD), the ROM of NLP was higher (P < 0.05). In lateral bending, the ROM of NLP was close to that of LSR and PSD (P > 0.05). In axial rotation, the ROM of NLP was higher than that of PSD (P < 0.05), and close to that of LSR (P > 0.05). CONCLUSIONS NLP can enhance surgical segment stability in all directions of motion, similar to LSR, but weaker than UPS and BPS in flexion-extension and rotation.
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Affiliation(s)
- Zecheng Cai
- Ningxia Medical University, Yinchuan, Ningxia, China
| | - Rong Ma
- Department of Orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Jianqun Zhang
- Department of Orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Xiaoyin Liu
- Department of Orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Wei Yang
- Ningxia Medical University, Yinchuan, Ningxia, China
| | - Zemin Wang
- Ningxia Medical University, Yinchuan, Ningxia, China
| | - Baochun Cai
- DECANS Medical Devices Co., Ltd., Jiaxing, Zhejiang, China
| | - Xiaobo Xu
- DECANS Medical Devices Co., Ltd., Jiaxing, Zhejiang, China
| | - Zhaohui Ge
- Department of Orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China.
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Alluri R, Mok JK, Vaishnav A, Shelby T, Sivaganesan A, Hah R, Qureshi SA. Intraoperative Neuromonitoring During Lateral Lumbar Interbody Fusion. Neurospine 2021; 18:430-436. [PMID: 34610671 PMCID: PMC8497239 DOI: 10.14245/ns.2142440.220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To review the evidence for the use of electromyography (EMG), motor-evoked potentials (MEPs), and somatosensory-evoked potentials (SSEPs) intraoperative neuromonitoring (IONM) strategies during lateral lumbar interbody fusion (LLIF), as well as discuss the limitations associated with each technique.
Methods A comprehensive review of the literature and compilation of findings relating to clinical studies investigating the efficacy of EMG, MEP, SSEP, or combined IONM strategies during LLIF.
Results The evidence for the use of EMG is mixed with some studies demonstrating the efficacy of EMG in preventing postoperative neurologic injuries and other studies demonstrating a high rate of postoperative neurologic deficits with EMG monitoring. Multimodal IONM strategies utilizing MEPs or saphenous SSEPs to monitor the lumbar plexus may be promising strategies based on results from a limited number of studies.
Conclusion The use of traditional EMG during LLIF remains without consensus. There is a growing body of evidence utilizing multimodal IONM with MEPs or saphenous SSEPs demonstrating a possible decrease in postoperative neurologic injuries after LLIF. Future prospective studies, with clear definitions of neurologic injury, that evaluate different multimodal IONM strategies are needed to better assess the efficacy of IONM during LLIF.
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Affiliation(s)
- Ram Alluri
- Hospital for Special Surgery, New York, NY, USA
| | | | | | - Tara Shelby
- Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | | | - Raymond Hah
- Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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Jung JM, Chung CK, Kim CH, Yang SH, Won YI, Choi Y. Effects of Total Psoas Area Index on Surgical Outcomes of Single-Level Lateral Lumbar Interbody Fusion. World Neurosurg 2021; 154:e838-e845. [PMID: 34411761 DOI: 10.1016/j.wneu.2021.08.031] [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: 07/11/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We evaluated the effect of the total psoas area index (TPAI = total psoas muscle area [cm2]/height squared [m2]) on neurological complications and clinical outcomes after lateral lumbar interbody fusion and identified the appropriate TPAI to achieve a substantial clinical benefit (SCB). METHODS A consecutive series of 123 patients who had undergone single-level lateral lumbar interbody fusion at a single center with ≥2 years of follow-up were retrospectively reviewed. The patient characteristics and operative data were evaluated. The neurological complications were classified as transient and persistent symptoms. The visual analog scale score for back pain was assessed preoperatively and at 1 and 2 years postoperatively. RESULTS The present study included 31 men and 92 women. The mean TPAI was 8.97 cm2/m2 for the men and 5.04 cm2/m2 for the women. The mean TPAI was not significantly different between the patients with and without perioperative neurological complications. Multiple logistic regression analysis showed that solid interbody fusion was the most significant factor for achieving an SCB regarding back pain in men (odds ratio [OR], 2.453; P = 0.019) and women (OR, 2.906; P = 0.042). The TPAI was one of the predictors for achieving an SCB in men (OR, 1.251; P = 0.038) and women (OR, 1.795; P = 0.023). The optimal cutoff point of the TPAI for an SCB was 8.18 cm2/m2 for the men and 4.43 cm2/m2 for the women. CONCLUSIONS The TPAI had little effect on the incidence of perioperative neurological complications. However, the TPAI was identified as one of the predictors for achieving an SCB regarding back pain.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Republic of Korea.
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Ii Won
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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The Effect of Patient Position on Psoas Morphology and in Lumbar Lordosis. World Neurosurg 2021; 153:e131-e140. [PMID: 34166827 DOI: 10.1016/j.wneu.2021.06.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Among the interbody fusions, lateral lumbar interbody fusion allows access to the lumbar spine through the major psoas muscle, which offers several advantages to the spine surgeon. However, some of its drawbacks cause surgeons to avoid using it as a daily practice. Therefore, to address some of these challenges, we propose the prone transpsoas technique, differing mainly from the traditional technique on patient position-moving from lateral to prone decubitus, theoretically enhancing the lordosis and impacting the psoas morphology. METHODS Twenty-four consecutive patients were invited to have magnetic resonance imaging examinations in 3 different positions (prone, dorsal, lateral). Two observers measured the following parameters: vertebral body size, psoas diameter, psoas anterior border distance, plexus distance, total lumbar lordosis, distal lumbar lordosis, and proximal lumbar lordosis. Values of P < 0.05 were deemed significant. RESULTS The prone position yielded a significant increase in the lumbar lordosis, both in L1-S1 (57° vs. 46.5°) and proximal lordosis (40.4° vs. 36.9°) compared with the lateral position. Regarding the morphologic aspects, patients in the prone position presented lesser psoas muscles forward shift, but no difference was noted in the plexus position neither for L3-L4 nor L4-L5. CONCLUSIONS The prone position resulted in a significantly increased lumbar lordosis, both distal and proximal, which may enable the spine surgeon to achieve significant sagittal restoration just by positioning. The prone position also produced a posterior retraction of the psoas muscle. However, it did not significantly affect the position of the plexus concerning the vertebral body.
