Tag: lateral lumbar interbody fusion

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Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach

World Neurosurg. (2019) 121:e647-e653

OBJECTIVE: To discuss lessons learned from an initial lateral lumbar interbody fusion (LLIF) experience with a focus on evolving surgical technique, complication avoidance, and new motor and sensory outcomes after implementation of a modified surgical approach.

METHODS: A retrospective analysis of a prospectively collected series of all patients undergoing LLIF by the senior author (A.D.L.) from January 2010 to January 2018 after implementation of a modified surgical mini-open technique, compared with previously reported institutional results with the originally recommended percutaneous technique. LLIF-specific complications examined included groin/thigh sensory dysfunction, flank bulge/pseudohernia, psoas-pattern weakness, and femoral nerve injury.

RESULTS: The incidence (19%, n [ 98 patients) of groin/ thigh sensory dysfunction in our cohort was significantly lower than that of the historical control (60%, n [ 59) (P < 0.0001). The incidence of abdominal flank bulge/pseudohernia (2.0%, n[98 patients) in our cohort was improved but not significantly lower than that of the historical control (4.2%, n[118) (P[0.36). The incidence of psoas-patternweakness (3.1%, n[98) in our cohort was significantly lower than that of the historical control (23.7%, n [ 59) (P [ 0.0001). The incidence of femoral nerve injury (0%, n[98 patients) in our cohort was improved but was not significantly lower than that of the historical control (1.7%, n [118) (P[0.20).

CONCLUSIONS: The adoption of an exclusive mini-open muscle-splitting approach with first-look inspection of the lumbosacral plexus nerve elements may improve motor and sensory outcomes in general and the incidence of postoperative groin/thigh sensory dysfunction and psoaspattern weakness in particular.

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Curve Laterality for Lateral Lumbar Interbody Fusion in Adult Scoliosis Surgery: The Concave Versus Convex Controversy

Neurosurgery 83:1219–1225, 2018

Minimally invasive lateral lumbar interbody fusion (LLIF) is an effective adjunct in adult degenerative scoliosis (ADS) surgery. LLIF approaches performed fromthe concavity or convexity have inherent approach-related risks and benefits.

OBJECTIVE: To analyze LLIF approach-related complications and radiographic and clinical outcomes in patients with ADS.

METHODS: A multicenter retrospective review of a minimally invasive adult spinal deformity database was queried with a minimum of 2-yr follow-up. Patients were divided into 2 groups as determined by the side of the curve from which the LLIF was performed: concave or convex.

RESULTS: No differences between groups were noted in demographic, and preoperative or postoperative radiographic parameters (all P > .05). There were 8 total complications in the convex group (34.8%) and 21 complications in the concave group (52.5%; P = .17). A subgroup analysis was performed in 49 patients in whom L4-5 was in the primary curve and not in the fractional curve. In this subset of patients, there were 6 complications in the convex group (31.6%) compared to 19 in the concave group (63.3%; P < .05) and both groups experienced significant improvements in coronal Cobb angle, Oswestry Disability Index, and Visual Analog Scale score with no difference between groups.

CONCLUSION: Patients undergoing LLIF for ADS had no statistically significant clinical or operative complication rates regardless of a concave or convex approach to the curve. Clinical outcomes and coronal plane deformity improved regardless of approach side. However, in cases wherein L4-5 is in the primary curve, approaching the fractional curve at L4-5 from the concavity may be associated with a higher complication rate compared to a convex approach.

 

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Lateral lumbar interbody fusion in the elderly

J Neurosurg Spine 29:525–529, 2018

Elderly patients, often presenting with multiple medical comorbidities, are touted to be at an increased risk of peri- and postoperative complications following spine surgery. Various minimally invasive surgical techniques have been developed and employed to treat an array of spinal conditions while minimizing complications. Lateral lumbar interbody fusion (LLIF) is one such approach. The authors describe clinical outcomes in patients over the age of 70 years following stand-alone LLIF.

