Category: MISS

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Adjacent segment disease treated with stand-alone lateral lumbar interbody fusion: an analysis of domino adjacent segment revisions

J Neurosurg Spine 44:884–893, 2026

This clinical study compares stand-alone lateral lumbar interbody fusion (LLIF) with circumferential LLIF plus posterior instrumentation for treating adjacent segment disease (ASD) after prior posterior lumbosacral fusion. Primary outcome focused on “domino” proximal ASD revisions, with secondary measures including cage subsidence, radiographic alignment, and perioperative metrics.

Results from 236 patients show stand-alone LLIF had significantly lower 5-year domino ASD revision rates, shorter operative times and hospital stays, and comparable alignment despite higher rates of moderate-to-severe cage subsidence. Multivariable and competing-risk analyses supported stand-alone LLIF’s protective association against subsequent adjacent-segment reoperations.

Objective Assess whether stand-alone LLIF is a durable ASD revision strategy with lower risk of subsequent “domino” adjacent-segment revision compared with circumferential LLIF (LLIF + posterior fusion extension).

Design/Methods Single-center retrospective cohort (Jan 2008–Aug 2023) of patients with prior posterior lumbosacral fusion undergoing ASD revision via stand-alone vs circumferential LLIF; primary outcome was domino ASD revision; survival analysis and multivariable Cox regression used, adjusting for alignment, stenosis severity, and fused levels.

Cohort 236 patients included (131 stand-alone; 105 circumferential); baseline demographics/treated levels similar; preop MRI showed more severe central stenosis in the circumferential group (more Schizas grade D).

Primary outcome Stand-alone LLIF had a lower 5-year incidence of domino ASD revision (13.7% vs 28.6%, p = 0.005).

Adjusted association After multivariable adjustment, stand-alone LLIF remained independently associated with fewer domino ASD revisions (HR 0.43, 95% CI 0.23–0.79; p = 0.007).

Radiographic outcomes Overall radiographic alignment was comparable between groups, but stand-alone LLIF had higher cage subsidence (Marchi grade ≥ II: 22.9% vs 9.5%, p = 0.019), and subsidence was not associated with increased revision risk.

Perioperative outcomes Stand-alone LLIF had significantly shorter operative time and hospital stay than circumferential LLIF (with lower blood loss also reported).

Conclusion Stand-alone LLIF is supported as a treatment option for ASD after prior posterior fusion, with less domino ASD revision and similar radiographic alignment, at the cost of higher subsidence rates.

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Low Posterior Electromyographic Threshold and Functional Outcomes After L4-5 Lateral Lumbar Interbody Fusion

Operative Neurosurgery 30:566–570, 2026

This single-institution retrospective study evaluates whether low posterior electromyography (EMG) stimulation thresholds during lateral L4-5 lumbar interbody fusion (LLIF) correlate with postoperative femoral nerve motor or sensory neurapraxia. Forty-two lateral-position single-level L4-5 LLIFs with neuromonitoring data showed no significant association between posterior EMG threshold or retractor time and transient postoperative anterior thigh numbness or weakness.

The cohort experienced transient sensory neurapraxia in 38% at six weeks that resolved by six months; only one patient had temporary motor neurapraxia. Limitations include small sample size, retrospective design, and short follow-up, leading authors to conclude no demonstrable link between posterior EMG threshold and plexus injury in this series.

Context: In L4-5 transpsoas LLIF, the retractor is placed near the lumbar plexus; directional EMG stimulation thresholds are used intraoperatively to estimate nerve proximity and potentially reduce injury risk.

Objective: Assessed whether posterior EMG stimulation threshold was associated with lumbar plexus injury/neurapraxia after single-level L4-5 LLIF performed in the lateral position.

Design/criteria: Retrospective, single-institution review of single-level L4-5 LLIF (Jan 2019–May 2022) with available neuromonitoring thresholds and retractor time; excluded cases with additional levels or missing monitoring data.

Cohort/intraop metrics: 42 patients (mean age 66 years); mean retractor time 12.4 minutes; mean posterior EMG threshold 10.4 mA.

Neurologic outcomes: Femoral motor neurapraxia occurred in 1 patient (2%); sensory neurapraxia (anterior thigh numbness) occurred in 16 patients (38%) at 6 weeks and resolved to 0% by 6 months.

