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Allison DW, Verma A, Holman PJ, Huang M, Trask TW, Barber SM, Cockrell AR, Weber MR, Brooks DW, Delgado L, Steele WJ, Sellin JN, Gressot LV, Lambert B, Ma BB, Faraji AH, Saifi C. Transabdominal motor evoked potential neuromonitoring of lumbosacral spine surgery. Spine J 2024:S1529-9430(24)00194-3. [PMID: 38685276 DOI: 10.1016/j.spinee.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/15/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND CONTEXT Transcranial Motor Evoked Potentials (TcMEPs) can improve intraoperative detection of femoral plexus and nerve root injury during lumbosacral spine surgery. However, even under ideal conditions, TcMEPs are not completely free of false-positive alerts due to the immobilizing effect of general anesthetics, especially in the proximal musculature. The application of transcutaneous stimulation to activate ventral nerve roots directly at the level of the conus medularis (bypassing the brain and spinal cord) has emerged as a method to potentially monitor the motor component of the femoral plexus and lumbosacral nerves free from the blunting effects of general anesthesia. PURPOSE To evaluate the reliability and efficacy of transabdominal motor evoked potentials (TaMEPs) compared to TcMEPs during lumbosacral spine procedures. DESIGN We present the findings of a single-center 12-month retrospective experience of all lumbosacral spine surgeries utilizing multimodality intraoperative neuromonitoring (IONM) consisting of TcMEPs, TaMEPs, somatosensory evoked potentials (SSEPs), electromyography (EMG), and electroencephalography. PATIENT SAMPLE Two hundred and twenty patients having one, or a combination of lumbosacral spine procedures, including anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), posterior spinal fusion (PSF), and/or transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES Intraoperative neuromonitoring data was correlated to immediate post-operative neurologic examinations and chart review. METHODS Baseline reliability, false positive rate, true positive rate, false negative rate, area under the curve at baseline and at alerts, and detection of pre-operative deficits of TcMEPs and TaMEPs were compared and analyzed for statistical significance. The relationship between transcutaneous stimulation voltage level and patient BMI was also examined. RESULTS TaMEPs were significantly more reliable than TcMEPs in all muscles except abductor hallucis. Of the 27 false positive alerts, 24 were TcMEPs alone, and 3 were TaMEPs alone. Of the 19 true positives, none were detected by TcMEPs alone, 3 were detected by TaMEPs alone (TcMEPs were not present), and the remaining 16 true positives involved TaMEPs and TcMEPs. TaMEPs had a significantly larger area under the curve (AUC) at baseline than TcMEPs in all muscles except abductor hallucis. The percent decrease in TcMEP and TaMEP AUC during LLIF alerts was not significantly different. Both TcMEPs and TaMEPs reflected three pre-existing motor deficits. Patient BMI and TaMEP stimulation intensity were found to be moderately positively correlated. CONCLUSIONS These findings demonstrate the high reliability and predictability of TaMEPs and the potential added value when TaMEPs are incorporated into multimodality IONM during lumbosacral spine surgery.
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Affiliation(s)
- David W Allison
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA.