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Comparison of outcomes between indirect decompression of oblique lumbar interbody fusion and MIS-TLIF in one single-level lumbar spondylosis. Sci Rep 2021; 11:12783. [PMID: 34140626 PMCID: PMC8211833 DOI: 10.1038/s41598-021-92330-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 06/09/2021] [Indexed: 02/06/2023] Open
Abstract
Minimal invasive spinal fusion has become popular in the last decade. Oblique lumbar interbody fusion (OLIF) is a relatively new surgical technique and could avoid back muscle stripping and posterior complex destruction as in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Between December 2016 and September 2018, patients with single level degenerative spondylosis were selected to enroll in this retrospective study. A total of 21 patients that underwent OLIF and 41 patients that received MIS-TLIF were enrolled. OLIF showed significantly less blood loss and shorter surgery time compared to MIS-TLIF (p < 0.05). The improvement in segmental lordosis and coronal balance was significantly more in OLIF group than MIS-TLIF group (p < 0.05). When comparing with MIS-TLIF, OLIF was significantly better in Oswestry Disability Index (ODI) and visual analogue scale for back pain improvement at post-operative 6 months (p < 0.05). Both OLIF and MIS-TLIF are becoming mainstream procedures for lumbar degenerative-related disease, especially for spondylolisthesis. However, the indirect decompression of OLIF has shown to have less perioperative blood loss and shorter surgery time than that of MIS-TLIF. In addition, OLIF gives superior outcome in restoring segmental lordosis and coronal imbalance. While both OLIF and MIS-TLIF provide optimal clinical outcomes, upon comparison between the two techniques, the indirect decompression of OLIF seems to be a superior option in modern days.
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Kaul R, Kumar K, Jeyaraman M, Goswami B, Choudhary MC, Chhabra HS, Kumar S. MRI-Based Morphometric Study Regarding Operative Windows of Oblique Lumbar Interbody Fusion in Indian Population. Indian J Orthop 2021; 55:366-373. [PMID: 34306549 PMCID: PMC8275717 DOI: 10.1007/s43465-021-00393-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/17/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The novel Oblique lumbar interbody fusion [OLIF] technique has been proposed as a solution to approach related complications of anterior lumbar interbody fusion [ALIF] and lateral lumbar interbody fusion [LLIF]. There exists no study concerning morphological evaluation of retroperitoneal oblique corridor for the Oblique lumbar interbody fusion (OLIF) technique in the Indian population. The aim of our study was (a) to measure magnetic resonance imaging (MRI) based anatomic parameters concerning OLIF operative windows from L2-L3 to L4-L5 level (b) to determine the feasibility of this technique following MRI-based morphometric evaluation in the Indian population. MATERIAL AND METHODS We did retrospective MRI analysis of 307 consecutive patients following our exclusion criteria. Bare window, psoas major window and psoas major width were measured from axial T2 MRI image taken at mid disc level from L2-L3 to L4-L5 levels. RESULTS The mean bare window size was largest at L2-L3 (1.39 cm) level followed by L3-L4 and L4-L5 level (1.28 and 0.62 cm respectively), and differences between them were statistically significant (P < 0.001). Females had statistically significant larger bare windows at L2-L3 and L3-L4 level than males (P < 0.001). With increasing age, there was a significant increase in bare window size at each level (P < 0.001). The mean psoas major window (PMO) and mean psoas major width (PMI) were largest at L4-L5 level (PMO = 1.27 cm, PMI = 3.61 cm) followed by L3-L4 and L2-L3 level (L3-L4: PMO = 1.19 cm, PMI = 2.36 cm; L2-L3: PMO = 0.88 cm, PMI = 1.39 cm), and differences among each level concerning both parameters were statistically significant (P < 0.001). Both parameters (PMO, PMI) were significantly larger in males than females at each level (P < 0.001). CONCLUSION The OLIF technique is well suited for lumbar interbody fusion at L2 -L3 and L3-L4 level in the Indian population irrespective of age and sex. At L4-L5 level, overall 17.9 percent of the study population were unsuitable for this technique due to inaccessible bare window. In our opinion, this level may be better suited for OLIF approach in the elderly Indian population, especially for surgeons who are beginning to attempt this technique in their surgical practice. Preoperative MRI evaluation for the OLIF is important to assess its feasibility, as there exists significant age and gender differences in the Indian population for anatomic parameters concerning OLIF operative windows from L2-L3 to L4-L5 levels. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00393-7.
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Affiliation(s)
- Rahul Kaul
- Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh India
| | - Khemendra Kumar
- Department of Radio-Diagnosis, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh India
| | - Madhan Jeyaraman
- Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh India
| | - Bharat Goswami
- Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh India
| | - Milind Chandra Choudhary
- Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh India
| | - H. S. Chhabra
- Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India
| | - Sudhir Kumar
- Department of Orthopaedics, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh India
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Yingsakmongkol W, Wathanavasin W, Jitpakdee K, Singhatanadgige W, Limthongkul W, Kotheeranurak V. Psoas Major Muscle Volume Does Not Affect the Postoperative Thigh Symptoms in XLIF Surgery. Brain Sci 2021; 11:brainsci11030357. [PMID: 33799645 PMCID: PMC7999586 DOI: 10.3390/brainsci11030357] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/08/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Extreme lateral interbody fusion (XLIF) is a minimally invasive surgery that accesses the lumbar spine through the psoas muscle. This study aimed to evaluate the correlation between the psoas major muscle volume and anterior thigh symptoms after XLIF. Methods: Eighty-one patients (mean age 63 years) with degenerative spine diseases underwent XLIF (total = 94 levels). Thirty-eight patients were female (46.9%), and 24 patients (29.6%) had a history of lumbar surgery. Supplemental pedicle screws were used in 48 patients, and lateral plates were used in 28 patients. Neuromonitoring devices were used in all cases. The patients were classified into two groups (presence of thigh symptoms and no thigh symptoms after the surgery). The psoas major volumes were measured and calculated by CT (computed tomography) scan and compared between the two patient groups. Results: In the first 24 h after surgery, 32 patients (39.5%) had thigh symptoms (20 reported pain, 9 reported numbness, and 18 reported weakness). At one year postoperatively, only 3 of 32 patients (9.4%) had persistent symptoms. Conclusions: As a final observation, no statistically significant difference in the mean psoas major volume was found between the group of patients with new postoperative anterior thigh symptoms and those with no thigh symptoms. Preoperative psoas major muscle volume seems not to correlate with postoperative anterior thigh symptoms after XLIF.