Main finding: Posterior EMG threshold was not associated with postoperative motor neurapraxia or sensory neurapraxia at 6 weeks (including logistic regression showing OR 1.00; P=.98 for thigh numbness).

Other associations: No significant correlation between posterior EMG threshold and retractor time (Spearman ρ=0.11; P=.50) or postoperative ODI (ρ=0.17; P=.33).

Notable case/interpretation: The single motor neurapraxia case had 27-minute retractor time with posterior EMG 5 mA and recovered by 6 months; median retractor time in the cohort was low (10.8 minutes), limiting conclusions about longer retraction durations.

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Outpatient minimally invasive transforaminal lumbar interbody fusion performed at a single ambulatory surgery center: the Semmes Murphey Clinic experience

Neurosurg Focus 60(4):E5, 2026

This study reports outcomes from 179 patients undergoing single-level minimally invasive transforaminal lumbar interbody fusion (miTLIF) at a single ambulatory surgery center (ASC) between 2012–2024. It presents demographics, surgical details, complications, and validated patient-reported outcomes with 2-year follow-up showing sustained pain reduction, functional improvement, and high satisfaction.

The authors detail selection criteria, perioperative technique using tubular retractors and percutaneous pedicle screws, low complication and 90-day readmission/reoperation rates, and discuss economic and policy implications for ASC-based lumbar fusion care.

Objective Report 2-year outcomes for outpatient minimally invasive TLIF (miTLIF) performed at a single ambulatory surgery center (ASC).

Cohort 485 single-level miTLIFs were performed at the ASC (2012–2024); 179 registry-enrolled patients were analyzed (mean age 54; BMI mean 31).

Selection ASC eligibility exclusions included BMI > 50, weight > 350 lb, cardiac disease not cleared “low risk,” ASA class IIIb or above, family history of malignant hyperthermia, or inability to ambulate; Medicare primary insurance was also excluded for reimbursement reasons.

Disposition 98.3% were discharged within a few hours; 1.1% observed < 23 hours for pain control; 0.56% required hospital transfer for new-onset atrial fibrillation (treated and discharged within 23 hours).

Patient-reported outcomes Mean scores improved from baseline to 3 months and remained improved through 2 years (e.g., back pain NRS 6.98→2.40 at 3 months and 2.86 at 2 years; ODI 44.14→19.37 at 3 months and 13.87 at 2 years; EQ-5D 0.56→0.81 at 3 months and 0.82 at 2 years).

Complications Durotomy occurred in 1.7% (treated with fibrin glue, discharged within hours); superficial surgical site infection 0.56% (oral antibiotics only); postoperative hematoma 0.56%; urinary tract infection 0.56%.

Readmissions/reoperations (90-day) 2.2% readmissions and 1.1% reoperations within 90 days (including hardware failure and delayed hematoma).

Conclusion For carefully selected patients, ASC-based miTLIF showed significant, durable PROM improvement with acceptably low complications, readmissions, and reoperations.

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Impact of lateral plate and screw fixation on long-term radiographic subsidence in lateral lumbar interbody fusion

J Neurosurg Spine 44:493–497, 2026

This clinical study evaluates long-term radiographic subsidence after lateral lumbar interbody fusion (LLIF), comparing stand-alone procedures with those augmented by lateral plate and screw fixation. Retrospective analysis of 146 patients (219 levels) with ≥1-year CT follow-up shows lateral plating significantly reduced subsidence odds, while 3D-printed porous titanium cages trended toward lower subsidence than PEEK.

Results note similar reoperation rates between groups, no grade III subsidence, and rare adverse events including one delayed vertebral fracture with plating; methodology included multivariate logistic regression and Marchi subsidence grading. Conclusions support lateral plate and screw fixation, particularly with porous titanium cages, as protective against severe radiographic subsidence.

Objective Assess whether adding lateral plate and screw fixation changes the long-term rate/grade of radiographic cage subsidence after LLIF (excluding posterior instrumented fusion).

Design/Population Retrospective review (2014–2022) of degenerative lumbar spondylosis LLIF cases at two centers; required ≥1-year postoperative CT; 146 patients/219 levels (45% plated, 55% stand-alone).

