Understanding Retroperitoneal Anatomy for Lateral Approach Spine Surgery

Effect of Low Thoracic Paravertebral Block via the Arcuate Ligament Under Direct Visualization on the Quality of Postoperative Recovery After Laparoscopic Donor Nephrectomy for Living-Donor Kidney Transplantation: Study Protocol for a Prospective, Blinded, Randomized Controlled Clinical Trial

Introduction

Laparoscopic donor nephrectomy (LDN) is the standard procedure for donor nephrectomy for living kidney transplantation. Compared with traditional open surgery, the laparoscopic techniques have been developed to significantly reduce postoperative pain and accelerate postoperative recovery; however, most donors still experience more than moderate pain after surgery. Ensuring maximum perioperative safety and postoperative pain control for donors remains a top priority for LDN. Our group reported a novel blockade technique that allows local anesthetic to be injected directly to reach the low thoracic paravertebral space under direct laparoscopic observation via the arcuate ligament to achieve somatic and visceral pain analgesia; this technique has been successfully applied to patients undergoing retroperitoneal laparoscopic nephrectomy. We hypothesized that compared with the transversus abdominis plane (TAP) block, low thoracic paravertebral block (TPVB) via the arcuate ligament under direct vision would reduce the consumption of postoperative opioids and improve the quality of postoperative recovery of donors after LDN.

Methods/Analysis

This study is a prospective blind, randomized, controlled clinical trial with a concealed allocation of donors scheduled to undergo elective LDN 1:1 to receive either a low TPVB via the arcuate ligament under direct vision or a TAP block. This study will recruit a total of 82 living kidney donors. The primary outcome is the 15-item recovery quality scale (QoR-15) score at 24 hours after surgery.

Ethics and Dissemination

This trial was approved by the Ethics Committee of Beijing Friendship Hospital, Capital Medical University. This trial study protocol was approved on 30 November 2024. The trial started recruiting patients after being registered on the Chinese Clinical Trial Registry.

Trial Registration Number

ChiCTR2400094612.

Anterior Lumbar Interbody Fusion Versus Oblique Lumbar Interbody Fusion Versus Lateral Lumbar Interbody Fusion: Which One in Which Patient?

Anterolateral approaches to the lumbar spine provide direct access to the disc space. These techniques facilitate thorough discectomy, which is essential for successful arthrodesis. They improve segmental lordosis without osteotomy and indirectly decompress neural elements in carefully selected patients. Benefits include shorter operative times, reduced blood loss, and rapid postoperative mobilization compared to posterior approaches. Each technique has specific advantages and limitations, thus none is inherently superior to another. Detailed knowledge of these techniques is essential for modern spine surgeon to provide personalized operative plan for each patient.

Systematic Lymphatic Repair for Reduction of Postoperative Lymphatic Leak Following Neuroblastoma Resection

BACKGROUND

Gross total resection of neuroblastoma is associated with lymphatic leaks that can delay postoperative resumption of treatment. To prevent postoperative lymphatic leak, we introduced systematic lymphatic repair (SLR), which involved oversewing the entire edge of the disrupted lymphatic plane after neuroblastoma resection. We sought to study the impact of SLR on postoperative lymphatic leak and time to return to treatment.

METHODS

We reviewed 60 neuroblastoma patients who underwent gross total resection at KK Women's and Children's Hospital. Patient, disease, and operative factors were correlated with surgical drainage, treatment delay and length of stay (LOS). Among patients with sufficient records, the interaction between variables associated with drainage, delay and LOS outcomes were compared in 14 patients who had SLR versus 35 historical controls who had targeted lymphatic repair (TLR).

RESULTS

Postoperative drain duration and volume were significantly higher in tumors with ≥2 image-derived risk factors (IDRFs, P = 0.005 and P = 0.013, respectively) or vessel encasement (P = 0.031 and P = 0.024, respectively). Longer LOS was significantly associated with ≥2 IDRFs (P = 0.006). All forms of suture repair of lymphatics and use of Tachosil™ were associated with significantly longer postoperative drain duration (P < 0.05); the former was also associated with significantly higher total drain volume (P < 0.05) - indicating appropriate use of these adjuncts in patients at risk of chyle leak. In patients who had suture repair of lymphatics, SLR was significantly associated with reduced postoperative interval to chemotherapy resumption (P = 0.014, two-way ANOVA).

CONCLUSION

A systematic approach to repair of lymphatic channels following neuroblastoma resection can significantly reduce time to postoperative resumption of treatment.