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Affiliation(s)
- Wicharn Yingsakmongkol
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University (Thai Red Cross Society), Bangkok 10330, Thailand; (W.Y.); (W.S.); (W.L.)
| | - Waranyoo Wathanavasin
- Department of Orthopaedics, Somdej Phra Phutthaloetla Hospital, Mae Klong, Samut Songkram 75000, Thailand;
| | - Khanathip Jitpakdee
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital (Thai Red Cross Society), Sriracha, Chonburi 20110, Thailand;
| | - Weerasak Singhatanadgige
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University (Thai Red Cross Society), Bangkok 10330, Thailand; (W.Y.); (W.S.); (W.L.)
| | - Worawat Limthongkul
- Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University (Thai Red Cross Society), Bangkok 10330, Thailand; (W.Y.); (W.S.); (W.L.)
| | - Vit Kotheeranurak
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital (Thai Red Cross Society), Sriracha, Chonburi 20110, Thailand;
- Correspondence: ; Tel.: +66-383-20-200
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Segawa T, Koga H, Oshina M, Ishibashi K, Takano Y, Iwai H, Inanami H. Clinical Evaluation of Microendoscopy-Assisted Oblique Lateral Interbody Fusion. ACTA ACUST UNITED AC 2021; 57:medicina57020135. [PMID: 33546404 PMCID: PMC7913526 DOI: 10.3390/medicina57020135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022]
Abstract
Background and objectives: Oblique Lateral Interbody Fusion (OLIF) is a widely performed, minimally invasive technique to achieve lumbar lateral interbody fusion. However, some complications can arise due to constraints posed by the limited surgical space and visual field. The purpose of this study was to assess the short-term postoperative clinical outcomes of microendoscopy-assisted OLIF (ME-OLIF) compared to conventional OLIF. Materials and Methods: We retrospectively investigated 75 consecutive patients who underwent OLIF or ME-OLIF. The age, sex, diagnosis, and number of fused levels were obtained from medical records. Operation time, estimated blood loss (EBL), and intraoperative complications were also collected. Operation time and EBL were only measured per level required for the lateral procedure, excluding the posterior fixation surgery. The primary outcome measure was assessed using the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ). The secondary outcome measure was assessed using the Oswestry Disability Index (ODI) and the European Quality of Life–5 Dimensions (EQ-5D), measured preoperatively and 1-year postoperatively. Results: This case series consisted of 14 patients in the OLIF group and 61 patients in the ME-OLIF group. There was no significant difference between the two groups in terms of the mean operative time and EBL (p = 0.90 and p = 0.50, respectively). The perioperative complication rate was 21.4% in the OLIF group and 21.3% in the ME-OLIF group (p = 0.99). In both groups, the postoperative JOABPEQ, EQ-5D, and ODI scores improved significantly (p < 0.001). Conclusions: Although there was no significant difference in clinical results between the two surgical methods, the results suggest that both are safe surgical methods and that microendoscopy-assisted OLIF could serve as a potential alternative to the conventional OLIF procedure.
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Affiliation(s)
- Tomohide Segawa
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
- Correspondence: ; Tel.: +81-03-3450-1773
| | - Hisashi Koga
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
- Department of Neurosurgery, Iwai FESS Clinic, Suite 101, 8-18-4 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan
| | - Masahito Oshina
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
| | - Katsuhiko Ishibashi
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
- Department of Neurosurgery, Iwai FESS Clinic, Suite 101, 8-18-4 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan
| | - Yuichi Takano
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
| | - Hiroki Iwai
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
- Department of Neurosurgery, Iwai FESS Clinic, Suite 101, 8-18-4 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan
| | - Hirohiko Inanami
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, 3-17-5 Higashishinagawa, Shinagawa City, Tokyo 140-0002, Japan; (M.O.); (Y.T.); (H.I.); (H.I.)
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan; (H.K.); (K.I.)
- Department of Neurosurgery, Iwai FESS Clinic, Suite 101, 8-18-4 Minamikoiwa, Edogawa City, Tokyo 133-0056, Japan
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Transpsoas Lumbar Interbody Fusion Without Psoas Stimulated Electromyography. Clin Spine Surg 2021; 34:E57-E63. [PMID: 32453162 DOI: 10.1097/bsd.0000000000001021] [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: 11/01/2019] [Accepted: 04/29/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a retrospective case review. OBJECTIVE The objective of this study was to present an anatomic approach to transpsoas interbody fusion without psoas stimulated electromyography (sEMG) and to evaluate the rate of neurological and approach-related complications. BACKGROUND The transpsoas approaches have become commonly utilized for lumbar interbody fusion and may have certain advantages compared with other methods of interbody stabilization. Traditionally, transpsoas approaches have been performed utilizing sEMG as it has been purported to reduce the risk of injury to the lumbar plexus; however, an anatomic approach to transpsoas surgery is also possible as cadaveric studies have demonstrated the anatomy of the psoas muscle and lumbar plexus. METHODS Patients who underwent transpsoas interbody fusion using an anatomic approach without psoas sEMG between 2005 and 2018 were enrolled in this study. The preoperative and postoperative medical records for this cohort were carefully reviewed to identify any new or persistent radicular symptoms, neurological deficits or approach-related complications. RESULTS A total of 133 patients (48 males, 85 females) underwent transpsoas interbody fusion at 222 levels in this cohort-which had a mean age of 63 (61, 65) years and body mass index of 28.8 (27.8, 29.9). New neurological complications were seen in 5 patients (3.8%) and 5 patients (3.8%) were found to have new postoperative radicular pain, up to 3 months postoperatively. The total number of perioperative, approach-related complications was 7 (5.3%) for the entire cohort. CONCLUSION An anatomic transpsoas approach to the interbody space without psoas sEMG demonstrated a rate of neurological and approach-related complications that was comparable or superior to the rate of complications reported using the traditional transpsoas approach with sEMG.
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Swiatek PR, McCarthy MH, Weiner J, Bhargava S, Vaishnav AS, Iyer S. Intraoperative image guidance for lateral position surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:90. [PMID: 33553383 PMCID: PMC7859765 DOI: 10.21037/atm-2020-ioi-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Recent advances in minimally invasive spine surgery techniques have precipitated the popularity of lateral position spine surgery, such as lateral lumbar interbody fusion (LLIF) and oblique lumbar interbody fusion (OLIF). Lateral position surgery offers a unique, minimally invasive approach to the lumbar spine that allows for preservation of anterior and posterior spinal elements. Traditionally, surgeons have relied upon fluoroscopy for triangulation and implant placement. Over the last decade, intraoperative 3-dimensional navigation (ION) has risen to the forefront of innovation in LLIF and OLIF. This technology utilizes intra-operative advanced imaging, such as comminuted tomography (CT), to map the patient’s 3D anatomy and allows the surgeon to accurately visualize instruments and implants in spatial relationship to the patient’s anatomy in real time. ION has the potential to improve accuracy during instrumentation, decrease operating room times, lower radiation exposure to the surgeon and staff, and increase feasibility of single-position surgery during which the spine is instrumented both laterally and posteriorly while the patient remains in the lateral decubitus position. Despite the advantages of ION, the intra-operative radiation exposure risk to patients is controversial. Future directions include continued innovation in ultra low radiation imaging (ULRI) techniques and image enhancement technology and in uses of robot-assisted navigation in single-position spine surgery.