Subsidence grading Long-term imaging graded by Marchi criteria (grade 0: 0%–24% disc height loss; I: 25%–49%; II: 50%–74%; III: 75%–100%); no intraoperative subsidence included.

Main finding (plating effect) Lateral plate + screws was significantly associated with reduced long-term radiographic subsidence (multivariable OR 0.484, p = 0.006).

Severity pattern All grade II (severe) subsidence cases occurred in the stand-alone LLIF group (4 patients); no grade III subsidence observed.

Cage material trend 3D-printed porous titanium cages trended toward lower subsidence versus PEEK but did not reach statistical significance (OR 0.401, p = 0.071).

Reoperation/fusion No significant difference in reoperation rate between plated and stand-alone groups; radiographic fusion rates were similar (83.1% plated vs 86.4% stand-alone; p = 0.58).

Noted complications/implant details One lateral-plate patient had a delayed vertebral body fracture; plated cases used 18-mm-wide cages, while nearly all stand-alone cases used 22-mm-wide cages.

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Comprehensive analysis of biomechanical stability and clinical efficacy in oblique lumbar interbody fusion with distinct anterolateral fixation modalities

J Neurosurg Spine 44:436–448, 2026

This study evaluates how different anterolateral screw angles in oblique lumbar interbody fusion with anterolateral fixation (OLIF-AF) affect cage subsidence, biomechanical stability, and clinical outcomes. A retrospective cohort of 80 L4–5 OLIF-AF patients was grouped by coronal and horizontal screw angles, supplemented by finite element models simulating four screw configurations under physiological loads.

Findings show coronal-plane parallel screw placement reduced cage subsidence, cage stress, displacement, and range of motion versus nonparallel placement, while horizontal bifurcation had no significant effect on subsidence; clinical scores and fusion rates were similar across groups. The authors recommend coronal parallelism with bicortical purchase to optimize stability and lower subsidence risk.

Coronal Plane Parallel Screw Placement: Parallel screw placement in the coronal plane during OLIF-AF significantly reduces the risk of cage subsidence (CS) and enhances biomechanical stability compared to nonparallel placement.

Nonparallel Coronal Screw Placement Risks: Nonparallel coronal screw placement (G2 and G3 groups) is independently associated with higher CS rates, greater reduction in disc height (ΔDH), increased cage stress, displacement, and range of motion (ROM), indicating poorer biomechanical outcomes.

Horizontal Screw Bifurcation: Horizontal screw bifurcation (difference in horizontal plane angle) does not have a statistically significant impact on CS risk or clinical outcomes when coronal plane parallelism is maintained.

Bicortical Purchase Importance: Ensuring that screws penetrate the contralateral vertebral cortex (bicortical purchase) may further reduce the risk of CS, while lack of penetration is associated with earlier and more severe subsidence.

Clinical Outcomes: No significant differences in pain relief (VAS-LBP, VAS-LP) or Oswestry Disability Index (ODI) were observed among the four screw configuration groups at any follow-up point; fusion rates were also similar.

Finite Element Analysis Validation: Finite element modeling confirmed that nonparallel screw configurations increase cage stress and spinal ligament tension, especially during flexion, supporting clinical findings.

Risk Factors for Subsidence: Lower bone mineral density (BMD) and nonparallel coronal screw placement are independent risk factors for cage subsidence after OLIF-AF.

Surgical Recommendation: For optimal biomechanical stability and reduced complication risk, OLIF-AF screws should be placed parallel to the coronal plane and close to the endplates, with bicortical purchase, as this configuration provides better load sharing and fusion environment.

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Cage migration in multilevel stand-alone lateral lumbar interbody fusion: incidence and clinical correlations

J Neurosurg Spine 44:426–435, 2026

This clinical case series compares the incidence and outcomes of lateral interbody cage migration (LCM) following multilevel stand-alone lateral lumbar interbody fusion (LLIF) versus LLIF with posterior pedicle screw instrumentation in 87 age-matched patients. The retrospective analysis reports similar LCM rates (7% vs 5%), no significant differences in complications, and comparable improvements in Oswestry Disability Index and pain scores at ≥1 year follow-up.