TYPE OF STUDY

Clinical Research.

LEVEL OF EVIDENCE

III.

A retrospective analysis of perioperative complications of lateral approach lumbar interbody fusion in patients with prior abdominal surgery or a history of colonic inflammatory disease

BACKGROUND CONTEXT

Lateral approaches for lumbar interbody fusion (LIF) allow for access to the lumbar spine and disc space by passing through a retroperitoneal corridor either pre- or trans-psoas. A contraindication for this approach is the presence of retroperitoneal scarring that may occur from prior surgical intervention in the retroperitoneal space or from inflammatory conditions with fibrotic changes and pose challenges for the mobilization and visualization needed in this approach. However, there is a paucity of evidence on the prevalence of surgical complications following lateral fusion surgery in patients with a history of abdominal surgery.

PURPOSE

The primary aim of this study is to describe the association between surgical complications following lateral interbody fusion surgery and prior abdominal surgical.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Patients over the age of 18 who underwent lateral lumbar interbody fusion at a large, tertiary care center between 2011 and 2019 were included in the study.

OUTCOME MEASURES

The primary outcome included medical, surgical, and thigh-related complications either in the intraoperative or 90-day postoperative periods. Additional outcome metrics included readmission rates, length of stay, and operative duration.

METHODS

The electronic health records of 250 patients were reviewed for demographic information, surgical data, complications, and readmission following surgery. The association of patient and surgical factors to complication rate was analyzed using multivariable logistic regression. Statistical analysis was performed using R statistical software (R, Vienna, Austria).

RESULTS

Of 250 lateral interbody fusion patients, 62.8% had a prior abdominal surgery and 13.8% had a history of colonic disease. The most common perioperative complication was transient thigh or groin pain/sensory changes (n=62, 24.8%). A multivariable logistic regression considering prior abdominal surgery, age, BMI, history of colonic disease, multilevel surgery, and the approach relative to psoas found no significant association between surgical complication rates and colonic disease (OR 0.40, 95% CI 0.02-2.22) or a history of prior abdominal surgeries (OR 0.56, 95% CI 0.20-1.55). Further, the invasiveness of prior abdominal surgeries showed no association with overall spine complication rate, lateral-specific complications, or readmission rates (p>.05).

CONCLUSION

Though retroperitoneal scarring is an important consideration for lateral approaches to the lumbar spine, this study found no association between lateral lumbar approach complication rates and prior abdominal surgery. Further study is needed to determine the impact of inflammatory colonic disease on lateral approach spine surgery.

Systematic review and meta-analysis of percutaneous nephrolithotomy in flank versus prone position

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the efficiency and safety of percutaneous nephrolithotomy (PCNL) between flank position and prone position for the treatment of renal stones.

METHODS

PubMed, Embase, OVID, and Cochrane Library were comprehensively searched from their inception to Jul 2024. Randomized and nonrandomized trials evaluating renal calculi patients who underwent PCNL via flank position or prone position were included. Data extraction and quality assessment were conducted by two independent reviewers. The outcomes and complications of both groups were compared in this meta-analysis.

RESULTS

This review involved five articles (554 patients). Specifically, four articles were randomized controlled trials, and the remaining publication was prospective cohort study. No significant difference was found in stone-free rate between the flank group and prone group after the PCNL procedure. Similarly, the percutaneous access time, operative time, and hospital stay of flank position had no significant difference compared with the prone group. There was no significant difference in the comparison of complication rates between the flank group and the prone group. Although further analysis indicated that patients in the prone position suffered more hemoglobin drop than the flank group, no significant difference was found in the hemorrhage and blood transfusion rates.

CONCLUSIONS

Both surgical positions were appropriate for most PCNL procedures and had shown similar efficacy and safety. In practice, the optimal choice should be made according to the patients' conditions and urologists' acquaintance.

Effect of thoracolumbar fascia injury on reported outcomes after percutaneous vertebroplasty

Purpose

Thoracolumbar fascia injury is often associated with poor early pain relief after percutaneous vertebroplasty (PVP). This study will evaluate the effects of thoracolumbar fascia injury on early pain relief and time to get out of bed after PVP.

Methods

A total of 132 patients treated with PVP for osteoporotic vertebral compression fractures (OVCF) were included and divided into injured group (52 cases) and non-injured group (80 cases) according to the existence of thoracolumbar fascia injury. Before surgery, 1 day, 3 days, 1 week, 1 month, and 3 months after surgery, and at the last follow-up, the primary patient-reported outcome measures (PROMs) were the visual analogue scale (VAS) of pain while rolling over and standing, and the secondary PROMs was the Oswestry disability index (ODI). Meanwhile, the achieved rate of minimal clinically important differences (MCID) and patient acceptable symptom states (PASS) of the above measures in both groups was evaluated at the last follow-up.