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Affiliation(s)
- Peter R Swiatek
- Department of Orthopaedic Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Michael H McCarthy
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Joseph Weiner
- Department of Orthopaedic Surgery, Northwestern Memorial Hospital, Chicago, IL, USA
| | | | - Avani S Vaishnav
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sravisht Iyer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Asad S, Dubey A, Dubey A, Sutterlin C. Clinical Outcomes after Minimally Invasive Trans-Psoas Lateral Lumbar Interbody Fusion for the Treatment of Adult Degenerative Scoliosis: Four Years’ Multicenter Study. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1710105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractThe use of minimally invasive transpsoas lateral lumbar interbody fusion (LLIF) surgery for treatment of adult degenerative scoliosis is rapidly increasing in popularity. However, limited data is available regarding its use in adult degenerative lumbar scoliosis surgery. The objective of this study was to evaluate the clinical outcomes of adults with degenerative lumbar scoliosis who were treated with minimally invasive LLIF. Thirty-two consecutive patients with adult degenerative scoliosis treated by a single surgeon at two spine centers were followed up for an average of 13.2 months. Interbody fusion was completed using the minimally invasive LLIF technique with supplemental 360 degrees’ posterior instrumentation. Oswestry disability index (ODI) scores were obtained preoperatively and at most recent follow-up. Complications were recorded. The study group demonstrated improvement in clinical outcome scores. ODI scores improved from 36.8 to 23.4 (p < 0.00001). A total of four complications (12%) were recorded, and two patients (6%) required additional surgery. Based on the significant improvement in validated clinical outcome scores, minimally invasive LLIF can be considered an effective procedure in the treatment of adult degenerative scoliosis.
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Affiliation(s)
- Sheikh Asad
- Department of Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Arjun Dubey
- Department of Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Arvind Dubey
- Department of Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
- Hobart Brain and Spine Centre, Hobart, Tasmania, Australia
| | - Chester Sutterlin
- Department of Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
- Hobart Brain and Spine Centre, Hobart, Tasmania, Australia
- Department of Neurosurgery, University of Florida, Gainesville, Florida, United States
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Garg B, Mehta N, Vijayakumar V, Gupta A. Defining a safe working zone for lateral lumbar interbody fusion: a radiographic, cross-sectional study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 30:164-172. [PMID: 33044660 DOI: 10.1007/s00586-020-06624-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/02/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To present a radiographic analysis of the anatomy of the lumbar plexus and retroperitoneal blood vessels with respect to psoas morphology and safe working zones (SWZ) for LLIF. METHODS A retrospective radiographic analysis of 158 MRI scans was performed. Selected morphometric measurements were performed at L1-L2, L2-L3, L3-L4 and L4-L5 levels: disc anteroposterior distance, psoas anteroposterior distance, lumbar plexus-anterior disc distance, lumbar plexus-anterior psoas distance, vena cava-anterior disc distance and calculation of SWZ in psoas on both left and right sides. The morphometric measurements were analysed for differences with sex and the level. RESULTS All the morphometric parameters differed significantly at all levels between males and females. The SWZ was significantly wider on the left side compared to the right-at L2-L3, L3-L4 and L4-L5 levels in females and at L3-L4 and L4-L5 levels in males. The SWZ at L4-L5 was narrowest on both left and right sides-and significantly reduced compared to other levels. 6.9% patients had a SWZ > 20 mm on the left side, and 44.9% patients had SWZ < 20 mm on the right side. With caudal progression of levels, the lumbar plexus and psoas muscle migrated anteriorly and the vena cava/right iliac vein migrated posteriorly. CONCLUSION A detailed study of preoperative MRI scans should be carried out in patients planned for LLIF-particularly, at L4-L5 level and in females. A left-sided trans-psoas approach is safer to perform compared to the right side-a right-sided approach should be avoided at L4-L5 considering the narrow SWZ at that level.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.
| | - Vivek Vijayakumar
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Anupam Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Lateral Lumbar Interbody Fusion: Review of Surgical Technique and Postoperative Multimodality Imaging Findings. AJR Am J Roentgenol 2020; 217:480-494. [PMID: 32903050 DOI: 10.2214/ajr.20.24074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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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Sadrameli SS, Davidov V, Huang M, Lee JJ, Ramesh S, Guerrero JR, Wong MS, Boghani Z, Ordonez A, Barber SM, Trask TW, Roeser AC, Holman PJ. Complications associated with L4-5 anterior retroperitoneal trans-psoas interbody fusion: a single institution series. JOURNAL OF SPINE SURGERY 2020; 6:562-571. [PMID: 33102893 DOI: 10.21037/jss-20-579] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Lateral lumbar interbody fusion (LLIF), first described in the literature in 2006 by Ozgur et al., involves direct access to the lateral disc space via a retroperitoneal trans-psoas tubular approach. Neuromonitoring is vital during this approach since the surgical corridor traverses the psoas muscle where the lumbar plexus lies, risking injury to the lumbosacral plexus that could result in sensory or motor deficits. The risk of neurologic injury is especially higher at L4-5 due to the anatomy of the plexus at this level. Here we report our single-center clinical experience with L4-5 LLIF. Methods A retrospective chart review of all patients who underwent an L4-5 LLIF between May 2016 and March 2019 was performed. Baseline demographics and clinical characteristics, such as body mass index (BMI), medical comorbidities, surgical history, tobacco status, operative time and blood loss, length of stay (LOS), and post-op complications were recorded. Results A total of 220 (58% female and 42% male) cases were reviewed. The most common presenting pathology was spondylolisthesis. The average age, BMI, operative time, blood loss, and LOS were 64.6 years, 29 kg/m2, 214 min, 75 cc, and 2.5 days respectively. A review of post-operative neurologic deficits revealed 31.4% transient hip flexor weakness and 4.5% quadricep weakness on the approach side. At 3-week follow-up, 9.1% of patients experienced mild hip flexor weakness (4 or 4+/5), 0.9% reported mild quadricep weakness, and 9.5% reported anterior thigh dysesthesias; 93.2% of patients were discharged home and 2.3% were readmitted within the first 30 days post discharge. Female sex, higher BMI and longer operative time were associated with hip flexor weakness. Conclusions LLIF at L4-5 is a safe, feasible, and versatile approach to the lumbar spine with an acceptable approach-related sensory and motor neurologic complication rates.
