Minimally Invasive Lateral Retroperitoneal Approach for Resection of Extraforaminal Lumbar Plexus Schwannomas: Operative Techniques and Literature Review

2018 ◽  
Vol 15 (5) ◽  
pp. 516-521 ◽  
Author(s):  
Michael M Safaee ◽  
Christopher P Ames ◽  
Vedat Deviren ◽  
Aaron J Clark
Keyword(s):  
Minimally Invasive ◽  
Good Condition ◽  
Tumor Resection ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Lumbar Plexus ◽  
Retroperitoneal Approach ◽  
Transpsoas Approach ◽  
Lateral Interbody ◽  
Traditional Approaches

Abstract BACKGROUND Traditional approaches for retroperitoneal lumbar plexus schwannomas involve anterior open or laparoscopic resection. For select tumors, the lateral retroperitoneal approach provides a minimally invasive alternative. OBJECTIVE To describe a minimally invasive lateral transpsoas approach for the resection of retroperitoneal schwannomas. METHODS A lateral retroperitoneal transpsoas approach was used to resect a 3.1 × 2.7 × 4.1 cm schwannoma embedded within the psoas muscle. A minimally invasive retractor system allows for appropriate visualization and complete resection with the aid of the microscope. The patient tolerated the procedure without complication and was discharged on postoperative day 2 in good condition at her neurological baseline. RESULTS The lateral retroperitoneal approach provides a minimally invasive alternative for select retroperitoneal schwannomas. In theory, this procedure allows for faster recovery and less blood loss compared to traditional open anterior approaches. For a subset of tumors, anterior laparoscopy may provide better access, but the lateral approach is well known to most neurosurgeons who perform lateral interbody fusions and can be easily tailored to extraforaminal tumor resection. CONCLUSION Retroperitoneal schwannomas pose a challenge due to their deep location. The lateral retroperitoneal approach provides a useful alternative for resection of a subset of retroperitoneal schwannomas.

Trajectory of the main sensory and motor branches of the lumbar plexus outside the psoas muscle related to the lateral retroperitoneal transpsoas approach

2011 ◽  
Vol 14 (2) ◽  
pp. 290-295 ◽  
Author(s):  
Elias Dakwar ◽  
Fernando L. Vale ◽  
Juan S. Uribe
Keyword(s):  
Minimally Invasive ◽  
Abdominal Wall ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Retroperitoneal Space ◽  
Lumbar Plexus ◽  
Pelvic Cavity ◽  
Abdominal Muscles ◽  
Transpsoas Approach ◽  
Risk Of Injury

Object The minimally invasive lateral retroperitoneal transpsoas approach is increasingly used to treat various spinal disorders. Accessing the retroperitoneal space and traversing the abdominal wall poses a risk of injury to the major nervous structures and adds significant morbidity to the procedure. Most of the current literature focuses on the anatomy of the lumbar plexus within the substance of the psoas muscle. However, there is sparse knowledge regarding the trajectory of the lumbar plexus nerves that travel along the retroperitoneum and abdominal wall muscles in relation to the lateral approach to the spine. The objective of this study is to define the anatomical trajectories of the major motor and sensory branches of the lumbar plexus that are located outside the psoas muscle. Methods Six adult fresh frozen cadaveric specimens were dissected and studied (12 sides). The relationship between the retroperitoneum, abdominal wall muscles, and the lumbar plexus nerves was analyzed in reference to the minimally invasive lateral retroperitoneal approach. Special attention was given to the lumbar plexus nerves that run outside of psoas muscle in the retroperitoneal cavity and within the abdominal muscle wall. Results The skin and muscles of the abdominal wall and the retroperitoneal cavity were dissected and analyzed with respect to the major motor and sensory branches of the lumbar plexus. The authors identified 4 nerves at risk during the lateral approach to the spine: subcostal, iliohypogastric, ilioinguinal, and lateral femoral cutaneous nerves. The anatomical trajectory of each of these nerves is described starting from the spinal column until their termination or exit from the pelvic cavity. Conclusions There is risk of direct injury to the main motor/sensory nerves that supply the anterior abdominal muscles during the early stages of the lateral retroperitoneal transpsoas approach while obtaining access to the retroperitoneum. There is also a risk of injury to the ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves in the retroperitoneal space where they travel obliquely during the blunt retroperitoneal dissection. Moreover, there is a latent possibility of lesioning these nerves with the retractor blades against the anterior iliac crest.