Results

Except for the postoperative 3 months and the last follow-up, there were statistically significant differences in VAS-standing and ODI between the two groups at other time points after surgery (P < 0.05), and the non-injured group was significantly better than the injured group. At the last follow-up, there was no statistically significant difference in the MCID and PASS achievement rates of the above measures between the two groups (P > 0.05). In addition, the proportion of patients who got out of bed 1 and 3 days after surgery in the non-injury group was significantly higher than that in the injury group (P = 0.000 for both).

Conclusion

Thoracolumbar fascia injury significantly affected early pain relief and extended time of getting out of bed after PVP. Attention should be paid to preoperative evaluation of thoracolumbar fascial injury in order to better predict the postoperative efficacy of PVP.

Single-Position Prone Lateral Lumbar Interbody Fusion Technique Guide: Surgical Tips and Tricks

Lateral lumbar interbody fusion (LLIF) is a popular technique as it allows for the placement of a large interbody implant through a retroperitoneal, transpsoas working corridor. Historically, the interbody is placed with the patient in lateral decubitus and then repositioned to prone for the posterior instrumentation. While this has been an effective and successful technique, removing the interoperative flip would improve the efficiency of these cases. This has led to modified LLIF approaches including single-position prone LLIF (pLLIF). This modification has shown to be an efficient and powerful technique; however, learning to navigate the LLIF approach in the prone position has its own challenges. The purpose of this article is to provide a detailed description of our pLLIF technique while simultaneously introducing surgical tips to overcome the challenges of the approach and optimize the implantation of the interbody device.

Retroperitoneal anatomy with the aid of pathologic fluid: An imaging pictorial review

The retroperitoneum, a complex anatomical space within the abdominopelvic region, encompasses various vital abdominal organs. It is compartmentalized by fascial planes and contains potential spaces critical in multiple disease processes, including inflammatory effusions, hematomas, and neoplastic conditions. A comprehensive understanding of the retroperitoneum and its potential spaces is essential for radiologists in identifying and accurately describing the extent of abdominopelvic disease. This pictorial review aims to describe the anatomy of the retroperitoneum while discussing commonly encountered pathologies within this region. Through a collection of illustrative images, this review will provide radiologists with valuable insights into the retroperitoneum, facilitating their diagnostic proficiency to aid in appropriate patient clinical management.

Retroperitoneal Continuous Local Antibiotic Perfusion for Refractory Pyogenic Vertebral Osteomyelitis: A Case Report

Pyogenic vertebral osteomyelitis (PVO) is a prevalent infection in the elderly, frequently complicated by iliopsoas and epidural abscesses. Traditional treatments are often ineffective for refractory cases. In this report, a 76-year-old man with PVO, iliopsoas, and epidural abscess was unresponsive to antibiotics, presenting with severe lower back pain and functional impairments. A two-stage surgical intervention was implemented: anterior debridement, autogenous bone graft fixation, and novel application of retroperitoneal continuous local antibiotic perfusion (CLAP), followed by posterior fixation. A contrast test verified correct CLAP perfusion into the iliopsoas abscess and intervertebral disc space. Substantial improvements were noted postoperatively, including a marked reduction in pain, inflammation, and the size of both abscesses. In conclusion, this case demonstrates the feasibility and effectiveness of retroperitoneal CLAP in treating refractory PVO, offering a potential innovative solution for cases resistant to conventional therapies.

Efficacy and safety of unilateral biportal endoscopy compared with microscopic decompression in the treatment of lumbar spinal stenosis: A systematic review and updated meta‑analysis