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Affiliation(s)
- Saeed S Sadrameli
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | | | - Meng Huang
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Jonathan J Lee
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Srivathsan Ramesh
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jaime R Guerrero
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Marcus S Wong
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Zain Boghani
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Adriana Ordonez
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Todd W Trask
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Andrew C Roeser
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Paul J Holman
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
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Lateral Lumbar Interbody Fusion at L4-5: A Morphometric Analysis of Psoas Anatomy and Cage Placement. World Neurosurg 2020; 141:e691-e699. [DOI: 10.1016/j.wneu.2020.05.274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 11/22/2022]
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Nojiri H, Okuda T, Miyagawa K, Kobayashi N, Sato T, Hara T, Ohara Y, Kudo H, Sakai T, Kaneko K. Localization of the Lumbar Plexus in the Psoas Muscle: Considerations for Avoiding Lumbar Plexus Injury during the Transpsoas Approach. Spine Surg Relat Res 2020; 5:86-90. [PMID: 33842715 PMCID: PMC8026205 DOI: 10.22603/ssrr.2020-0074] [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: 04/24/2020] [Accepted: 06/09/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction Transpsoas lumbar spine surgery is minimally invasive and has very good corrective effects. However, approach-side nerve complications delay post-operative rehabilitation. We anatomically investigated the localization of the lumbar plexus running in the psoas muscle. Methods We examined 27 formalin-fixed cadavers. The left-sided psoas muscle was extracted and cut parallel to the intervertebral disc at the L2/3, L3/4, and L4/5 disc levels. Using digitized photographs, we calculated the ratio of the distance from the front edge of the psoas muscle to the center of the lumbar plexus in the anteroposterior diameter of the psoas muscle (%). Then, we calculated the ratio of the distance from the lateral edge of the psoas muscle to the center of the lumbar plexus in the lateral diameter of the psoas muscle (%). Results The anterior-posterior lumbar plexus localization was 74.5 at L2/3, 74.7 at L3/4, and 81.2 at L4/5. There was a significant difference between L2/3 and L4/5 and between L3/4 and L4/5, but not between L2/3 and L3/4 (P=0.02, 0.01, and 0.94, respectively). The lateral and medial lumbar plexus localization was 85.4 at L2/3, 83.9 at L3/4, and 77.7 at L4/5. There was a significant difference between L2/3 and L4/5 and between L3/4 and L4/5, but not between L2/3 and L3/4 (P=0.01, 0.04, and 0.41, respectively). Conclusions The lumbar plexus was localized in the posterior one-third and medial one-third of the psoas muscle and moved to a posterolateral location at L4/5. To avoid neuropathy, consider the psoas muscle's position relative to that of the intervertebral disc. It is essential to understand lumbar plexus localization in the psoas muscle when looking directly at this muscle to enter the pricking point or route with a lower risk of nerve damage.
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Affiliation(s)
- Hidetoshi Nojiri
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan.,Spine and Spinal Cord Center, Juntendo Hospital, Juntendo University School of Medicine, Tokyo, Japan
| | - Takatoshi Okuda
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan.,Spine and Spinal Cord Center, Juntendo Hospital, Juntendo University School of Medicine, Tokyo, Japan
| | - Kei Miyagawa
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan.,Spine and Spinal Cord Center, Juntendo Hospital, Juntendo University School of Medicine, Tokyo, Japan
| | - Nozomu Kobayashi
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan.,Spine and Spinal Cord Center, Juntendo Hospital, Juntendo University School of Medicine, Tokyo, Japan
| | - Tatsuya Sato
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan.,Spine and Spinal Cord Center, Juntendo Hospital, Juntendo University School of Medicine, Tokyo, Japan
| | - Takeshi Hara
- Department of Neurosurgery, Juntendo University, Tokyo, Japan.,Spine and Spinal Cord Center, Juntendo Hospital, Juntendo University School of Medicine, Tokyo, Japan
| | - Yukoh Ohara
- Department of Neurosurgery, Juntendo University, Tokyo, Japan.,Spine and Spinal Cord Center, Juntendo Hospital, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Kudo
- Department of Anatomy and Life Structure, Juntendo University, Tokyo, Japan
| | - Tatsuo Sakai
- Department of Anatomy and Life Structure, Juntendo University, Tokyo, Japan
| | - Kazuo Kaneko
- Department of Orthopedic Surgery, Juntendo University, Tokyo, Japan.,Spine and Spinal Cord Center, Juntendo Hospital, Juntendo University School of Medicine, Tokyo, Japan
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Uchikado H, Nishimura Y, Hattori G, Ohara Y. Micro-anatomical structures of the lumbar intervertebral foramen for full-endoscopic spine surgery: review of the literatures. JOURNAL OF SPINE SURGERY 2020; 6:405-414. [PMID: 32656378 DOI: 10.21037/jss.2019.10.07] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive spinal surgical technique. PELD can be performed via 2 routes, transforaminal (TF) or interlaminar. The TF approach is a well-established modality in the treatment of patients with herniated lumbar discs. This technique makes the most of the space within the intervertebral foramen where, as Kambin claimed, the safe approach to the lesion is possible. Knowledge of the lumbar artery with its branches and various ligaments of anatomies of the intervertebral foramen are needed to perform successful surgeries and to reduce complications.
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Affiliation(s)
| | | | - Gohsuke Hattori
- Department of Neurosurgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Yukoh Ohara
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
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Reliability of the new modified Moro's classification and oblique corridor grading to assess the feasibility of oblique lumbar interbody fusion. J Orthop 2020; 21:321-325. [PMID: 32641880 DOI: 10.1016/j.jor.2020.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/31/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The modified Moro's classification (MMC) of psoas morphology and oblique corridor (OC) grading were recently proposed. Their reliability needs to be tested. Methods T2 weighted lumbar disc level axial-cut MRI images of patients with degenerative spondylosis were distributed to five spine surgeons. The inter and intra-rater reliability of MMC and OC grading were calculated based on their ratings. Results Based on kappa statistics, we inferred that both MMC and OC grading are reliable measures. Conclusion Both MMC and OC grading, in combination, can be used to predict the feasibility of oblique lumbar interbody fusion and aid in patient selection.
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Wang Z, Liu L, Xu XH, Cao MD, Lu H, Zhang KB. The OLIF working corridor based on magnetic resonance imaging: a retrospective research. J Orthop Surg Res 2020; 15:141. [PMID: 32293492 PMCID: PMC7158069 DOI: 10.1186/s13018-020-01654-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/27/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To provide an anatomical basis for the development of oblique lumbar interbody fusion (OLIF) in Chinese patients. METHODS Between November 2018 and June 2019, 300 patients' lumbar MRI data were reviewed. According to the Moro system and zone method described by us, the axial view was vertically divided into 6 zones (A, I II, III, IV, P) and was horizontally divided into 4 zones (R, a, b, c, L). The locations of left psoas muscle and the major artery at L2/3, L3/4, and L4/5 levels were evaluated by the grid system. The aortic bifurcation segments will also be evaluated at the level of the vertebral body or the disc. RESULTS At the L2/3 level, left psoas muscle and the major artery in zone Ib were found in 28.0% of subjects, in zone IIb in 20.3%, and in zone Ic in 20.0%; at the L3/4 level, in zone Ab in 20.7% of subjects, in zone Ac in 26.0%, and in zone Ic in 11.0%; and at the L4/5 level, areas in zone Ab in 31.0% of subjects, in zone Ac in 26.0%, and in zone Ib in 11.7%. The aortic bifurcation segments were mainly at the L4 level. The zone of the left psoas muscle at all levels, the zone of the major artery at L4/5 level, and the zone of the aortic bifurcation segments had significant correlation with gender difference (P < 0.05). CONCLUSION The left-sided OLIF at L2-L5 disc levels can be a feasible type of surgery for lumbar interbody fusion in the majority of Chinese patients. Before the operation, in order to screen out the appropriate surgical approach, routine lumbar magnetic resonance imaging is recommended to analyze the patient's local anatomical features.