| | - Amit Verma
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Paul J Holman
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Meng Huang
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Todd W Trask
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Anthony R Cockrell
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Matthew R Weber
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Dalton W Brooks
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Leo Delgado
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - William J Steele
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Jonathan N Sellin
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Loyola V Gressot
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Bradley Lambert
- Department of Orthopedics, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Brandy B Ma
- Department of Neurology, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Amir H Faraji
- Department of Neurosurgery, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
| | - Comron Saifi
- Department of Orthopedics, Houston Methodist Health System, 6560 Fannin Street, Houston, TX 77030, USA
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NaPier Z. Prone Transpsoas Lateral Interbody Fusion (PTP LIF) with Anterior Docking: Preliminary functional and radiographic outcomes. N Am Spine Soc J 2023; 16:100283. [PMID: 37915968 PMCID: PMC10616382 DOI: 10.1016/j.xnsj.2023.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/05/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023]
Abstract
Background Disadvantages of lateral interbody fusion (LIF) through a direct, transpsoas approach include difficulties associated with lateral decubitus positioning and limited sagittal correction without anterior longitudinal ligament release or posterior osteotomy. Prior technical descriptions advocate anchoring or docking the retractor into the posterior to middle aspect of the disc space. Methods 72 patients who underwent 116 total levels of Prone Transpsoas (PTP) LIF with anterior docking with a single surgeon between December 2021 and May 2023 were included. Patient characteristics, perioperative data, as well as postoperative functional and radiographic outcomes were recorded. Subgroup analysis was performed for patients who underwent single-level PTP LIF with single-level percutaneous fixation (SLP). Patients in the SLP subgroup did not undergo direct decompression, release, or osteotomy. Results N=41 (56.9%) of cases included the L4-5 level. No vascular, bowel, or other visceral complications occurred. No patients developed a permanent motor deficit. Both the total cohort and the SLP group demonstrated statistically significant improvements in functional outcomes including Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) as well as all radiographic parameters measured. Mean total operative time (incision to completion of closure for lateral and posterior fusion) in the SLP group was 104.3 minutes with a significant downward trend with increasing surgeon experience. The SLP group demonstrated a 9.9° increase in segmental lordosis (SL), a 7.5° increase in lumbar lordosis (LL), 5.3° reduction in pelvic tilt (PT), and a decrease in pelvic incidence - lumbar lordosis mismatch (PI-LL) from 11.0° preoperatively to 3.9°, postoperatively (p<.01). Conclusions PTP LIF with anterior docking may address shortcomings associated with traditional lateral interbody fusion by producing safe and reproducible access with improved restoration of segmental lordosis and optimization of spinopelvic parameters.
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Affiliation(s)
- Zachary NaPier
- Indiana Spine Group, 13225 N Meridian St, Carmel, IN 46032, United States
- Sierra Spine Institute, 5 Medical Plaza Dr, Suite 120, Roseville, CA, 95661, United States
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Mok JM, Lin Y, Tafur JC, Diaz RL, Amirouche F. Biomechanical Comparison of Multilevel Stand-Alone Lumbar Lateral Interbody Fusion With Posterior Pedicle Screws: An In Vitro Study. Neurospine 2023; 20:478-486. [PMID: 37401066 PMCID: PMC10323329 DOI: 10.14245/ns.2244734.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/06/2023] [Accepted: 02/05/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE Lumbar lateral interbody fusion (LLIF) allows placement of large interbody cages while preserving ligamentous structures important for stability. Multiple clinical and biomechanical studies have demonstrated the feasibility of stand-alone LLIF in single-level fusion. We sought to compare the stability of 4-level stand-alone LLIF utilizing wide (26 mm) cages with bilateral pedicle screw and rod fixation. METHODS Eight human cadaveric specimens of L1-5 were included. Specimens were attached to a universal testing machine (MTS 30/G). Flexion, extension, and lateral bending were attained by applying a 200 N load at a rate of 2 mm/sec. Axial rotation of ± 8° of the specimen was performed at 2°/sec. Three-dimensional specimen motion was recorded using an optical motion-tracking device. Specimens were tested in 4 conditions: (1) intact, (2) bilateral pedicle screws and rods, (3) 26-mm stand-alone LLIF, (4) 26-mm LLIF with bilateral pedicle screws and rods. RESULTS Compared to the stand-alone LLIF, bilateral pedicle screws and rods had 47% less range of motion in flexion-extension (p < 0.001), 21% less in lateral bending (p < 0.05), and 20% less in axial rotation (p = 0.1). The addition of bilateral posterior instrumentation to the stand-alone LLIF resulted in decreases of all 3 planes of motion: 61% in flexion-extension ( p < 0.001), 57% in lateral bending (p < 0.001), 22% in axial rotation (p = 0.002). CONCLUSION Despite the biomechanical advantages associated with the lateral approach and 26 mm wide cages, stand-alone LLIF for 4-level fusion is not equivalent to pedicle screws and rods.