The incidence of lumbar spinal stenosis is increasing annually, and with an ever-aging population and longer life expectancies, this trend will further continue. It is hoped that a more effective treatment can be found so that the patients can be relieved of their pain. The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of unilateral biportal endoscopic surgery (UBE) and microscopic decompression surgery (MD) for the treatment of lumbar spinal stenosis. A literature search of related studies published until April 2022 was performed using PubMed, EMBASE, Cochrane Library, Web of Science, ClinicalTrials.gov, Google Scholar, China National Knowledge Infrastructure (CNKI), and other databases. After filtering of references, 12 eligible studies were identified that compared UBE with MD as a treatment for lumbar spinal stenosis. Data were extracted and analysed using R. A total of 12 articles (four randomized controlled and eight cohort studies) were included, with a total of 1,067 patients: 250 men and 249 women in the UBE group and 290 men and 278 women in the MD group. The meta-analysis showed that the mean intraoperative blood loss in the UBE group [standardized mean difference (SMD)=-2.10, 95% confidence interval (CI) (-3.97, -0.23), P=0.03] was lower than that in the MD group. The postoperative Visual analogue scale (VAS) score for back pain [SMD=-0.52, 95% CI (-0.76, -0.27), P<0.01], leg pain [SMD=-0.30, 95% CI (-0.51, -0.08), P<0.01], postoperative Oswestry disability index [(ODI); SMD=-0.25, 95% CI (-0.48, -0.03), P=0.03], and postoperative C-reactive protein [(CRP); odds ratio (OR)=-0.92, 95% CI (-1.80, 0.03), P=0.04] were lower than those in the MD group. Complications (OR=0.60, 95% CI (0.37, 0.98), P=0.04) and hospital stay (SMD=-1.84, 95% CI (-2.85, 0.83), P <0.01] were also lesser in the UBE group than in the MD group. UBE was preferable to that in the MD group according to the modified MacNab score [OR=2.28, 95% CI (1.28, 4.06), P<0.01]. No significant differences were observed in the operation times between the groups. UBE surgery was found to be a better option for the treatment of lumbar spinal stenosis than MD surgery.

CT-based analysis of oblique lateral interbody fusion from L1 to L5: location of incision, feasibility of safe corridor approach, and influencing factors

PURPOSE

The primary aim was to measure the safe corridor (SC), surgical incision anterior margin (AM), and posterior margin (PM) for OLIF bilaterally from L1 to L5. The secondary aim was to determine the feasibility of approach via the SC. The tertiary aim was to analyze the influence of demographic and anthropometric factors on OLIF parameters.

METHODS

We performed a radiographic analysis of 100 subjects who received an abdominal CT. Measurements of the AM, PM, and SC were obtained as well as patient age, sex, height, weight, and BMI. The intraclass correlation coefficient was used to evaluate interrater reliability. To assess associations among variables, Pearson's correlation tests and multivariate linear regression models were constructed. Sex differences were analyzed using Student's t tests.

RESULTS

At L1-2, L2-3, L3-4, and L4-5, the PM was 6.6, 8.2, 9.4, and 10.2 cm on the left side and 7.2, 7.7, 8.8, and 9.5 cm on the right side in relation to the disk space center. The SC was less than 1 cm 1%, 3%,3%, and 18% of the time on the left side, and 15%, 12%,29%, and 60% on the right side. None of the anthropometric factors demonstrated a strong correlation with incision location. SC was larger on the left side. Interrater ICC was .934.

CONCLUSIONS

This study is the first to provide guidelines on the appropriate location of the incision line during OLIF based on SC from L1 to L5. SC measurements do not vary by sex. OLIF is more feasible via a left-sided approach.

Iliolumbar vein: a challenge for the exposure of the L4-5 disc in the anterior approach to the lumbar spine

PURPOSE

Anterior lumbar spine arthrodesis has been increasingly prescribed. In order to obtain better exposure of the intervertebral discs, it is necessary to identify vascular structures depending on the level to be approached. Systematic ligation of the iliolumbar vein has been suggested for access to the L4-L5 level, which may be technically challenging. The goal of the present study was to determine a safe limit for separating the iliolumbar vein safely without the need for its ligation.

METHODS

In total, 2284 patients involving the topography of the iliolumbar vein were included. If this vein was up to 5 mm distant from the inferior border of the L4-L5 intervertebral disc, its ligature was performed. In cases that the distance was greater than 5 mm, only the retraction was performed without ligature.

RESULTS

A total of 115 ligatures were necessary (5% of cases). Among the 2169 cases with no ligature, bleeding due to ruptures occurred during traction in only 55 patients (3% of cases). The time taken for ligation ranged from five minutes to thirty-two minutes, with an average of 18.3 min per ligature. In cases in which ligatures were needed (distance less than 5 mm), there was loosening of the ligatures leading to bleeding in 23 cases (20% of ligatures).

CONCLUSIONS

Systematic ligature is not necessary for accessing the anterior route to the L4-L5 level, leading to a reduction in the time of surgery and avoiding serious vascular injuries that can occur.