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Affiliation(s)
- Zhe Wang
- Department of Spine Surgery, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Lei Liu
- Department of Spine Surgery, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Xiang-He Xu
- Department of Orthopaedics, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Ming-de Cao
- Department of Orthopaedics, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Hai Lu
- Department of Spine Surgery, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Kui-Bo Zhang
- Department of Spine Surgery, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China.
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Wu T, Xiao L, Liu C, Tao X, Xu H. Anatomical Study of the Lumbar Segmental Arteries in Relation to the Oblique Lateral Interbody Fusion Approach. World Neurosurg 2020; 138:e778-e786. [PMID: 32217175 DOI: 10.1016/j.wneu.2020.03.080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To use computed tomography angiography to evaluate the regional anatomy of the lumbar segmental arteries (LAs) associated with the surgical field in oblique lateral interbody fusion (OLIF). METHODS Computed tomography angiography images from 50 patients were reviewed. In the sagittal plane, distances from the LA to the upper and inferior edges of the vertebral body were measured in the anterior quarter of the anterior and median lines of the intervertebral disc (IVD). LAs were classified as types I-IV based on the zone in which they passed through the vertebral body. RESULTS The LA branch angles were acute (<90°) at L1-L3 and blunt (>90°) at L4-L5. The average distances from the LA to the upper and inferior edges of the vertebral body in the anterior quarter position revealed that La1.2 > Lb1.2 and Lb3.4.5 > La3.4.5. For the IVD of L1-L2, Lb1 < La2; IVD of L2-L3, Lb2 < La3; IVD of L3-L4, Lb3 > La4; IVD of L4-L5, Lb4 > La5. In zone I, the most frequent LA type was type IV at L1 (n = 41; 85.4%) and L2 (n = 42; 84.0%), type III at L3 (n = 20; 40.0%), and type II at L4 (n = 36; 80.0%) and L5 (n = 5; 83.3%). In zone II, the most frequent LA type was type III at L1 (n = 38; 79.2%), L2 (n = 39; 78.0%), L3 (n = 43; 86.0%), and L4 (n = 28; 62.2%), whereas type II was the most frequent LA type at L5 (n = 5; 83.3%). In zone III, type III was the most frequent LA type at L1-L4. In zone IV, type IV was the most frequent LA type at L3 (n = 44; 88.0%), L4 (n = 42; 93.3%), and L5 (n = 6; 100%). CONCLUSIONS The risk of LA injury during OLIF is the least when the cage is placed in zones II and III. Care is required during OLIF in zone IV of L3-L5. The fixation pin should be fixed on the upper edge of the lower vertebral body at L1-L2 and L2-L3, and on the lower edge of the upper vertebral body at L3-L4 and L4-L5.
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Affiliation(s)
- Tianliang Wu
- School of Medicine, Shandong University, Jinan, Shandong, China; Department of Orthopaedics, the Second People's Hospital of Wuhu, Wuhu, Anhui, China; Department of Spine Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China; Spine Research Center of Wannan Medical College, Wuhu, Anhui, China
| | - Liang Xiao
- Department of Spine Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China; Spine Research Center of Wannan Medical College, Wuhu, Anhui, China
| | - Chen Liu
- Department of Spine Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China; Spine Research Center of Wannan Medical College, Wuhu, Anhui, China
| | - Xiuxia Tao
- Department of Nuclear Medicine, the Second People's Hospital of Wuhu, Wuhu, Anhui, China
| | - Hongguang Xu
- School of Medicine, Shandong University, Jinan, Shandong, China; Department of Spine Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China; Spine Research Center of Wannan Medical College, Wuhu, Anhui, China.
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Li J, Wang X, Zhang W, Guo L, Shen Y. Novel Implementation of Extreme Lateral Interbody Fusion to Avoid Intraoperative Lumbar Plexus Injury: Technical Note and Preliminary Results. World Neurosurg 2020; 138:332-338. [PMID: 32151770 DOI: 10.1016/j.wneu.2020.02.167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study modified the traditional extreme lateral lumbar interbody fusion (XLIF) surgery and was intended to reduce the approach related to lumbar plexus injury. METHODS The patients receiving a new modified XLIF for treatment of lumbar degenerative diseases since September 2017 in our hospital were retrospectively collected. Postoperative additional symptoms of leg numbness, pain, or weakness were recorded as lumbar plexus nerve injury. Intraoperative electromyographic monitoring was recorded during surgery to evaluate the safety of the modified entry point. The visual analog scale and Oswestry Disability Index were adopted to evaluate the postoperative clinical efficacy. Modified MacNab criteria were introduced to evaluate the patients' satisfaction 12 months after surgery. The preoperative and postoperative intervertebral height, foraminal height, and lumbar lordotic angle were measured. Repeated measurement variance analysis was used for comparison of clinical and imaging indexes in various periods. P < 0.05 indicated statistical difference. RESULTS Fifty-nine patients were finally included in the retrospective study. The intraoperative average blood loss and operation time were 70 mL (40-130 mL) and 77.90 ± 13.65 minutes. The average follow-up time was 18 months. Postoperative visual analog scale and Oswestry Disability Index were significantly decreased compared with those before the operation. The intervertebral height and foraminal height were dramatically higher than those before surgery. No lumbar plexus injury occurred. CONCLUSIONS The initial result was optimistic in reducing lumbar plexus injury and obtaining good clinical efficacy. We need to further expand the sample size and carry out a comparative study to observe the advantages and disadvantages of modified XLIF.
