Nerve injury during the transpsoas approach for lumbar fusion

2011 ◽  
Vol 15 (3) ◽  
pp. 280-284 ◽  
Author(s):  
John K. Houten ◽  
Lucien C. Alexandre ◽  
Rani Nasser ◽  
Adam L. Wollowick
Keyword(s):  
Nerve Injury ◽  
Interbody Fusion ◽  
Lumbar Fusion ◽  
Iliopsoas Muscle ◽  
Motor Deficits ◽  
Limited Information ◽  
Lateral Interbody Fusion ◽  
Transpsoas Approach ◽  
Clinical Events ◽  
Lateral Interbody

A lateral transpsoas approach to achieve interbody fusion in the lumbar spine using either the extreme lateral interbody fusion or direct lateral interbody fusion technique is an increasingly popular method to treat spinal disease. Dissection and dilation through the iliopsoas muscle places the lumbosacral plexus at risk for injury, but there is very limited information in the published literature about adverse clinical events resulting in postoperative motor deficits or reports of failure of electrophysiological monitoring to detect nerve injury. The authors present 2 cases of postoperative motor deficits following the transpsoas approach not detected by intraoperative monitoring, review the medical literature, and discuss strategies for complication avoidance.

scholarly journals Lateral Transpsoas Fusion: Indications and Outcomes

2012 ◽  
Vol 2012 ◽  
pp. 1-6 ◽  
Author(s):  
Vishal C. Patel ◽  
Daniel K. Park ◽  
Harry N. Herkowitz
Keyword(s):  
Interbody Fusion ◽  
Motor Deficits ◽  
Low Grade ◽  
Disc Disease ◽  
Lateral Interbody Fusion ◽  
Transpsoas Approach ◽  
Lower Blood ◽  
Short And Long Term ◽  
Lateral Interbody

Spinal fusion historically has been used extensively, and, recently, the lateral transpsoas approach to the thoracic and lumbar spine has become an increasingly common method to achieve fusion. Recent literature on this approach has elucidated its advantage over more traditional anterior and posterior approaches, which include a smaller tissue dissection, potentially lower blood loss, no need for an access surgeon, and a shorter hospital stay. Indications for the procedure have now expanded to include degenerative disc disease, spinal stenosis, degenerative scoliosis, nonunion, trauma, infection, and low-grade spondylolisthesis. Lateral interbody fusion has a similar if not lower rate of complications compared to traditional anterior and posterior approaches to interbody fusion. However, lateral interbody fusion has unique complications that include transient neurologic symptoms, motor deficits, and neural injuries that range from 1 to 60% in the literature. Additional studies are required to further evaluate and monitor the short- and long-term safety, efficacy, outcomes, and complications of lateral transpsoas procedures.

Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach

2011 ◽  
Vol 14 (1) ◽  
pp. 31-37 ◽  
Author(s):  
Antoine G. Tohmeh ◽  
William Blake Rodgers ◽  
Mark D. Peterson
Keyword(s):  
Real Time ◽  
Nerve Injury ◽  
Interbody Fusion ◽  
Psoas Muscle ◽  
Sensory Loss ◽  
Motor Deficits ◽  
Disc Space ◽  
Lateral Interbody Fusion ◽  
Extreme Lateral Interbody Fusion ◽  
Lateral Interbody

Object Because the psoas muscle, which contains nerves of the lumbar plexus, is traversed during the extreme lateral interbody fusion (XLIF) approach, appropriate nerve monitoring is needed to avoid nerve injury during surgery and prevent approach-related neural deficit. This study was performed to assess the effectiveness of dynamically evoked electromyography (EMG) to detect and prevent neural injury during the XLIF approach. Methods One hundred two patients undergoing XLIF at L3–4 and/or L4–5 were enrolled in a prospective, multicenter, nonrandomized clinical study. The EMG threshold values for each of the 3 successive dilators were recorded at the surface of the psoas muscle, mid-psoas, and on the spine. At each location, the dilators were rotated 360°, taking recordings immediately posterior, superior, anterior, and inferior. For each dilator, the authors noted the rotational position (the angle in degrees) at which the lowest threshold was found. Findings of pre- and postoperative neurological examinations were also recorded. Results Nerves were identified within proximity of the dilators (alert-level EMG feedback) in 55.7% of all cases during the XLIF approach. Although nerves were more commonly identified in the posterior margin (63%), there was significant variability in the location of nerves identified. Despite the fact that the posterior half of the disc space was targeted in 90% of cases, no significant long-lasting neural deficits were identified in any case; 27.5% experienced new iliopsoas/hip flexion weakness and 17.6% experienced new postoperative upper medial thigh sensory loss. Transient motor deficits were identified in 3 patients (2.9%), and all had resolved by the 6-month follow-up visit. Conclusions The ability to identify and report a discrete, real-time EMG threshold during the transpsoas approach helps to avoid nerve injury and is required for the safe performance of the XLIF procedure. Additionally, nerve location is variable, thus reinforcing the need for real-time directional and proximity information.