Evaluation of Sensory Loss and Postoperative Analgesia Obtained by Diaphragmatic Apposition Zone Block Under Direct Laparoscopic Visualization in Patients Undergoing Nephrectomy: A Descriptive Study

Purpose

Local anesthetics can spread into the subendothoracic fascia compartment via the arcuate ligament and apposition zone of the diaphragm after the anterior quadratus lumborum blocks. Therefore, a new block may be achieved if local anesthetic is administered into the diaphragmatic apposition zone (DAZ) under direct laparoscopic visualization by surgeons. Therefore, we evaluated the sensory loss and postoperative analgesic efficacy of this new block in patients receiving laparoscopic nephrectomy.

Methods

A total of 28 patients scheduled to receive elective laparoscopic nephrectomy under general anesthesia were enrolled in this study. The DAZ blocks were performed in patients under direct laparoscopic visualization with 20 mL of 0.5% ropivacaine before the dissected kidneys or renal tumors were taken out from the incision. All patients received the intravenous patient-controlled analgesia after surgery. The dermatomes of sensory loss and the muscle weakness of quadriceps femoris were assessed at 2 h post-surgery in the wards. The postoperative pain was scored. The opioid consumption in the first 24 h after surgery was recorded.

Results

The average number of dermatomes of sensory block was 8.6 ± 1.2. The highest level of sensory loss was T6 (T5-T6) [median (interquartile range, IQR)], and the lowest level of sensory block was L1 (L1–L2). The postoperative pain scores at rest or on movement at 2 h, 6 h, 12 h, 24 h and 48 h were kept at the low levels (less than 4). The muscle strength of the quadriceps femoris evaluated was 5 (5–5) points [median (IQR)]. Total dose of intravenous morphine equivalent consumption in the first 24 h after surgery was 21.2 ± 4.1 mg.

Conclusion

The DAZ block manifests a wide dermatomal coverage of sensory loss and is associated with the low levels of postoperative pain intensity and opioid use. It provides a new postoperative analgesia option for patients undergoing laparoscopic nephrectomy.

Supra-Arcuate Ligament Blocks: Anatomy, Mechanisms, and Techniques

Quadratus lumborum block (QLB) is clinically used for postoperative analgesia of abdominal or hip surgery, which can reduce the dose of general anesthetic, inhibit postoperative pain, and promote postoperative rehabilitation. However, accumulated studies have shown several drawbacks of QLB, such as only a small portion of local anesthetic spread into the thoracic paravertebral space, relatively longer onset time, and easily-influenced block effect by the integrity of lumbar fascia, etc. Therefore, on the basis of traditional anterior QLB, our group proposed the techniques of a supra-arcuate ligament block, which include a paramedian short-axis scanning approach, paramedian long-axis scanning approach, infra-lateral arcuate ligament QLB with the apposition zone between diaphragm and quadratus lumborum as drug diffusion target and supra-arcuate ligament block under direct laparoscopic visualization. Recent studies have demonstrated that the supra-arcuate ligament blocks have the advantages of clear anatomy, are easy to perform, and have rapid onset, which avoid some drawbacks of the conventional QLB techniques. This article reviews the anatomical basis, sonoanatomy, technical points, and clinical considerations of supra-arcuate ligament blocks.

Comparison of Outcomes between Minimally Invasive Lateral Approach Vertebral Reconstruction Using a Rectangular Footplate Cage and Conventional Procedure Using a Cylindrical Footplate Cage for Osteoporotic Vertebral Fracture

The aim of the current study was to compare outcomes between lateral access vertebral reconstruction (LAVR) using a rectangular footplate cage and the conventional procedure using a cylindrical footplate cage in patients with osteoporotic vertebral fracture (OVF). We included 46 patients who underwent anterior-posterior combined surgery for OVF: 24 patients underwent LAVR (Group L) and 22 underwent the conventional procedure (Group C). Preoperative, postoperative, and 1- and 2-year follow-up X-ray images were used to measure local lordotic angle, correction loss, and cage subsidence (>2 mm in vertebral endplate depression). In anterior surgery, the operation time was significantly shorter (183 vs. 248 min, p < 0.001) and the blood loss was significantly less (148 vs. 406 mL, p = 0.01) in Group L than in Group C. In Group C, two patients had anterior instrumentation failure. Correction loss was significantly smaller in Group L than in Group C (1.9° vs. 4.9° at 1 year, p = 0.02; 2.5° vs. 6.5° at 2 years, p = 0.04, respectively). Cage subsidence was significantly less in Group L than in Group C (29% vs. 80%, p < 0.001). LAVR using a rectangular footplate cage is an effective treatment for OVF to minimize surgical invasiveness and postoperative correction loss.