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Affiliation(s)
- James M. Mok
- NorthShore University HealthSystem, Skokie, IL, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | - Ye Lin
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
| | | | | | - Farid Amirouche
- NorthShore University HealthSystem, Skokie, IL, USA
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, USA
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Silverstein JW, Block J, Smith ML, Bomback DA, Sanderson S, Paul J, Ball H, Ellis JA, Goldstein M, Kramer DL, Arutyunyan G, Marcus J, Mermelstein S, Slosar P, Goldthwaite N, Lee SI, Reynolds J, Riordan M, Pirnia N, Kunwar S, Abbi G, Bizzini B, Gupta S, Porter D, Mermelstein LE. Femoral nerve neuromonitoring for lateral lumbar interbody fusion surgery. Spine J 2022; 22:296-304. [PMID: 34343664 DOI: 10.1016/j.spinee.2021.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/26/2021] [Accepted: 07/26/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The transpsoas lateral lumbar interbody fusion (LLIF) technique is an effective alternative to traditional anterior and posterior approaches to the lumbar spine; however, nerve injuries are the most reported postoperative complication. Commonly used strategies to avoid nerve injury (eg, limiting retraction duration) have not been effective in detecting or preventing femoral nerve injuries. PURPOSE To evaluate the efficacy of emerging intraoperative femoral nerve monitoring techniques and the importance of employing prompt surgical countermeasures when degraded femoral nerve function is detected. STUDY DESIGN/SETTING We present the results from a retrospective analysis of a multi-center study conducted over the course of 3 years. PATIENT SAMPLE One hundred and seventy-two lateral lumbar interbody fusion procedures were reviewed. OUTCOME MEASURES Intraoperative femoral nerve monitoring data was correlated to immediate postoperative neurologic examinations. METHODS Femoral nerve evoked potentials (FNEP) including saphenous nerve somatosensory evoked potentials (snSSEP) and motor evoked potentials with quadriceps recordings were used to detect evidence of degraded femoral nerve function during the time of surgical retraction. RESULTS In 89% (n=153) of the surgeries, there were no surgeon alerts as the FNEP response amplitudes remained relatively unchanged throughout the surgery (negative group). The positive group included 11% of the cases (n=19) where the surgeon was alerted to a deterioration of the FNEP amplitudes during surgical retraction. Prompt surgical countermeasures to an FNEP alert included loosening, adjusting, or removing surgical retraction, and/or requesting an increase in blood pressure from the anesthesiologist. All the cases where prompt surgical countermeasures were employed resulted in recovery of the degraded FNEP amplitudes and no postoperative femoral nerve injuries. In two cases, the surgeons were given verbal alerts of degraded FNEPs but did not employ prompt surgical countermeasures. In both cases, the degraded FNEP amplitudes did not recover by the time of surgical closure, and both patients exhibited postoperative signs of sensorimotor femoral nerve injury including anterior thigh numbness and weakened knee extension. CONCLUSIONS Multimodal femoral nerve monitoring can provide surgeons with a timely alert to hyperacute femoral nerve conduction failure, enabling prompt surgical countermeasures to be employed that can mitigate or avoid femoral nerve injury. Our data also suggests that the common strategy of limiting retraction duration may not be effective in preventing iatrogenic femoral nerve injuries.
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Affiliation(s)
- Justin W Silverstein
- Neuro Protective Solutions, New York, NY 11788, USA; Northwell Health Lenox Hill Hospital, New York, NY, USA; Northwell Health Huntington Hospital, Huntington, NY, USA.