The report details patient selection, radiographic assessment methods, operative characteristics, and risk-factor analysis, emphasizing meticulous selection for multilevel stand-alone LLIF. Authors conclude multilevel stand-alone LLIF can be safe in selected patients but call for prospective studies to validate findings and clarify factors contributing to cage migration.

Lateral Cage Migration (LCM) Incidence: LCM occurred in 7% of multilevel stand-alone LLIF cases and 5% of LLIF cases with posterior instrumentation; this difference was not statistically significant.

Patient Selection Criteria: Optimal candidates for multilevel stand-alone LLIF have neutral sagittal and coronal balance, mild to moderate facet arthropathy, stable grade 1 spondylolisthesis, absence of severe central canal stenosis, normal or mildly reduced bone mineral density, and comorbidities or age that increase surgical risk with posterior fixation.

Clinical Outcomes: Both cohorts (stand-alone and posterior instrumentation) showed significant postoperative improvement in Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, with no significant differences between groups.

Complication Rates: Postoperative complication rates were similar between groups (23% stand-alone vs. 20% posterior instrumentation), and no intraoperative complications were reported in either group.

Biomechanical Considerations: Supplemental posterior instrumentation increases construct stability, but clinical significance in preventing LCM in well-selected patients remains unclear; stand-alone LLIF can be safe with meticulous patient selection.

Role of Lateral Plates: Adding lateral plates to stand-alone LLIF does not significantly improve stability or reduce cage migration/subsidence in multilevel constructs and may increase cost and risk.

Risk Factors for LCM: No significant demographic, radiographic, or procedural risk factors for LCM were identified in this study; all patients with LCM had normal bone density, and meticulous surgical technique and patient selection are emphasized.

Study Limitations: Retrospective design, single institution, and small sample size may limit generalizability; prospective studies are needed for further validation.

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Postoperative loss in segmental lumbar lordosis following L5–S1 anterior lumbar interbody fusion

J Neurosurg Spine 44:420–425, 2026

This clinical study evaluates predictors and thresholds for postoperative loss of L5–S1 segmental lordosis following anterior lumbar interbody fusion (ALIF) in 94 adults treated for degenerative disc disease. Multivariate analyses identified baseline obesity, absence of posterior fixation, and larger immediate lordotic correction as independent predictors of 6-week to 1-year segmental lordosis loss, which related to higher rates of cage subsidence and revision.

The authors derived 6-week postoperative L5–S1 lordosis thresholds (overall range 21.6°–26.8°, PI-specific: low 19.0°–24.8°, average 21.0°–26.4°, high 24.1°–28.7°) that minimized subsequent loss and need for revision. Findings support targeted preoperative planning to achieve sustainable correction while balancing risks of overcorrection and subsidence.

Segmental Lordosis Restoration: L5–S1 anterior lumbar interbody fusion (ALIF) provides strong and durable correction of segmental lumbar lordosis and disc height, with most correction maintained at 1 year postoperatively.

Predictors of Lordosis Loss: Baseline obesity, lack of posterior fixation, and larger initial correction in L5–S1 lordosis are independent predictors of postoperative segmental lordosis loss within 1 year.

Complications: Loss of segmental lordosis increases the risk of cage subsidence and revision surgery, particularly due to pseudarthrosis.

Optimal Correction Thresholds: Achieving 6-week postoperative L5–S1 segmental lordosis between 21.6° and 26.8° minimizes the risk of lordotic loss and need for revision; PI-specific thresholds are 19.0°–24.8° (low PI), 21.0°–26.4° (average PI), and 24.1°–28.7° (high PI).

Risks of Overcorrection/Undercorrection: Overcorrection (>26.8°) increases risk of cage subsidence and mechanical complications, while undercorrection (<21.6°) may predispose to implant failure and adjacent segment disease.

Surgical Planning Importance: Preoperative planning should target lordosis correction within these thresholds and consider modifiable risk factors to optimize outcomes and reduce complications.

Comparison to Other Techniques: ALIF offers greater segmental correction than other lumbar interbody fusion techniques such as TLIF or XLIF.

Clinical Implications: Nearly half of patients experience some degree of lordosis loss post-ALIF, highlighting the need for careful patient selection, surgical technique, and postoperative monitoring.