The rising psoas sign: an analysis of preoperative imaging characteristics of aborted minimally invasive lateral interbody fusions at L4–5

2014 ◽  
Vol 20 (5) ◽  
pp. 531-537 ◽  
Author(s):  
Jean-Marc Voyadzis ◽  
Daniel Felbaum ◽  
Jay Rhee
Keyword(s):  
Minimally Invasive ◽  
Preoperative Evaluation ◽  
Femoral Nerve ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Preoperative Imaging ◽  
Disc Disease ◽  
Disc Space ◽  
Imaging Characteristics ◽  
Lateral Interbody

Minimally invasive lateral interbody fusion for the treatment of degenerative disc disease, spondylolisthesis, or scoliosis is becoming increasingly popular. The approach at L4–5 carries the highest risk of nerve injury given the proximity of the lumbar plexus and femoral nerve. The authors present 3 cases that were aborted during the approach because of pervasive electromyography responses throughout the L4–5 disc space. Preoperative imaging characteristics of psoas muscle anatomy in all 3 cases are analyzed and discussed. In all cases, the psoas muscle on axial views was rising away from the vertebral column as opposed to its typical location lateral to it. Preoperative evaluation of psoas muscle anatomy is important. A rising psoas muscle at L4–5 on axial imaging may complicate a lateral approach.

An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine

2009 ◽  
Vol 10 (2) ◽  
pp. 139-144 ◽  
Author(s):  
David M. Benglis ◽  
Steve Vanni ◽  
Allan D. Levi
Keyword(s):  
Lumbar Spine ◽  
Minimally Invasive ◽  
Interbody Fusion ◽  
Psoas Muscle ◽  
Anatomical Study ◽  
Lumbosacral Plexus ◽  
Disc Space ◽  
Lateral Interbody Fusion ◽  
Transpsoas Approach ◽  
Lateral Interbody

Object Minimally invasive anterolateral approaches to the lumbar spine are options for the treatment of a number of adult degenerative spinal disorders. Nerve injuries during these surgeries, although rare, can be devastating complications. With an increasing number of spine surgeons utilizing minimal access retroperitoneal surgery to treat lumbar problems, the frequency of complications associated with this approach will likely increase. The authors sought to better understand the location of the lumbar contribution of the lumbosacral plexus relative to the disc spaces encountered when performing the minimally invasive transpsoas approach, also known as extreme lateral interbody fusion or direct lateral interbody fusion. Methods Three fresh cadavers were placed lateral, and a total of 3 dissections of the lumbar contribution of the lumbosacral plexus were performed. Radiopaque soldering wire was then laid along the anterior margin of the nerve fibers and the exiting femoral nerve. Markers were placed at the disc spaces and lateral fluoroscopy was used to measure the location of the lumbar plexus along each respective disc space in the lumbar spine (L1–2, L2–3, L3–4, and L4–5). Results The lumbosacral plexus was found lying within the substance of the psoas muscle between the junction of the transverse process and vertebral body and exited along the medial edge of the psoas distally. The lumbosacral plexus was most dorsally positioned at the posterior endplate of L1–2. A general trend of progressive ventral migration of the plexus on the disc space was noted at L2–3, L3–4, and L4–5. Average ratios were calculated at each level (location of the plexus from the dorsal endplate to total disc length) and were 0 (L1–2), 0.11 (L2–3), 0.18 (L3–4), and 0.28 (L4–5). Conclusions This anatomical study suggests that positioning the dilator and/or retractor in a posterior position of the disc space may result in nerve injury to the lumbosacral plexus, especially at the L4–5 level. The risk of injuring inherent nerve branches directed to the psoas muscle as well as injury to the genitofemoral nerve do still exist.

scholarly journals MINIMALLY INVASIVE EXTREME LATERAL APPROACH IN SPINAL LUMBAR METASTASIS

2018 ◽  
Vol 26 (3) ◽  
pp. 191-193
Author(s):  
LUCAS CASTRILLON CARMO MACHADO ◽  
DOUGLAS KENJI NARAZAKI ◽  
WILLIAN GEMIO JACOBSEN TEIXEIRA ◽  
ALEXANDRE FOGAÇA CRISTANTE ◽  
MANOEL JACOBSEN TEIXEIRA ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Minimally Invasive ◽  
Anterior Approach ◽  
Treatment Options ◽  
Spinal Metastases ◽  
Case Series ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Level Of Evidence ◽  
Transpsoas Approach