Anterior quadratus lumborum block at the lateral supra-arcuate ligament versus transmuscular quadratus lumborum block for postoperative analgesia in patients undergoing laparoscopic nephrectomy: A randomized controlled trial

STUDY OBJECTIVE

The analgesic efficacy of transmuscular quadratus lumborum block (TQLB) to decrease the need for opioid consumption after laparoscopic nephrectomy has been demonstrated in several studies. However, the effect of an anterior QLB approach at the lateral supra-arcuate ligament (QLB-LSAL) in this surgical context is unclear. Here, we aimed to compare postoperative analgesic effects of the two block approaches in laparoscopic nephrectomy.

DESIGN

A single-center, randomized controlled trial.

SETTING

University-affiliated tertiary care hospital.

PATIENTS

A total of 106 patients with American Society of Anesthesiologists (ASA) physical status of I-III scheduled to undergo elective laparoscopic nephrectomy under general anesthesia.

INTERVENTIONS

Patients were randomly allocated to receive preoperative TQLB or QLB-LSAL with 0.5% ropivacaine (25 mL). Postoperatively, patient-controlled analgesia with intravenous sufentanil was administered.

MEASUREMENTS

The primary outcome was postoperative intravenous morphine equivalent consumption within the first 24 h postoperatively. Secondary outcomes included pain scores, satisfaction scores, levels of sedation, and incidence of nausea or vomiting.

MAIN RESULTS

Patients who underwent preoperative QLB-LSAL used a significantly lower intravenous morphine equivalent dose than those who underwent preoperative TQLB within the initial 24 h after surgery (34.3 ± 6.3 mg vs 23.5 ± 3.2 mg, P < 0.001). No significant differences were observed in pain scores, satisfaction scores, sedation scores, or incidence of nausea or vomiting between the groups.

CONCLUSIONS

The results indicate that, compared to TQLB, QLB-LSAL is a beneficial nerve block that can reduce postoperative opioid consumption, making it a potentially superior approach to achieve multimodal analgesia after laparoscopic nephrectomy.

Differences in surgical outcome after anterior corpectomy and reconstruction with an expandable cage with rectangular footplates between thoracolumbar and lumbar osteoporotic vertebral fracture

Background

Anterior and posterior spinal fixation (APSF) can provide rigid structural anterior column support in patients with osteoporotic vertebral fracture (OVF). A new rectangular footplate designed based on biomechanical studies of endplates provides better resistance to subsidence. However, differences in characteristics exist between the thoracolumbar and lower lumbar spine. The purpose of this study was to evaluate the surgical outcomes following APSF using an expandable cage with rectangular footplates in the thoracolumbar/lumbar region.

Methods

Consecutive patients who underwent APSF for OVF at multiple centers were retrospectively reviewed. Clinical and radiographic evaluations were performed by dividing the patients into thoracolumbar (TL, T10–L2) and lumbar (L, L3–L5) groups. Surgical indications were incomplete neurologic deficit or intractable back pain with segmental spinal instability. Surgical outcomes including the Japanese Orthopaedic Association (JOA) score and reoperation rate were compared between TL and L groups.

Results

Sixty-nine patients were followed-up for more than 12 months and analyzed. Operative intervention was required for 35 patients in the TL group and 34 patients in the L group. Mean ages in the TL and L groups were 76.5 years and 75.1 years, respectively. Intra-vertebral instability was more frequent in the TL group (p<0.001). Screw fixation range was significantly longer in the TL group (p=0.012). The rate of cage subsidence did not differ significantly between the TL group (46%) and L group (44%). Reoperation rate tended to be higher in the TL group (p=0.095). Improvement ratio of JOA score was significantly better in the L group (60%) than in the TL group (46.9%, p=0.029).

Conclusion

APSF using an expandable cage was effective to treat OVF at both lumbar and thoracolumbar levels. However, the improvement ratio of the JOA score was better in the L group than in the TL group.

A Modified Approach Below the Lateral Arcuate Ligament to Facilitate the Subcostal Anterior Quadratus Lumborum Block

Purpose

The subcostal quadratus lumborum (QL) block was used in postoperative analgesia for abdominal surgery. However, it is difficult to precisely put the needle tip into the target fascia compartment. In the current study, we proposed a modified approach to facilitate the subcostal QL block.