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A pilot randomized control trial comparing posterior paramedian versus midline incisions for interbody fusions of the lumbar spine

The Spine Journal 26 (2026) 85−93

This single-center pilot randomized controlled trial compares posterior midline versus posterior paramedian (Wiltse/minimally invasive) approaches for 1–2 level lumbar interbody fusions, assessing feasibility, infection rates, and reoperation. One hundred-one patients were randomized, with reported differences: higher deep infection (9.6% vs 4.1%) and greater reoperation rates (25% vs 6.1%) in the midline group, alongside improvements in PROMs for both groups.

Methods, perioperative care, and outcome measures are detailed, including CDC-defined deep infection, PROMs (ODI, SF-12, EQ-5D, VAS), and feasibility metrics for a multicenter RCT. The authors conclude the pilot supports a larger trial, recommend an interim analysis for reoperation differences, and outline limitations related to single-surgeon data, recruitment disruptions, and clustering effects.

Pilot RCT Findings: A single-center pilot randomized controlled trial compared posterior paramedian and midline incisions for lumbar interbody fusion, finding potential differences in deep infection and reoperation rates, with both groups showing improvement in patient-reported outcomes.

Infection Rates: Deep infection occurred in 9.6% of midline patients versus 4.1% in the paramedian group within 3 months post-surgery.

Reoperation Rates: 25% of midline patients required revision surgery compared to 6.1% in the paramedian group during follow-up.

Patient Outcomes: Both surgical approaches led to improvements in disability, pain, and quality of life scores at 6–18 weeks and 1 year postoperatively, with slightly greater improvements noted in the paramedian group.

Intraoperative Metrics: The paramedian group had lower average blood loss (268ml vs. 313ml) and a shorter average hospital stay (3.3 vs. 4.2 days) compared to the midline group.

Feasibility: The trial demonstrated high protocol adherence, low loss to follow-up, and good participant acceptance, supporting the feasibility of a larger multicenter RCT.

Limitations: The pilot was limited by single-center design, small sample size, protocol violations, and short follow-up; results may not be generalizable until confirmed by a larger trial.

Next Steps: The pilot data will inform sample size calculations and study design for a multicentered RCT to clarify whether paramedian approaches offer significant clinical advantages over midline incisions.

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Radiation exposure in XLIF surgery utilizing ultra-low radiation imaging with image enhancement software: a randomized controlled trial

The Spine Journal 25 (2025) 2692−2700

This randomized controlled trial evaluates ultra-low radiation imaging with image enhancement (mFluoro) versus conventional fluoroscopy during single-level XLIF lateral interbody fusion in 57 analyzed patients. Results show marked reductions in OR staff exposure (surgeon −72.1%, assistant −76.1%, scrub nurse −67.5%), lower patient DAP (−66.1%), fewer images, and shorter procedure times without increased complications.

The study used live dosimeters, standardized protocols, and optical reposition-assist technology (LessRay/PULSE) with Cios Spin. Findings support ULRI+IE as an effective strategy to decrease occupational and patient radiation during minimally invasive lateral spine surgery, noting limitations including lack of surgeon blinding and early learning-curve crossovers.

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Comparison of Sagittal Plane Correction With “Bullet” Versus “Banana” Type Transforaminal Lumbar Interbody Fusion Devices

Operative Neurosurgery 29:624–632, 2025

This clinical study evaluates whether “Banana” versus “Bullet” transforaminal lumbar interbody fusion (TLIF) devices produce different immediate postoperative segmental lordosis in one- and two-level degenerative lumbar fusions. Using 241 treated levels from 198 patients, the authors compare radiographic outcomes and perform multivariable regression to identify independent predictors of postoperative segmental lordosis and its change.

Findings show univariable advantages for “Banana” cages in small magnitudes, but multivariable analysis identifies preoperative segmental lordosis, implant-listed lordosis, pelvic incidence, and use of bilateral TLIF windows—not cage morphology—as primary predictors of immediate postoperative segmental correction. The paper recommends further work on subsidence risk and maintenance of correction.

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Five-year follow-up after minimally invasive transforaminal lumbar interbody fusion versus decompression alone for grade 1 spondylolisthesis: are there any differences in outcomes?