METHODS A retrospective query of a prospectively maintained database was performed for patients over the age of 70 years who underwent stand-alone LLIF. Patients with posterior segmental fixation and/or fusion were excluded. The preoperative and postoperative values for the Oswestry Disability Index (ODI) were analyzed to compare outcomes after intervention. Femoral neck t-scores were acquired from bone density scans and correlated with the incidence of graft subsidence.

RESULTS Among the study cohort of 55 patients, the median age at the time of surgery was 74 years (range 70–87 years). Seventeen patients had at least 3 medical comorbidities at surgery. Twenty-three patients underwent a 1-level, 14 a 2-level, and 18 patients a 3-level or greater stand-alone lateral fusion. The median estimated blood loss was 25 ml (range 5–280 ml). No statistically significant relationship was detected between volume of blood loss and the number of operative levels. The median length of hospital stay was 2 days (range 1–4 days). No statistically significant relationship was observed between the length of hospital stay and age at the time of surgery. There was one intraoperative death secondary to cardiac arrest, with a mortality rate of 1.8%. One patient developed a transient femoral nerve injury. Five patients with symptomatic graft subsidence subsequently underwent posterior instrumentation. A lower femoral neck t-score < -1.0 correlated with a higher incidence of graft subsidence (p = 0.006). The mean ODI score 1 year postoperatively of 31.1 was significantly (p = 0.003) less than the mean preoperative ODI score of 46.2.

CONCLUSIONS Stand-alone LLIF can be safely and effectively performed in the elderly population. Careful evaluation of preoperative bone density parameters should be employed to minimize risk of subsidence and need for additional surgery. Despite an association with increased comorbidities, age alone should not be a deterrent when considering stand-alone LLIF in the elderly population.

 

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Lateral interbody fusion combined with open posterior surgery for adult spinal deformity

J Neurosurg Spine 25:697–705, 2016

Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD.

Methods All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients.

Results LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045).

Conclusions LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors’ OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

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A Cost-Effectiveness Comparison Between Open Transforaminal and Minimally Invasive Lateral Lumbar Interbody Fusions

lateral lumbar interbody fusion

Neurosurgery 78:585–595, 2016

Direct cost comparisons between minimally invasive spine surgeries and the open options are rare.

OBJECTIVE: To compare healthcare costs associated with open transforaminal lumbar interbody fusion (TLIF) and minimally invasive lateral lumbar interbody fusion (LLIF) by calculating the incremental cost-effectiveness ratio (ICER) and to calculate the thresholds for minimum clinically important difference and minimum cost-effective difference for patient-reported outcome measures at the 2-year follow-up.

METHODS: Forty-five patients who underwent single-level TLIF and 29 patients who underwent single-level stand-alone LLIF were included in the comparison. All costs from diagnosis through the 2-year follow-up were available from a comprehensive single-center data bank within a unified hospital system. Payment provided for all spine-related medical resource use from the time of diagnosis through 2 years was recorded. A 0% discount rate was applied. Quality-adjusted life-years (QALYs) were calculated from the EuroQol-5D collected in an unbiased manner. Difference in total cost per QALY gained for LLIF minus that for TLIF was assessed as the estimate of the ICER from a US perspective.

RESULTS: Significant improvements were observed at the 2-year follow-up for both TLIF and LLIF with the Short Form-36 physical component summary, Oswestry Disability Index, visual analog scale back pain and leg pain scores, and EuroQol-5D. ICER calculations revealed similar mean cumulative QALYs gained at the 2-year interval (0.67 for TLIF and 0.60 for LLIF; P = .33). Median total costs of care after TLIF and LLIF were $44 068 and $45 574, respectively (P = .96). Minimum cost-effective difference thresholds with an anchor of ,$50 000 per QALY were higher than minimum clinically important difference thresholds for all patient-reported outcome measures. Total mean cost and EuroQol-5D were statistically equivalent between the 2 treatment groups.