scholarly journals A psoas splitting approach developed for outpatient lateral interbody fusion versus a standard transpsoas approach

2018 ◽  
Vol 4 (2) ◽  
pp. 195-202 ◽  
Author(s):  
Kingsley R. Chin ◽  
Fabio J. R. Pencle ◽  
Morgan D. Brown ◽  
Jason A. Seale
Keyword(s):  
Interbody Fusion ◽  
Lateral Interbody Fusion ◽  
Transpsoas Approach ◽  
Lateral Interbody

scholarly journals Simultaneous Lateral Interbody Fusion and Posterior Percutaneous Instrumentation: Early Experience and Technical Considerations

2015 ◽  
Vol 2015 ◽  
pp. 1-8 ◽  
Author(s):  
Doniel Drazin ◽  
Terrence T. Kim ◽  
J. Patrick Johnson
Keyword(s):  
Interbody Fusion ◽  
Lumbar Fusion ◽  
Posterior Instrumentation ◽  
Lateral Approach ◽  
Control Group ◽  
Percutaneous Instrumentation ◽  
Lateral Interbody Fusion ◽  
Simultaneous Group ◽  
Simultaneous Procedures ◽  
Lateral Interbody

Lumbar fusion surgery involving lateral lumbar interbody graft insertion with posterior instrumentation is traditionally performed in two stages requiring repositioning. We describe a novel technique to complete the circumferential procedure simultaneously without patient repositioning. Twenty patients diagnosed with worsening back pain with/without radiculopathy who failed exhaustive conservative management were retrospectively reviewed. Ten patients with both procedures simultaneously from a single lateral approach and 10 control patients with lateral lumbar interbody fusion followed by repositioning and posterior percutaneous instrumentation were analyzed. Pars fractures, mobile grade 2 spondylolisthesis, and severe one-level degenerative disk disease were matched between the two groups. In the simultaneous group, avoiding repositioning leads to lower mean operative times: 130 minutes (versus control 190 minutes;p=0.009) and lower intraoperative blood loss: 108 mL (versus 93 mL; NS). Nonrepositioned patients were hospitalized for an average of 4.1 days (versus 3.8 days; NS). There was one complication in the control group requiring screw revision. Lateral interbody fusion and percutaneous posterior instrumentation are both readily accomplished in a single lateral decubitus position. In select patients with adequately sized pedicles, performing simultaneous procedures decreases operative time over sequential repositioning. Patient outcomes were excellent in the simultaneous group and comparable to procedures done sequentially.

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

2020 ◽  
Vol 4 (2) ◽  
pp. 152-158
Author(s):  
Masahiro Inoue ◽  
Sumihisa Orita ◽  
Kazuhide Inage ◽  
Kazuki Fujimoto ◽  
Yasuhiro Shiga ◽  
...  
Keyword(s):  
Interbody Fusion ◽  
Iliopsoas Muscle ◽  
Radiological Assessment ◽  
Lateral Interbody Fusion ◽  
Oblique Lateral Interbody Fusion ◽  
Lateral Interbody ◽  
Fusion 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 lateral transpsoas approach for lumbar corpectomy and stabilization

2019 ◽  
Vol 10 ◽  
pp. 153
Author(s):  
Umesh Srikantha ◽  
Yadhu Kasetti Lokanath ◽  
Akshay Hari ◽  
S. Nirmala ◽  
Ravi Gopal Varma
Keyword(s):  
Minimally Invasive ◽  
Interbody Fusion ◽  
Compression Fracture ◽  
Early Mobilization ◽  
Tubular Retractor ◽  
Lateral Interbody Fusion ◽  
Transpsoas Approach ◽  
Lateral Interbody ◽  
Anterior Column Reconstruction ◽  
Lumbar Corpectomy