ABSTRACT Introduction The extreme lateral approach has been widely used for the treatment of degenerative diseases. The objective of this study is to present a minimally invasive extreme lateral approach for the treatment of metastatic lesions in the lumbar spine without the use of the evoked potential exam (MEP). Methods Two patients with spinal metastases and indication for surgery via the anterior approach were treated in a cancer referral center in Brazil. They were placed in right lateral decubitus, and an oblique incision was made, exposing the psoas muscle. The anterior approach permitted the release of the psoas muscle from vertebral body and disc, without the need for MEP. Conclusions When cancer cure is no longer possible, a minimally invasive extreme lateral approach to treat tumor metastases in the lumbar spine is a viable option, with short hospitalization time and low morbidity. The dislocation of the psoas muscle avoids the use of the transpsoas approach, which requires MEP equipment and a trained physician. Clinical studies are needed to extend these benefits to oncological patients who have treatment options for their primary disease. Level of Evidence IV; Case series.

scholarly journals Four-level minimally invasive lateral interbody fusion for treatment of degenerative scoliosis

2013 ◽  
Vol 35 (v2supplement) ◽  
pp. Video10 ◽  
Author(s):  
Beejal Y. Amin ◽  
Praveen V. Mummaneni ◽  
Tarik Ibrahim ◽  
Alex Zouzias ◽  
Juan Uribe
Keyword(s):  
Minimally Invasive ◽  
Abdominal Wall ◽  
Interbody Fusion ◽  
Patient Positioning ◽  
Lumbar Plexus ◽  
Degenerative Scoliosis ◽  
Promising Alternative ◽  
Transpsoas Approach ◽  
Adult Degenerative Scoliosis ◽  
Lateral Interbody

The benefits of anterior interbody arthrodesis in deformity surgery are well known and include load sharing and increased fusion rates. A minimally invasive lateral transpsoas approach to the anterior lumbar spine is a promising alternative to traditional interbody techniques for the treatment of adult degenerative scoliosis. The reported advantages of the minimally invasive lateral transpsoas approach include reduced blood loss and shorter length of stay. However, there are several approach-related complications associated with this technique including injury to the nerves within the abdominal wall leading to abdominal wall paresis, bowel injury, and injury to the lumbar plexus.In this video, we demonstrate the key steps of the minimally invasive lateral retroperitoneal transpsoas technique for interbody fusion in the treatment of adult degenerative scoliosis.The video demonstrates patient positioning, surgical opening, passage through the anatomical safe zone, use of multidirectional EMG to navigate away from the lumbar plexus, placement of the expandable retractor, discectomy, endplate preparation, graft insertion, and wound closure. Special emphasis is placed on the approach. We highlight the relevant nerves passing through the abdominal wall with the aid of a microscope.The video can be found here: http://youtu.be/XU1OujNF8F8.

scholarly journals Stand-Alone Lateral Interbody Fusion for the Treatment of Low-Grade Degenerative Spondylolisthesis

2012 ◽  
Vol 2012 ◽  
pp. 1-7 ◽  
Author(s):  
Luis Marchi ◽  
Nitamar Abdala ◽  
Leonardo Oliveira ◽  
Rodrigo Amaral ◽  
Etevaldo Coutinho ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Interbody Fusion ◽  
Degenerative Spondylolisthesis ◽  
Lateral Approach ◽  
Low Grade ◽  
Mean Values ◽  
Single Level ◽  
Lateral Interbody Fusion ◽  
Cage Subsidence ◽  
Lateral Interbody

The purpose of this paper was to investigate the stand-alone lateral interbody fusion as a minimally invasive option for the treatment of low-grade degenerative spondylolisthesis with a minimum 24-month followup. Prospective nonrandomized observational single-center study. 52 consecutive patients (67.6±10 y/o; 73.1% female;27.4±3.4 BMI) with single-level grade I/II single-level degenerative spondylolisthesis without significant spine instability were included. Fusion procedures were performed as retroperitoneal lateral transpsoas interbody fusions without screw supplementation. The procedures were performed in average 73.2 minutes and with less than 50cc blood loss. VAS and Oswestry scores showed lasting improvements in clinical outcomes (60% and 54.5% change, resp.). The vertebral slippage was reduced in 90.4% of cases from mean values of 15.1% preoperatively to 7.4% at 6-week followup (P<0.001) and was maintained through 24 months (7.1%,P<0.001). Segmental lordosis (P<0.001) and disc height (P<0.001) were improved in postop evaluations. Cage subsidence occurred in 9/52 cases (17%) and 7/52 cases (13%) spine levels needed revision surgery. At the 24-month evaluation, solid fusion was observed in 86.5% of the levels treated. The minimally invasive lateral approach has been shown to be a safe and reproducible technique to treat low-grade degenerative spondylolisthesis.