CONCLUSION: TLIF and LLIF produced equivalent 2-year patient outcomes at an equivalent cost-effectiveness profile.

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Three-Dimensional Computed Tomography-Based Spinal Navigation in Minimally Invasive Lateral Lumbar Interbody Fusion

Three-Dimensional Computed Tomography-Based Spinal Navigation in Minimally Invasive Lateral Lumbar Interbody Fusion4

Operative Neurosurgery 11:259–267, 2015

As with most minimally invasive spine procedures, lateral lumbar interbody fusion (LLIF) requires the use of biplanar fluoroscopy for localization and safe interbody cage placement. Computed tomography (CT)-based intraoperative spinal navigation has been shown to be more effective than fluoroscopic guidance for posterior-based approaches such as pedicle screw instrumentation. However, the use of spinal navigation in LLIF has not been well studied.

OBJECTIVE: To present the technique for using an intraoperative cone-beam CT and image-guided navigation system in LLIF and to provide a preliminary analysis of outcomes.

METHODS: We retrospectively analyzed a prospectively acquired database and the electronic records of patients undergoing LLIF with spinal navigation. Eight patients were identified. Postoperative neurological deficits were recorded. All patients underwent postprocedural CT and x-ray imaging for analysis of accuracy of cage placement. Accuracy of cage placement was determined by location within the disk space.

RESULTS: The mean age was 66 years, and 6 patients were women. A mean 2.8 levels were treated with a total of 22 lateral cages implanted via navigation. All cages were placed within quarters 1 to 2 or 2 to 3, signifying the anterior half or middle portions of the disk space. There were no sensory or motor deficits postoperatively.

CONCLUSION: Use of an intraoperative cone-beam CT with an image-guided navigation system is feasible and safe and appears to be accurate, although a larger study is required to confirm these results.

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Minimally invasive lateral lumbar interbody fusion and transpsoas approach–related morbidity

Neurosurgical Focus Oct 2011 / Vol. 31 / No. 4 / Page E4

Recently, the minimally invasive, lateral retroperitoneal, transpsoas approach to the thoracolumbar spinal column has been described by various authors. This is known as the minimally invasive lateral lumbar interbody fusion. The purpose of this study is to elucidate the approach-related morbidity associated with the minimally invasive transpsoas approach to the lumbar spine. To date, there have been only a couple of reports regarding the morbidity of the transpsoas muscle approach.

METHODS

A nonrandomized, prospective study utilizing a self-reported patient questionnaire was conducted between January 2006 and June 2008 at Northwestern University. Data were collected in 53 patients with a follow-up period ranging from 6 months to 3.5 years. Only 2 patients were lost to follow-up.

RESULTS

Thirty-six percent (19 of 53) of patients reported subjective hip flexor weakness, 25% (13 of 53) anterior thigh numbness, and 23% (12 of 53) anterior thigh pain. However, 84% of the 19 patients reported complete resolution of their subjective hip flexor weakness by 6 months, and most experienced improved strength by 8 weeks. Of those reporting anterior thigh numbness and pain, 69% and 75% improved to their baseline function by the 6-month follow-up evaluations, respectively. All patients with self-reported subjective hip flexor weakness underwent examinations during subsequent clinic visits after surgery; however, these examinations did not confirm a motor deficit less than Grade 5. Subset analysis showed that the L3–4 and L4–5 levels were most often affected.

CONCLUSIONS

The minimally invasive, transpsoas muscle approach to the lumbar spine has a number of advantages. The data show that a percentage of the patients undergoing the transpsoas approach will have temporary sensory and motor symptoms related to this approach. The majority of the symptoms are thought to be related to psoas muscle inflammation and/or stretch injury to the genitofemoral nerve due to the surgical corridor traversed during the operation. No major injuries to the lumbar plexus were encountered. It is important to educate patients prior to surgery of the possibility of these largely transient symptoms.

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