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Affiliation(s)
- Jiaqi Li
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xianzheng Wang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Zhang
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Lei Guo
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yong Shen
- Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
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Manning J, Wang E, Varlotta C, Woo D, Ayres E, Eisen L, Bendo J, Goldstein J, Spivak J, Protopsaltis TS, Passias PG, Buckland AJ. The effect of vascular approach surgeons on perioperative complications in lateral transpsoas lumbar interbody fusions. Spine J 2020; 20:313-320. [PMID: 31669613 DOI: 10.1016/j.spinee.2019.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lateral lumbar interbody fusion (LLIF) is a popular technique used in spine surgery. It is minimally invasive, provides indirect decompression, and allows for coronal plane deformity correction. Despite these benefits, the approach to LLIF has been linked to complications associated with the lumbosacral plexus and vascular anatomy. As a result, vascular surgeons may be recruited for the exposure portion of the procedure. PURPOSE The purpose of this study was to compare exposure-related complication and postoperative (postop) neuropraxia rates between exposure (EXP) and spine surgeon only (SSO) groups while performing the approach for LLIF. STUDY DESIGN/SETTING Retrospective analysis of patients treated at a single institution. PATIENT SAMPLE Patients undergoing LLIF procedures between 2012 and 2018. OUTCOME MEASURES Operative time, estimated blood loss, fluoroscopy, length of stay (LOS), intra- and postoperative complications, and physiologic measures including pre- and postoperative motor examinations and unresolved neuropraxia. METHODS Patients who underwent LLIF were separated into EXP and SSO groups based on the presence or absence of vascular/general surgeon during the approach. The entire clinical history of patients with a decrease in pre- and postop motor examination was reviewed for the presence of neuropraxia. All other intra- and postop exposure-related complications were recorded for comparison. Propensity score matching (PSM) was performed to account for age, Charlson Comorbidity Index (CCI) percentage of LLIFs including L4-L5, and number of levels fused. Independent t test and chi-square analyses were used to identify significant differences between EXP and SSO groups. Statistical significance was set at p<.05. RESULTS Two hundred and seventy-five patients underwent LLIF procedures, 155 SSO and 120 EXP. Postoperatively, 26 patients (11.1%) experienced a drop in any Medical Research Council (MRC) score, and two patients (0.7%) experienced unresolved quadriceps palsies. The mean recovery time for MRC scores was 84.4 days. Other complications included 2 pneumothoraces (0.7%), 1 iliac vein injury (0.4%), 14 cases of ileus (5.1%), 3 pulmonary emboli (1.1%), 2 deep vein thrombosis (0.7%), 3 cases of abdominal wall paresis (1.1%), and one abdominal hematoma (0.4%). After PSM, demographics including age, gender, body mass index, CCI, levels fused, and operative time were similar between cohorts. Twenty patients had changes in pre- to postop motor scores (SSO 9.4%, EXP 12.4%, p>.05). Iliopsoas motor scores decreased at the highest rate (EXP 12.4%, SSO 8.2%, p>.05) followed by quadriceps (EXP 5.2%, SSO 4.7%, p>.05). One SSO patient's postop course was complicated by a foot drop but returned to baseline within 1 year. One patient in EXP group developed an unresolved quadriceps palsy (EXP 1.0%, SSO 0.0%, p>.05). Intraoperative exposure complications included one pneumothorax (EXP 1.0%, SSO 0.0%, p>.05). There were no differences in PE/DVT, Ileus, or LOS. In the EXP cohort, three patients experienced abdominal wall paresis (EXP 2.9%, SSO 0.00%, p=.246). CONCLUSIONS Comparing the LLIF exposures performed by EXP and SSO, we found no significant difference in the rates of complications. Additional research is needed to determine the etiology of the abdominal wall complications. In conclusion, neuropraxia- and approach-related complications are similarly low between exposure and spine surgeons.
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Affiliation(s)
- Jordan Manning
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Erik Wang
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | | | - Dainn Woo
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Ethan Ayres
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Leon Eisen
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - John Bendo
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Jeffrey Goldstein
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Jeffrey Spivak
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | | | - Peter G Passias
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA
| | - Aaron J Buckland
- NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003, USA.
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Wang C, Zeng J, Yang Z. [Guiding role of imaging evaluation in oblique lumbar interbody fusion]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1572-1577. [PMID: 31823561 PMCID: PMC8355787 DOI: 10.7507/1002-1892.201904021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/02/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To summarize the guiding role of imaging evaluation of oblique lumbar interbody fusion (OLIF) in recent years. METHODS The reports of OLIF surgical imaging research at home and abroad in recent years were extensively reviewed and analyzed. RESULTS Preoperative imaging evaluation plays an important role in guiding the operation of OLIF, the placement of fusion Cage, the selection of indications, and the reduction of complications. CONCLUSION Detailed preoperative imaging evaluation can correctly estimate the indications of OLIF, and avoid the nerve, blood vessel, and muscle injuries.
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Affiliation(s)
- Chaoyang Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jiancheng Zeng
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
| | - Zhiqiang Yang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Shirahata T, Okano I, Salzmann SN, Sax OC, Shue J, Sama AA, Cammisa FP, Toyone T, Inagaki K, Hughes AP, Girardi FP. Association Between Surgical Level and Early Postoperative Thigh Symptoms Among Patients Undergoing Standalone Lateral Lumbar Interbody Fusion. World Neurosurg 2019; 134:e885-e891. [PMID: 31733379 DOI: 10.1016/j.wneu.2019.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lateral lumbar interbody fusion (LLIF) has often been associated with postoperative lumbar plexus symptoms, including pain, paresthesia, and motor deficits in the lower extremities, especially the anterior thigh regions. Previous studies have suggested that LLIF procedures at L4-L5 will be associated with a greater motor deficit rate than other levels. However, it is unclear which level has the greatest risk of pain and paresthesia. The purpose of the present retrospective observational study was to investigate the difference in the incidence of early postoperative thigh symptoms (pain and paresthesia) stratified by procedure level among patients who had undergone standalone LLIF. METHODS We reviewed the data from consecutive patients who had undergone LLIF at a single academic institution. A total of 285 standalone LLIF cases without preoperative motor deficits were identified. The incidence of postoperative thigh pain and paresthesia at the 6-week postoperative follow-up examination was assessed at all levels from T12-L1 to L4-L5. RESULTS A total of 81 patients (28.4%) had anterior thigh pain and 62 (21.8%) had anterior thigh paresthesia. The presence of ≥3 levels fused (odds ratio [OR], 2.96; P = 0.004) and surgery at L2-L3 (OR, 2.59; P = 0.001) were significant risk factors for postoperative anterior thigh paresthesia on univariate analysis but were not associated with anterior thigh pain. Multivariate analyses demonstrated that only surgery L2-L3 was an independent risk factor for anterior thigh paresthesia (OR, 2.09; P = 0.049). CONCLUSIONS Our results have demonstrated that standalone LLIF at the L2-L3 was significantly associated with a greater incidence of postoperative anterior thigh paresthesia but that the incidence of postoperative thigh pain showed no significant association with any operative level.
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Affiliation(s)
- Toshiyuki Shirahata
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA; Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan.