scholarly journals Minimally Invasive Direct Lateral Transpsoas Approach for the Resection of a Lumbar Plexus Schwannoma: Technique Report

2016 ◽  
Vol 02 (03) ◽  
pp. e66-e69 ◽  
Author(s):  
Carolina Benjamin ◽  
Eric Oermann ◽  
J. Thomas ◽  
Casey Distaso ◽  
Faheem Sandhu
Keyword(s):  
Postoperative Complications ◽  
Minimally Invasive ◽  
Retroperitoneal Tumor ◽  
Lumbar Plexus ◽  
Intraoperative Blood Loss ◽  
Effective Technique ◽  
Tubular Retractor ◽  
Leg Strength ◽  
Transpsoas Approach ◽  
Retroperitoneal Schwannoma

Objective Traditional techniques for resection of lumbar plexus tumors have been associated with approach-related morbidity. We describe a case utilizing a minimally invasive transpsoas lateral access approach to resect a retroperitoneal tumor of the lumbar plexus. Methods We report a case with an extradural retroperitoneal schwannoma of the L4 nerve root that was treated with a minimally invasive direct lateral transpsoas approach using atraumatic tissue dilators and an expandable tubular retractor. The use of directional and continuous electromyographic monitoring was critical in locating the plexus and positioning the retractor immediately anterior to the tumor. Results The patient tolerated the procedure well without postoperative complications. The operative approach was direct and intraoperative blood loss was negligible. The patient demonstrated improved left leg strength and ambulation and resolution of paresthesias. Conclusions A minimally invasive direct lateral transpsoas access approach is an effective technique to safely and adequately resect extradural retroperitoneal lumbar plexus tumors.

Lumbar Plexus Anatomy within the Psoas Muscle: Implications for the Transpsoas Lateral Approach to the L4-L5 Disc

2011 ◽  
Vol 93 (16) ◽  
pp. 1482-1487 ◽  
Author(s):  
Timothy T Davis ◽  
Hyun W Bae ◽  
MAJ James M Mok ◽  
Alexandre Rasouli ◽  
Rick B Delamarter
Keyword(s):  
Psoas Muscle ◽  
Lateral Approach ◽  
Lumbar Plexus ◽  
Transpsoas Lateral Approach

Genitofemoral Nerve Protection During the Lateral Retroperitoneal Transpsoas Approach

2013 ◽  
Vol 73 (2) ◽  
pp. ons192-ons197 ◽  
Author(s):  
Gabriel C. Tender ◽  
Daniel Serban
Keyword(s):  
Length Of Stay ◽  
Blood Loss ◽  
Minimally Invasive ◽  
Operative Time ◽  
Femoral Nerve ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Direct Visualization ◽  
Genitofemoral Nerve ◽  
Estimated Blood Loss

Abstract BACKGROUND: The minimally invasive lateral retroperitoneal approach for lumbar fusions is a novel technique with good results, but also with significant sensory and motor complications. OBJECTIVE: To present the early results of a modified surgical technique, in which the psoas muscle is dissected under direct visualization. METHODS: Thirteen consecutive patients with L4-5 or L3-4 pathology were prospectively followed after being treated using a minimally invasive lateral approach with direct exposure of the psoas muscle before dissection. There were 7 woman and 6 men with a mean age of 52.3 years. Perioperative parameters like operative time, estimated blood loss, and length of stay, were noted. Pain, paresthesia, and motor weakness, as well as any other complications, were evaluated at 2 weeks and 3 months postoperatively. RESULTS: The mean operative time, estimated blood loss, and length of stay were 163 minutes, 126 mL, and 3 days, respectively. One patient exhibited anterior thigh pain and paresthesia at 2 weeks, both of which resolved by 3 months. Two patients experienced superficial wound infections that healed with antibiotics. The genitofemoral nerve was identified and protected in 7 patients; in 4 patients, it had a more posterior anatomic location than expected. The femoral nerve was not exposed or detected in the operative field by neuromonitoring, nor were there any symptoms related to a femoral nerve injury in any patient. CONCLUSION: Dissection of the psoas muscle under direct visualization during the minimally invasive lateral approach may provide increased safety to the genitofemoral and femoral nerves.

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