Rate of failure of indirect decompression in lateral single-position surgery: clinical results

Abstract

OBJECTIVELateral single-position surgery (LSPS) of the lumbar spine generally involves anterior lumbar interbody fusion (ALIF) performed in the lateral position (LALIF) at L5–S1 with or without lateral lumbar interbody fusion (LLIF) at L4–5 and above, followed by bilateral pedicle screw fixation (PSF) without repositioning the patient. One obstacle to more widespread adoption of LSPS is the perceived need for direct decompression of the neural elements, which typically requires flipping the patient to the prone position. The purpose of this study was to examine the rate of failure of indirect decompression in a cohort of patients undergoing LSPS from L4 to S1.METHODSA multicenter, post hoc analysis was undertaken from prospectively collected data of patients at 3 institutions who underwent LALIF at L5–S1 with or without LLIF at L4–5 with bilateral PSF in the lateral decubitus position between March 2018 and March 2020. Inclusion criteria were symptoms of radiculopathy or neurogenic claudication, central or foraminal stenosis (regardless of degree or etiology), and indication for interbody fusion at L5–S1 or L4–S1. Patients with back pain only; those who were younger than 18 years; those with tumor, trauma, or suspicion of infection; those needing revision surgery; and patients who required greater than 2 levels of fusion were excluded. Baseline patient demographic information and surgical data were collected and analyzed. The number of patients in whom indirect decompression failed was recorded and each individual case of failure was analyzed.RESULTSA total of 178 consecutive patients underwent LSPS during the time period (105 patients underwent LALIF at L5–S1 and 73 patients underwent LALIF at L5–S1 with LLIF at L4–5). The mean follow-up duration was 10.9 ± 6.5 months. Bilateral PSF was placed with the patient in the lateral decubitus position in 149 patients, and there were 29 stand-alone cases. The mean case time was 101.9 ± 41.5 minutes: 79.3 minutes for single-level cases and 134.5 minutes for 2-level cases. Three patients (1.7%) required reoperation for failure of indirect decompression.CONCLUSIONSThe rate of failure of indirect decompression in LSPS from L4 to S1 is exceedingly low. This low risk of failure should be weighed against the risks associated with direct decompression as well as the risks of the extra operative time needed to perform this decompression.

Utilization of lateral anterior lumbar interbody fusion for revision of failed prior TLIF: illustrative case

“… 6 , 7 There is evidence in the literature that using the anterior-lateral corridor to the spine results in less pain, better cosmesis, reduced postoperative ileus, and similar deformity correction and outcomes compared to surgery in the supine position. 4 , 6 , 9 , 10 From a technical perspective, LALIF offers all the benefits of an anterior approach to the spine, even in the presence of posterior instrumentation. 1 , 2 , 4 , 5 , 14 , 15 , 18 …”

Applied anatomy and surgical technique of the lateral single‐position L5–S1 fusion

“…“Lateral single position surgery” was also proven feasible in obese patients, using gravity to assist in mobilizing the peritoneal contents away from the anterior spine (Malham et al, 2019). Recently, lateral single‐position surgery has been shown to be effective in the lumbar spine at L4 and L5 and L5–S1 levels with a low (1.7%) rate of failure of indirect decompression and also a low (5.1%) complication rate (Thomas et al, 2020).…”

“…Anterior approaches to this junction serve as an alternative to transforaminal lumbar interbody fusion (TLIF), giving clinical, radiological, and biomechanical results superior to TLIF (Kapustka et al, 2019; Mobbs et al, 2015; Mun et al, 2020; Xu et al, 2018). The latest development in the anterior lumbar interbody fusion (ALIF) procedure is its application to the lateral position, allowing for simultaneous posterior percutaneous screw placement as a single level surgery at L5–S1, or as part of a multilevel procedure enabling surgeons to complete lumbar fusion procedures from L1 to S1 in a single lateral position (Drazin et al, 2015; Malham et al, 2019; Thomas et al, 2020).…”

A comparative study of L4-L5-S1 and L5-S1 vertebral fusion in high-grade L5-S1 spondylolisthesis

“…This low risk of failure should be weighed against the risks associated with direct decompression as well as the risks of the extra operative time needed to perform this decompression. [ 31 ]…”