| | - Ichiro Okano
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Stephan N Salzmann
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Oliver C Sax
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Tomoaki Toyone
- Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Katsunori Inagaki
- Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, New York, New York, USA
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Safaee MM, Ames CP, Deviren V, Clark AJ. Minimally Invasive Lateral Retroperitoneal Approach for Resection of Extraforaminal Lumbar Plexus Schwannomas: Operative Techniques and Literature Review. Oper Neurosurg (Hagerstown) 2019; 15:516-521. [PMID: 29351647 DOI: 10.1093/ons/opx304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 12/26/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Traditional approaches for retroperitoneal lumbar plexus schwannomas involve anterior open or laparoscopic resection. For select tumors, the lateral retroperitoneal approach provides a minimally invasive alternative. OBJECTIVE To describe a minimally invasive lateral transpsoas approach for the resection of retroperitoneal schwannomas. METHODS A lateral retroperitoneal transpsoas approach was used to resect a 3.1 × 2.7 × 4.1 cm schwannoma embedded within the psoas muscle. A minimally invasive retractor system allows for appropriate visualization and complete resection with the aid of the microscope. The patient tolerated the procedure without complication and was discharged on postoperative day 2 in good condition at her neurological baseline. RESULTS The lateral retroperitoneal approach provides a minimally invasive alternative for select retroperitoneal schwannomas. In theory, this procedure allows for faster recovery and less blood loss compared to traditional open anterior approaches. For a subset of tumors, anterior laparoscopy may provide better access, but the lateral approach is well known to most neurosurgeons who perform lateral interbody fusions and can be easily tailored to extraforaminal tumor resection. CONCLUSION Retroperitoneal schwannomas pose a challenge due to their deep location. The lateral retroperitoneal approach provides a useful alternative for resection of a subset of retroperitoneal schwannomas.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California.,Department of Orthopedic Surgery, University of California, San Francisco, California
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, California
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, California
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Salzmann SN, Shirahata T, Okano I, Winter F, Sax OC, Yang J, Shue J, Sama AA, Cammisa FP, Girardi FP, Hughes AP. Does L4-L5 Pose Additional Neurologic Risk in Lateral Lumbar Interbody Fusion? World Neurosurg 2019; 129:e337-e342. [DOI: 10.1016/j.wneu.2019.05.144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 11/26/2022]
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Zhengkuan X, Qixin C, Gang C, Fangcai L. The technical note and approach related complications of modified lateral lumbar interbody fusion. J Clin Neurosci 2019; 66:182-186. [DOI: 10.1016/j.jocn.2019.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 02/20/2019] [Accepted: 04/28/2019] [Indexed: 02/02/2023]
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The Anatomic Characteristics of the Retroperitoneal Oblique Corridor to the L1-S1 Intervertebral Disc Spaces. Spine (Phila Pa 1976) 2019; 44:E697-E706. [PMID: 30475333 DOI: 10.1097/brs.0000000000002951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a cross-sectional study. OBJECTIVE To investigate the oblique corridor to the L1-S1 intervertebral disc space between the psoas muscle and the great vessels in cadaveric specimens bilaterally and the location of genitofemoral nerve and the diaphragmatic crura relative to the oblique corridor. SUMMARY OF BACKGROUND DATA Although use of oblique lumbar interbody fusion is rapidly expanding, the morphometric data related to the procedure are limited. METHODS Twelve fresh-frozen full-torso cadaveric specimens were dissected to examine the oblique corridor to access the L1-S1 space in a static state and with mild retraction of the psoas. The level at which the genitofemoral nerve pierces from the psoas major and the diaphragmatic crura originate from the lumbar vertebral body was also investigated. RESULTS The mean width of oblique corridor in the static state and with mild psoas retraction, respectively, were as follows: on the right side: (L1-2) 13.33 and 16.75 mm; (L2-3) 15.42 and 21.42 mm; (L3-4) 16.58 and 22.67 mm; (L4-5) 12.75 and 21.17 mm; (L5-S1) 5.92 and 12.00 mm; on the left side: (L1-2) 16.75 and 19.67 mm; (L2-3) 18.50 and 25.33 mm; (L3-4) 20.58 and 28.00 mm; (L4-5) 18.17 and 26.08 mm; and (L5-S1) 5.83 and 12.00 mm. The level at which the genitofemoral nerve pierces from the psoas major was between L2 and L4. The diaphragmatic crura originates from L1 to L3. CONCLUSION The oblique corridor allows access to the L1-L5 discs from both sides, but it is larger on the left side. The corridor between the iliac vessels and the psoas for L5-S1 is difficult to be applied clinically. Mild psoas retraction can moderately enlarge the oblique corridor. The genitofemoral nerve and diaphragmatic crura may be encountered in this approach and should be carefully observed. LEVEL OF EVIDENCE 5.
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Eguchi Y, Norimoto M, Suzuki M, Haga R, Yamanaka H, Tamai H, Kobayashi T, Orita S, Suzuki M, Inage K, Kanamoto H, Abe K, Umimura T, Sato T, Aoki Y, Watanabe A, Koda M, Furuya T, Nakamura J, Akazawa T, Takahashi K, Ohtori S. Diffusion tensor tractography of the lumbar nerves before a direct lateral transpsoas approach to treat degenerative lumbar scoliosis. J Neurosurg Spine 2019; 30:461-469. [PMID: 30684934 DOI: 10.3171/2018.9.spine18834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the relationship between vertebral bodies, psoas major morphology, and the course of lumbar nerve tracts using diffusion tensor imaging (DTI) before lateral interbody fusion (LIF) to treat spinal deformities. METHODS DTI findings in a group of 12 patients (all women, mean age 74.3 years) with degenerative lumbar scoliosis (DLS) were compared with those obtained in a matched control group of 10 patients (all women, mean age 69.8 years) with low-back pain but without scoliosis. A T2-weighted sagittal view was fused to tractography from L3 to L5 and separated into 6 zones (zone A, zones 1-4, and zone P) comprising equal quarters of the anteroposterior diameters, and anterior and posterior to the vertebral body, to determine the distribution of nerves at various intervertebral levels (L3-4, L4-5, and L5-S1). To determine psoas morphology, the authors examined images for a rising psoas sign at the level of L4-5, and the ratio of the anteroposterior diameter (AP) to the lateral diameter (lat), or AP/lat ratio, was calculated. They assessed the relationship between apical vertebrae, psoas major morphology, and the course of nerve tracts. RESULTS Although only 30% of patients in the control group showed a rising psoas sign, it was present in 100% of those in the DLS group. The psoas major was significantly extended on the concave side (AP/lat ratio: 2.1 concave side, 1.2 convex side). In 75% of patients in the DLS group, the apex of the curve was at L2 or higher (upper apex) and the psoas major was extended on the concave side. In the remaining 25%, the apex was at L3 or lower (lower apex) and the psoas major was extended on the convex side. Significant anterior shifts of lumbar nerves compared with controls were noted at each intervertebral level in patients with DLS. Nerves on the extended side of the psoas major were significantly shifted anteriorly. Nerve pathways on the convex side of the scoliotic curve were shifted posteriorly. CONCLUSIONS A significant anterior shift of lumbar nerves was noted at all intervertebral levels in patients with DLS in comparison with findings in controls. On the convex side, the nerves showed a posterior shift. In LIF, a convex approach is relatively safer than an approach from the concave side. Lumbar nerve course tracking with DTI is useful for assessing patients with DLS before LIF.
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Affiliation(s)
| | - Masaki Norimoto
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | | | - Ryota Haga
- 3Radiology, Shimoshizu National Hospital, Yotsukaido, Chiba
| | | | | | | | - Sumihisa Orita
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Miyako Suzuki
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Kazuhide Inage
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Hirohito Kanamoto
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Koki Abe
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Tomotaka Umimura
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Takashi Sato
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Yasuchika Aoki
- 4Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Chiba
| | - Atsuya Watanabe
- 4Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Chiba
| | - Masao Koda
- 5Department of Orthopaedic Surgery, University of Tsukuba, Tsukuba City, Ibaraki; and
| | - Takeo Furuya
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Junichi Nakamura
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Tsutomu Akazawa
- 6Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Kazuhisa Takahashi
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
| | - Seiji Ohtori
- 2Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba
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