| | - Jon Block
- ION Intraoperative Neurophysiology, Orinda, CA, USA
| | - Michael L Smith
- Rothman Orthopedic Institute, New York, NY, USA; Northwell Health Lenox Hill Hospital, New York, NY, USA
| | - David A Bomback
- Connecticut Neck and Back Specialists, Danbury, CT, USA; Nuvance Health, Danbury, CT, USA
| | - Scott Sanderson
- Elite Brain and Spine of Connecticut, Danbury CT, USA; Nuvance Health, Danbury, CT, USA
| | - Justin Paul
- OrthoConnecticut, Danbury CT, USA; Nuvance Health, Danbury, CT, USA
| | - Hieu Ball
- San Ramone Regional Medical Center, San Ramon, CA, USA
| | - Jason A Ellis
- Northwell Health Lenox Hill Hospital, New York, NY, USA
| | - Matthew Goldstein
- Orthopedic Associates of Manhasset, Great Neck, NY, USA; St. Francis Hospital, Roslyn, NY, USA
| | - David L Kramer
- Connecticut Neck and Back Specialists, Danbury, CT, USA; Nuvance Health, Danbury, CT, USA
| | - Grigoriy Arutyunyan
- Rothman Orthopedic Institute, New York, NY, USA; Northwell Health Lenox Hill Hospital, New York, NY, USA
| | - Joshua Marcus
- Elite Brain and Spine of Connecticut, Danbury CT, USA; Nuvance Health, Danbury, CT, USA
| | - Sara Mermelstein
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | | | | | | | | | | | | | | | | | | | - Sarita Gupta
- ION Intraoperative Neurophysiology, Orinda, CA, USA
| | | | - Laurence E Mermelstein
- Long Island Spine Specialists, Long Island, NY, USA; Northwell Health Huntington Hospital, Huntington, NY, USA
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Shasti M, Koenig SJ, Nash AB, Bahrami S, Jauregui JJ, O'Hara NN, Jazini E, Gelb DE, Ludwig SC. Biomechanical evaluation of lumbar lateral interbody fusion for the treatment of adjacent segment disease. Spine J 2019; 19:545-551. [PMID: 30201269 DOI: 10.1016/j.spinee.2018.09.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Adjacent segment disease (ASD) is a well-known complication after lumbar fusion. Lumbar lateral interbody fusion (LLIF) may provide an alternative method of treatment for ASD while avoiding the morbidity associated with revision surgery through a traditional posterior approach. This is the first biomechanical study to evaluate the stability of lateral-based constructs for treating ASD in existing multilevel fusion model. PURPOSE We aimed to evaluate the biomechanical stability of anterior column reconstruction through the less invasive lateral-based interbody techniques compared with traditional posterior spinal fusion for the treatment of ASD in existing multilevel fusion. STUDY DESIGN/SETTING Cadaveric biomechanical study of laterally based interbody strategies for treating ASD. METHODS Eighteen fresh-frozen cadaveric specimens were nondestructively loaded in flexion, extension, and lateral bending. The specimens were randomized into three different groups according to planned posterior spinal instrumented fusion (PSF): group 1: L5-S1, group 2: L4-S1, and group 3: L3-S1. In each group, ASD was considered the level cranial to the upper-instrumented vertebrae (UIV). After testing the intact spine, each specimen underwent PSF representing prior fusion in the ASD model. The adjacent segment for each specimen then underwent (1) Stand-alone LLIF, (2) LLIF + plate, (3) LLIF + single screw rod (SSR) anterior instrumentation, and (4) LLIF + traditional posterior extension of PSF. In all conditions, three-dimensional kinematics were tracked, and range of motion (ROM) was calculated for the comparisons. RESULTS ROM results were expressed as a percentage of the intact spine ROM. LLIF effectively reduces ROM in all planes of ROM. Supplementation of LLIF with plate or SSR provides further stability as compared with stand-alone LLIF. Expansion of posterior instrumentation provides the most substantial stability in all planes of ROM (p <.05). All constructs demonstrated a consistent trend of reduction in ROM between all the groups in all bending motions. CONCLUSIONS This biomechanical study suggests potential promise in exploring LLIF as an alternative treatment of ASD but reinforces previous studies' findings that traditional expansion of posterior instrumentation provides the most biomechanically stable construct.
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Affiliation(s)
- Mark Shasti
- University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA
| | - Scott J Koenig
- University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA
| | - Alysa B Nash
- University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA
| | - Shahrzad Bahrami
- University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA
| | - Julio J Jauregui
- University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA
| | - Nathan N O'Hara
- University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA
| | - Ehsan Jazini
- Virginia Spine Institue, 11800 Sunrise Vallley Drive, Reston Virginia, 20191
| | - Daniel E Gelb
- University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA
| | - Steven C Ludwig
- University of Maryland Medical Center, Department of Orthopaedics, 110 S. Paca St, 6th Floor. Suite 300, Baltimore MD 21201-1642, USA.
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