Patients and Methods

Twenty-four patients scheduled for laparoscopic renal surgery were enrolled. The modified QL block was placed preoperatively. The transducer was placed just laterally to the tip of L1 transverse process to perform the parasagittal scan. The needle was inserted in-plane and advanced toward the target compartment between the QL muscle and the anterior thoracolumbar fascia and just below the lateral arcuate ligament. The 20 mL of 0.5% ropivacaine was injected slowly if the saline spread cranially via the posterior pathway of lateral arcuate ligament was observed on the sonogram. Then, the paramedian transverse scanning at the level of T12-L1 was performed to observe the injectate diffusion. The dermatomal coverage of sensory block was tested at 5 min and 10 min after LA injections. The complications associated with the block were recorded.

Results

Twenty-three (95.8%) patients received the successful block. All patients achieved the sensory block dermatomes of T9–T12 and T6–L1, at 5 and 10 minutes after injection, respectively. The mean numbers of block dermatomes were 5.6±1.8 at 5 min and 6.5±2.2 at 10 min after injection. Two out of twenty-three (8.7%) patients achieved coverage as cephalad as T5 at 10 min after injections. The lunar-shaped spread of LA along the diaphragm into the T12 paravertebral space was observed in every patient. No complications occurred.

Conclusion

The modified subcostal QL block has the advantages of clear sonoanatomy, rapid onset time, and consistent dermatomal coverage and provides a new choice for postoperative analgesia of abdominal surgery.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR2000029210.

Dermatomal coverage of single-injection ultrasound-guided parasagittal approach to anterior quadratus lumborum block at the lateral supra-arcuate ligament

The subcostal quadratus lumborum (QL) block is used in postoperative analgesia for abdominal surgery. However, only a small portion of local anesthetic can spread into the thoracic paravertebral space from the injection site via the lateral arcuate ligament, due to the barrier action of the ligament. In this study, we determined the effectiveness of a new ultrasound-guided parasagittal approach to anterior QL block at the lateral supra-arcuate ligament. Twenty six patients scheduled for laparoscopic renal surgery were enrolled. The parasagittal approach to the anterior QL block at the lateral supra-arcuate ligament was carried out preoperatively. Our data showed that at 5 and 10 min after injection, the patients achieved the sensory block of dermatomes T9-T12 and T7-L1, respectively. Some patients achieved coverage as cephalad as T5 and as caudal as L3. Four patients (16.7%) developed quadriceps weakness after the blocks. The parasagittal technique provides a new choice for postoperative analgesia of abdominal surgery with rapid onset and reliable dermatomal coverage.Trial registration: Chinese Clinical Trial Registry: ChiCTR2000029211.

Lumbar Spinal Fusion Using Lateral Oblique (Pre-psoas) Approach (Review)

Lumbar spinal fusion is one of the most common operations in spinal surgery. For its implementation, anterolateral (pre-psoas) approach (oblique lumbar interbody fusion, OLIF) is now increasingly used due to its high efficacy and safety. However, there is still little information on the clinical and radiological results of using this technique.

The aim of the study was to analyze the safety and efficacy of OLIF in the treatment of lumbar spine disorders as presented in the literature.

Hernia after retroperitoneoscopic adrenalectomy, case report

We report the first case of a previously undocumented complication after posterior retroperitoneal adrenalectomy (PRA). Extensive diagnostic procedures for persisting abdominal pain led to diagnosis of an incisional hernia (IH) approximately 2.5 years after surgery for a pheochromocytoma of the right adrenal gland. Thus, IHs need to be recognized as a potential complication after PRA, particularly if the symptoms are non-specific. The differential diagnosis of an IH after PRA includes a type of spontaneous lumbar hernia due to a pre-existing weakness of the abdominal wall however the treatment for both type of hernias is similar by mesh repair. A possible risk factor for IH after PRA might be obesity, due to different factors including difficulties in closing the fascia in depth under subcutaneous tissue.

Radiological Assessment of Damage to the Iliopsoas Muscle by the Oblique Lateral Interbody Fusion Approach

INTRODUCTION

There are several reports about invasive muscle injury during posterior spinal surgery. However, few reports have evaluated the association between the clinical symptoms and changes in the physical properties of the psoas major after oblique lateral interbody fusion (OLIF). Therefore, the current study aimed to investigate the relationship between the clinical symptoms and changes in the psoas major muscle before and after OLIF.