Background: Here, we present our experience with the minimally invasive (MI) transpsoas approach for lumbar corpectomy and stabilization. Transpsoas approach accesses the lumbar spine and includes both the direct lateral interbody fusion and extreme lateral interbody fusion techniques. Both procedures utilize a tubular retractor system which facilitates adequate retraction and direct visualization of the target, while supposedly reducing soft tissue trauma. Case Description: We evaluated two patients, one with a traumatic L2 wedge compression fracture and the other with an L3 pathological compression fracture due to multiple myeloma. Both patients underwent MI transpsoas lumbar corpectomy, anterior column reconstruction with an expandable cage, and posterior pedicle screw instrumentation to correct a kyphotic deformity. Both patients were mobilized on the 1st postoperative day and experienced significant postoperative pain relief. Conclusion: In two cases involving L2 and L3 compression fractures, MI transpsoas lumbar corpectomy was safely performed, with reduced perioperative and postoperative morbidity. Here, the transpsoas approach also allowed for early mobilization, adequate postoperative biomechanical stability, and resulted in immediate good outcomes.

scholarly journals Minimally invasive lateral interbody fusion for the treatment of rostral adjacent-segment lumbar degenerative stenosis without supplemental pedicle screw fixation

2014 ◽  
Vol 21 (6) ◽  
pp. 861-866 ◽  
Author(s):  
Michael Y. Wang ◽  
Ram Vasudevan ◽  
Stefan A. Mindea
Keyword(s):  
Minimally Invasive ◽  
Interbody Fusion ◽  
Lumbar Fusion ◽  
Ct Scanning ◽  
Lateral Approach ◽  
Leg Pain ◽  
Adjacent Segment ◽  
Lateral Interbody Fusion ◽  
The Mean ◽  
Lateral Interbody

Object Adjacent-segment degeneration and stenosis are common in patients who have undergone previous lumbar fusion. Treatment typically involves a revision posterior approach, which requires management of postoperative scar tissue and previously implanted instrumentation. A minimally invasive lateral approach allows the surgeon to potentially reduce the risk of these hazards. The technique relies on indirect decompression to treat central and foraminal stenosis and placement of a graft with a large surface area to promote robust fusion and stability in concert with the surrounding tensioned ligaments. The goal in this study was to determine if lateral interbody fusion without supplemental pedicle screws is effective in treating adjacent-segment disease. Methods For a 30-month study period at two institutions, the authors obtained all cases of lumbar fusion with new back and leg pain due to adjacent-segment stenosis and spondylosis failing conservative measures. All patients had undergone minimally invasive lateral interbody fusion from the side of greater leg pain without supplemental pedicle screw fixation. Patients were excluded from the study if they had undergone surgery for a nondegenerative etiology such as infection or trauma. They were also excluded if the intervention involved supplemental posterior instrumented fusion with transpedicular screws. Postoperative metrics included numeric pain scale (NPS) scores for leg and back pain. All patients underwent dynamic radiographs and CT scanning to assess stability and fusion after surgery. Results During the 30-month study period, 21 patients (43% female) were successfully treated using minimally invasive lateral interbody fusion without the need for subsequent posterior transpedicular fixation. The mean patient age was 61 years (range 37–87 years). Four patients had two adjacent levels fused, while the remainder had single-level surgery. All patients underwent surgery without conversion to a traditional open technique, and recombinant human bone morphogenetic protein–2 was used in the interbody space in all cases. The mean follow-up was 23.6 months. The mean operative time was 86 minutes, and the mean blood loss was 93 ml. There were no major intraoperative complications, but one patient underwent subsequent direct decompression in a delayed fashion. The leg pain NPS score improved from a mean of 6.3 to 1.9 (p < 0.01), and the back pain NPS score improved from a mean of 7.5 to 2.9 (p < 0.01). Intervertebral settling averaged 1.7 mm. All patients had bridging bone on CT scanning at the last follow-up, indicating solid bony fusion. Conclusions Adjacent-segment stenosis and spondylosis can be treated with a number of different operative techniques. Lateral interbody fusion provides an attractive alternative with reduced blood loss and complications, as there is no need to re-explore a previous laminectomy site. In this limited series a minimally invasive lateral approach provided high fusion rates when performed with osteobiological adjuvants.

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