J Neurosurg Spine 43:547–556, 2025

This multicenter, prospective registry study compares 60-month outcomes after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) versus minimally invasive tubular decompression for Meyerding grade 1 degenerative spondylolisthesis. Patient-reported outcomes (ODI, NRS for back/leg pain, EQ-5D, NASS satisfaction) improved significantly in both cohorts, with MIS TLIF showing greater back-pain reduction and higher satisfaction rates.

Durability differs: MIS TLIF had a markedly lower 5-year reoperation rate than MIS decompression (2.8% vs 15.5%), and multivariable analysis found fusion reduced reoperation odds despite similar long-term PROs. Authors conclude both MIS approaches benefit selected patients, but fusion offers superior reoperation durability.

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Development and internal validation of a risk score for subsidence of expandable spacers in transforaminal lumbar interbody fusion (TLIF) surgery

Brain and Spine 5 (2025) 104322

This study developed and internally validated the Expandable TLIF Subsidence Index (ETSI) to predict risk of cage subsidence after TLIF surgery with expandable spacers. Key risk factors include high ASA score, non-degenerative indication, lower lumbar levels, small cage size, and posterior cage position.

• A risk score (Expandable TLIF Subsidence Index, ETSI) was developed to predict cage subsidence (CS) after transforaminal lumbar interbody fusion (TLIF) using expandable spacers.

• The study analyzed 388 patients (482 levels), finding a 31.7% CS rate at 3 months.

• Independent risk factors for CS included high ASA score, non-degenerative surgical indication, lower lumbar level, small cage size, and posterior cage position.

• The ETSI score ranges from -2 to 6; higher scores indicate higher CS risk (each point increases CS odds by about 2x).

• Modifiable risk factors (cage size and position) can reduce CS risk if addressed during surgery.

• Higher ETSI scores are also associated with increased risk of non-union/pseudarthrosis.

• The ETSI demonstrated moderate predictive performance (AUROC ≈ 0.68).

• The score may aid surgical planning and should be externally validated in future studies.

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Does Transforaminal Endoscopic Lumbar Discectomy Provide More Value than Microdiscectomy?

Operative Neurosurgery 29:209–218, 2025

Microdiscectomy (MD) provided greater value than transforaminal endoscopic discectomy (TED) for lumbar disc herniations at this institution, with higher improvement in patient-reported outcomes per dollar spent and shorter operative times. TED had higher costs and a steeper learning curve, but similar reoperation rates.

• This study compares the value of transforaminal endoscopic lumbar discectomy (TED) and microdiscectomy (MD) for lumbar disc herniation using a novel Operative Value Index (OVI).

• OVI measures percent change in Oswestry Disability Index (ODI) per $1000 spent intraoperatively, integrating patient outcomes and time-driven activity-based costing.

• MD had a significantly higher OVI, lower operative times, and lower intraoperative costs than TED; no significant difference in length of stay or reoperation rates was found.

• Only 43.5% of TED cases achieved clinically important improvement (MCID), compared to 66.3% for MD.

• TED was mainly used for foraminal herniations and had a higher proportion of older patients and comorbidities.

• Longer OR setup times and higher costs for TED may relate to the learning curve and surgeon experience.

• Authors suggest OVI is a practical, real-time value metric but note limitations including small TED sample size and retrospective design.

• Future studies should assess long-term outcomes, total episode costs, and track OVI as surgeons gain TED experience.

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The role of XLIF in spinal revision surgery involving failed interbody implants

Acta Neurochirurgica (2025) 167:221

This review evaluates the use of Extreme Lateral Interbody Fusion (XLIF) for removing failed spinal implants. XLIF offers advantages over traditional approaches, including reduced operative risk, blood loss, and hospital stay, but requires surgical expertise due to potential nerve and vascular complications.

• XLIF (Extreme Lateral Interbody Fusion) is increasingly used for spinal revision surgery to remove failed interbody implants and other foreign bodies.

• A systematic literature review identified only a few published cases (seven documented, four included) using XLIF for this purpose.

• XLIF offers advantages over anterior and posterior approaches, including reduced operative time, less blood loss, shorter hospital stays, and safer navigation around scar tissue and neurovascular structures.

• The technique allows for insertion of larger interbody cages, improving spinal stability and fusion outcomes.