METHODS

Twenty-seven patients who underwent single-level OLIF following the diagnosis of degenerative lumbar disease were included in the study. The cross-sectional areas (CSAs) of the psoas major on the approaching and contralateral sides were measured in the axial computed tomography view of the surgical intervertebral space preoperatively and postoperatively at 1 week and 3, 6, and 12 months. The preoperative and postoperative changes in the CSAs were compared. Muscle degeneration was evaluated using axial magnetic resonance images at the same level as that in the CSA evaluation preoperatively and at 12 months postoperatively. Additionally, the relationship between these parameters and postoperative lower limb symptoms was investigated.

RESULTS

Significant swelling of the psoas major on the approach side was observed 1 week postoperatively (p < 0.05). No postoperative muscle degeneration was observed. Three cases of paresthesia in the front of the thigh were observed, but no association was found with changes in CSA in any of the cases.

CONCLUSIONS

The OLIF approach caused swelling of the psoas major 1 week postoperatively with no more muscle degeneration in the mid-term. Although numbness of the lower limbs was found in some cases, no association was found with changes in CSA. Our study findings suggest that the OLIF approach causes temporary injury or swelling of the psoas major, but the long-term damage to the muscle is not significant.

Intraoperative ultrasound visualization of paravertebral anatomy in the retroperitoneal space during lateral lumbar spine surgery

OBJECTIVE

Lumbar surgery via a lateral approach is a minimally invasive and highly useful procedure. However, care must be taken to avoid its potentially fatal complications of intestinal and vascular injuries. The object of this study was to evaluate the usefulness of intraoperative ultrasound in improving the safety of lateral lumbar spine surgery.

METHODS

A transvaginal ultrasound probe was inserted into the operative field, and the intestinal tract, kidney, psoas muscle, and vertebral body were identified using B-mode ultrasound. The aorta, vena cava, common iliac vessels, and lumbar arteries and their associated branches were identified using the color Doppler mode.

RESULTS

The study cohort comprised 100 patients who underwent lateral lumbar spine surgery, 92 via a left-sided approach. The intestinal tract and kidney lateral to the psoas muscle on the anatomical approach pathway were visualized in 36 and 26 patients, respectively. A detachment maneuver displaced the intestinal tract and kidneys in an anteroinferior direction, enabling confirmation of the absence of organ tissues above the psoas. In all patients, the major vessels anterior to the vertebral bodies and the lumbar arteries and associated branches in the psoas on the approach path were clearly visualized in the Doppler mode, and their orientation, location, and positional relationship with regard to the vertebral bodies, intervertebral discs, and psoas were determined.

CONCLUSIONS

When approaching the lateral side of the lumbar spine in the retroperitoneal space, intraoperative ultrasound allows real-time identification of the blood vessels surrounding the lumbar spine, intestinal tract, and kidney in the approach path and improves the safety of surgery without increasing invasiveness.

Minimally Invasive Endoscopic-Assisted Lateral Lumbar Interbody Fusion: Technical Report and Preliminary Results

OBJECTIVE

Lateral lumbar interbody fusion (LLIF) is a highly useful lumbar fusion surgical technique for degenerative spinal disease. However, many complications have already been reported. The purpose of this study is to report the concept, surgical technique, and clinical results of the first 70 consecutive cases treated with a safer and minimally invasive endoscopic-assisted LLIF (ELLIF).

METHODS

This retrospective study included 70 cases involving 106 segments in which ELLIF was used to treat degenerative spinal disease. We examined the clinical progress, complications and analyzed radiographic images. Regarding the fusion rate, 49 cases involving 72 segments whose follow-up period was more than 7 months were evaluated.

RESULTS

The mean of preoperative Numerical Rating Scale (NRS) was 7.0 and postoperative NRS was 1.4. Postoperative NRS had a significant correlation with the number of fusion segments (p = 0.028). The mean of preoperative disc space height, foraminal height, sagittal rotation angle, whole lumbar lordosis and sagittal translation distance were 3.3 mm, 14.3 mm, 2.4°, 9.7°, and 3.2 mm, respectively. Postoperative values were 9.4 mm, 17.9 mm, -4.9°, 36.3°, and 0.7 mm. The fusion rate was 79.2%. Complications included, transient psoas muscle weakness 1, sensory disturbance in the thigh 2, retroperitoneal injury 1, postoperative ileus possibly involving a retroperitoneal injury 1, and cage migration 4.

CONCLUSION

Using the ELLIF in the degenerative spinal disease, we obtained good radiological reduction and good clinical results. Our study confirms that ELLIF is safer and provides better results for degenerative spinal disease. However, the issue of cage migration remains to be resolved.