Extreme lateral and direct lateral lumbar interbody fusion may be a viable treatment option for degenerative lumbar disease if non-surgical treatment fails. It shows notable benefits such as minimal blood loss, preservation of posterior structures, ability to perform an extensive discectomy, and placement of large intervertebral cages. Potential disadvantages include damage to nerves, vessels, or injuries to abdominals organs.
After completing the preoperative imaging, including CT or MRI scans and X-ray images to assess for instability, confirm the surgical level with fluoroscopy images. Use skin markers to visualize the disc space. Make a three to five centimeter long skin incision over the disc space in a single-level surgery.
Open the fascia and use clamps to bluntly split this three layers of the oblique muscles until you reach the retroperitoneal space. Identify the psoas and split it in a longitudinal direction. Look out for any changes in somatosensory evoked potentials, motor evoked potentials, and spontaneous electromyography during approach and when dissecting psoas using a handheld EMG probe.
After fluoroscopically confirming the correct level, place a self-retaining retractor system. Here, use a scalpel to perform an annulotomy and resect all discal material using a rongeur. Carefully remove any remaining disc material and cartilage from both endplates using Cobb or curettes.
Use different trial components to restore normal disc height and to relieve any pressure on nerve roots. Use fluoroscopy in both AP and lateral views to confirm correct trial position. After identifying the correct size, the final cage is implanted under fluoroscopic guidance.
Check for hemostasis and remove retractors carefully. The wound is closed in a multi-layered fashion. In a recent study, we investigated the complication rates following a standalone lateral interbody fusion.
We retrospectively investigated 158 patients who received an LF between 2016 and 2020 with a mean followup of 14 months. The primary pathologies was stenosis due to adult deformity and isolated stenosis. The average blood loss was 121 milliliters.
Most patients received a single-level fusion in both study cohorts. However, in the trans-psoas group, one patient received a three-level fusion. Overall, we observed a complication rate of 19.6%The most prevalent complication observed was a temporary weakness of the hip flexor on the same side as the surgical procedure.
The weakness, however, was complete resolved in all patients by the final clinical follow-up. A single patient endured permanent nerve damage to the femoral nerve. Wound complications were found in 1.3%and symptomatic pseudarthoris in 2.1%during follow up.
A recurrent stenosis was the imminent reason for revision at 4.1%after a mean of 239 days. In addition to our analysis, Walker et al showed in their systematic review that most common complications were transient sensory symptoms at 21.7%A transient hip flexor motor weakness was found at 19.7%Persistent neurological symptoms were found in 2.8%of all cases, whereas wound infection was reported in 3.1%Many studies have shown that a standalone lateral interbody fusion is a relatively safe procedure for treatment of certain types of generative lumbar spine disease, foraminal stenosis, and some adult deformities. Utilizing neuromonitoring offers a reduced muscle disruption and potentially a faster recovery.
However, the procedure is recommended to be performed by a skilled surgical team well-versed in neuromonitoring and lateral access to spine surgery techniques.