• Most reported complications are minor and transient, such as temporary nerve injury, but careful patient selection and surgical expertise are required.

• XLIF is especially valuable in complex revision cases where traditional approaches pose higher risks due to scar tissue or anatomical challenges.

• Current evidence is limited to case reports and small series; more robust studies are needed to validate safety and efficacy.

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Anatomy of the superior hypogastric plexus and its relevance to anterior lumbar interbody fusion

J Neurosurg Spine 43:19–25, 2025

This cadaveric study details the anatomy of the superior hypogastric plexus (SHP) at L5–S1, its variations, and implications for anterior lumbar interbody fusion (ALIF). The authors recommend left-sided SHP retraction to minimize nerve injury and retrograde ejaculation; if unfeasible, midline splitting and lateral mobilization are advised.

• The study examined the anatomy of the superior hypogastric plexus (SHP) at the L5–S1 level and its relevance to anterior lumbar interbody fusion (ALIF) surgery.

• Injury to the SHP during ALIF can cause retrograde ejaculation (RE) in males and sexual dysfunction in females.

• The SHP typically overlays the midline at L5–S1 with a slight leftward shift and is covered by connective tissue beneath the peritoneum.

• Three morphological types of SHP were found: single cord, plexiform, and fiber; the plexus divides into hypogastric nerves below the aortic bifurcation.

• Retraction of the SHP to the left side is generally more feasible (up to 15.3 mm) than to the right (up to 5.3 mm); left-sided retraction is recommended.

• If left retraction is not possible, splitting the SHP at the midline and retracting both components laterally is advised.

• Careful SHP mobilization and avoidance of electrocautery are crucial to reduce risk of RE and sexual dysfunction in ALIF patients.

• The findings highlight the importance of detailed SHP anatomy knowledge for safer ALIF, especially with minimally invasive approaches.

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Development and internal validation of a risk score for subsidence of expandable spacers in transforaminal lumbar interbody fusion (TLIF) surgery

Brain and Spine 5 (2025) 104322

This study developed and validated the Expandable TLIF Subsidence Index (ETSI) to predict risk of cage subsidence after TLIF surgery with expandable spacers. Key risk factors include high ASA score, non-degenerative indications, lower lumbar level, small cage size, and posterior cage position. Some risk factors are modifiable.

• A risk score (ETSI) was developed to predict cage subsidence (CS) after TLIF surgery using expandable spacers.

• Independent risk factors for CS include high ASA score, non-degenerative surgical indication, lower lumbar level, small cage size, and posterior cage position.

• ETSI ranges from -2 to 6 points and shows a moderate ability to classify CS risk (AUROC ≈ 0.68).

• Modifiable risk factors (cage size and position) can reduce CS risk if optimized by the surgeon.

• Higher ETSI scores are associated with increased risk of non-union/pseudarthrosis at 3 and 12 months.

• Anterior placement of the cage lowers subsidence risk, while posterior placement increases it.

• The study included 388 patients with a 3-month CS rate of 31.7%.

• The ETSI is the first comprehensive scoring system for CS risk with expandable TLIF cages.

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Cost and operating room time savings with single-position prone lateral lumbar interbody circumferential fusion

J Neurosurg Spine 42:768–774, 2025

Single-position prone lateral lumbar interbody fusion (LLIF+PPS) reduces operating room time and costs compared to dual-position surgery, especially for 2-level fusions, while maintaining similar hospital stays and clinical outcomes. Cost savings are most significant in complex, multilevel cases due to eliminated patient repositioning.

• Single-position (SP) prone lateral lumbar interbody fusion (LLIF) eliminates patient repositioning compared to dual-position (DP) LLIF+PPS.

• Study compared costs, operating room (OR) time, and hospital stay between SP and DP LLIF+PPS for 1- and 2-level fusions.

• For 2-level fusions, SP surgery had significantly shorter OR time, lower OR and anesthesiology costs than DP surgery.

• For 1-level fusions, differences in OR time and costs between SP and DP were not statistically significant.

• Hospital length of stay was similar between SP and DP groups for both 1- and 2-level fusions.

• Both approaches showed similar safety, fusion rates, and patient-reported outcomes after at least 1 year.

• SP prone LLIF+PPS is most beneficial for complex, multi-level cases, offering efficiency and cost savings.

• Further studies with larger cohorts are needed to confirm these findings.

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Clinical Outcomes and Radiographic Results of Prone Transpsoas Lateral Lumbar Interbody Fusion

Neurosurgery 96:763–768, 2025

The study evaluates the prone transpsoas (PTP) approach for lateral lumbar interbody fusion, showing improved lumbar lordosis, reduced complications, and enhanced patient-reported outcomes. Conducted on 106 patients, the approach minimized operative time and demonstrated safety and efficacy in lumbar fusion.

Clinical Research Summary

• Study Focus: Prone transpsoas lateral lumbar interbody fusion (PTP) for lumbar fusion.

• Study Design: Retrospective observational study of 106 patients, single-surgeon series.

• Patient Demographics: Mean age 66 years, mean BMI 29.3, follow-up 13 months.

• Surgical Technique: Prone positioning, single-position access to anterior/posterior lumbar spine.

• Common Levels: The most common level treated was L4-5.

• Outcomes: Improved lumbar lordosis, reduced pelvic tilt, and decreased PI-LL mismatch.

• Complications: Minimal, with transient hip flexor weakness in 0.9% of patients.

• Pain Scores: VAS pain scores improved from 6 to 5 postoperatively.

• Surgical Indications: Degenerative scoliosis, spondylolisthesis, disk disease, adjacent segment disease, pseudoarthrosis.

• Adverse Events: No bowel or major vessel injuries were reported.

• Radiographic Results: Significant improvement in lumbar lordosis and pelvic parameters.

• Limitations: Single-surgeon study, short follow-up, retrospective data collection.

• Conclusion: PTP approach is safe and effective for lumbar fusion with minimal complications.

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Fully Navigated Single-Position Prone Lateral Lumbar Interbody Fusion: A Detailed Technical Report and Description of 15 Cases

Int J Spine Surg 2025, 19 (1) 70-80

Surgical Technique and Study Overview

• Single-position prone lateral lumbar interbody fusion improves surgery efficiency and safety.

• Navigation enhances precision in pedicle screw placement and reduces radiation exposure.

• Study involved 15 patients with simultaneous cage and screw placement using intraoperative navigation.

• Mean surgery duration was 263 ± 94 minutes with blood loss of 315 ± 143 mL.

• No major complications reported, except for two cases of cerebrospinal fluid leakage.

Clinical Outcomes and Findings

• Significant improvements in Oswestry Disability Index (ODI) scores post-surgery (51.38 to 32.81).

• Segmental lordosis improved significantly from 3.26° to 13.09° (P < 0.001).

• No significant changes in total lumbar lordosis or sagittal vertical axis.

Technical Insights and Considerations

• Intraoperative navigation used for cage and screw placement without additional fluoroscopy.

• Radiation exposure reduced for surgical teams due to minimized fluoroscopy use.

• Simultaneous screw and cage placement guided by navigation and neuromonitoring.

• Challenges include navigation system inaccuracies due to segmental distraction.

• Learning curve observed with new workflow implementation affecting time savings.

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Prone Lateral Transpsoas Approach to the Spine: A Technical Guide for Mastery

Int J Spine Surg 2025, 19 (S1) S19-S27

• The prone lateral transpsoas (PTP) approach offers an alternative to traditional lateral lumbar interbody fusion (LLIF), allowing direct posterior access without repositioning the patient.

• Advantages of PTP include improved segmental lordosis, single-position surgery, and ease of posterior techniques, though it has a distinct learning curve.

• The technical guide aims to shorten the learning curve, optimize surgical workflow, and ensure patient safety through preoperative planning and technical adjustments.

• Preoperative imaging is crucial for assessing anatomical characteristics and guiding surgical approach decisions.

• Patient positioning in PTP involves prone positioning on a radiolucent table, with special attention to stabilizing the pelvis and optimizing working angles.

• Intraoperative monitoring with triggered electromyography (t-EMG) is essential to minimize lumbar plexus injury risk.

• Technical pearls include strategies for retractor positioning, minimizing retraction time, and using intraoperative navigation to enhance safety and efficiency.

• Conclusion: PTP LIF is a viable alternative to traditional methods, offering significant benefits but requiring mastery of its unique technical nuances.

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