Location of the Femoral Nerve in the Lateral Decubitus Versus Prone Position

2021 ◽  
pp. 219256822110491
Author(s):  
Ram Alluri ◽  
Nicholas Clark ◽  
Evan Sheha ◽  
Karim Shafi ◽  
Matthew Geiselmann ◽  
...  
Keyword(s):  
Prone Position ◽  
Interbody Fusion ◽  
Femoral Nerve ◽  
Psoas Muscle ◽  
Lateral Decubitus Position ◽  
Lumbar Plexus ◽  
Lumbar Interbody Fusion ◽  
Posterior Edge ◽  
Disc Space ◽  
Lateral Decubitus

Study Design Cadaveric study. Objective To compare the position of the femoral nerve within the lumbar plexus at the L4-L5 disc space in the lateral decubitus vs prone position. Methods Seven lumbar plexus specimens were dissected and the femoral nerve within the psoas muscle was identified and marked with radiopaque paint. Lateral fluoroscopic images of the cadaveric specimens in the lateral decubitus vs prone position were obtained. The location of the radiopaque femoral nerve at the L4-L5 disc space was normalized as a percentage of the L5 vertebral body (0% indicates posterior location and 100% indicates anterior location at the L4-L5 disc space). The location of the femoral nerve at L4-L5 in the lateral decubitus vs prone position was compared using a paired t test. Results In the lateral decubitus position, the femoral nerve was located 28% anteriorly from the posterior edge of the L4-L5 disc space, and in the prone position, the femoral nerve was relatively more posterior, located 18% from the posterior edge of the L4-L5 disc space ( P = .037). Conclusions The femoral nerve was on average more posteriorly located at the L4-L5 disc space in the prone position compared to lateral decubitus. This more posterior location allows for a larger safe zone at the L4-L5 disc space, which may decrease the incidence of neurologic complications associated with Lateral lumbar interbody fusion in the prone vs lateral decubitus position; however, further studies are needed to evaluate this possible clinical correlation.

scholarly journals Oblique Lumbar Interbody Fusion at the L5-S1 Segment via an Approach Between the Psoas Muscle and the Great Vessels: Technique Note and Case Presentations.

2020 ◽  
Author(s):  
Xigong Li ◽  
Weiyi Diao ◽  
Yuzhu Zhang ◽  
Junsong Wu ◽  
Chunyang Xing ◽  
...  
Keyword(s):  
Interbody Fusion ◽  
Perioperative Complications ◽  
Psoas Muscle ◽  
Common Iliac Vein ◽  
Type I ◽  
Lumbar Interbody Fusion ◽  
Disc Space ◽  
Type Iii ◽  
Great Vessels ◽  
Oblique Lumbar Interbody Fusion

Abstract Study DesignTechnique note.ObjectivesTo describe our modified oblique lumbar interbody fusion (OLIF) technique in the reconstruction of the L5-S1 segment.Summary of Background DataRecently, OLIF has been generally recognized as an effective procedure in the treatment of various spinal pathologies at L2-L5 segments. However, the usage of OLIF at the L5-S1 segment doesn’t have gained widespread acceptance in spine community. Some authors still concern about the feasibility of OLIF used in lumbosacral fusionMethodsTen consecutive patients underwent L5-S1 interbody fusion using the OLIF technique in our institution. The L5–S1 disc space is approached via one retroperitoneal oblique corridor between the psoas muscle and the great vessels. The discectomy and endplate preparation are performed through a surgical window developed on the anterolateral side of L5-S1 disc. A secondary cage insertion technique is used for safe placement of interbody fusion cages.ResultsOf the 10 patients, 6 were males and 4 were females, with an average age of 55.4±6.8 years. There were 8 single-level and 2 two-level procedures, including 2 at L4–L5 and 10 at L5–S1. Preoperative axial MR images confirmed 1 patient with type I LCIV (left common iliac vein), 6 with type II LCIV and 3 with type III LCIV. The average blood loss was 133.4±88.5 ml, and the average operative times were 153.6±38.3 minutes. Postoperative radiographs examination confirmed all patients obtained a better reconstruction at the lumbosacral junction. Two patients with type III LCIV sustained iliolumbar vein laceration during the exposure, and no other perioperative complications were encountered.ConclusionOur novel OLIF L5-S1 technique is a more feasible procedure of lumbosacral fusion, which shared the common surgical plane with OLIF L2-5, allowing for L2 to S1 reproducible multi-levels interbody fusions via a retroperitoneal oblique corridor between the psoas muscle and the great vessels. Detailed preoperative plan and meticulous intraoperative manipulation are prerequisite for the success of OLIF L5-S1 procedure.

scholarly journals Oblique lumbar interbody fusion in management of lumbar degenerative spinal stenosis in Chinese population

2020 ◽  
Vol 27 (2) ◽  
pp. 119-127
Author(s):  
Man Yee Cheung ◽  
Philip Cheung
Keyword(s):  
Spinal Stenosis ◽  
Interbody Fusion ◽  
Posterior Instrumentation ◽  
Psoas Muscle ◽  
Chinese Patients ◽  
Lumbar Interbody Fusion ◽  
Disc Space ◽  
Lateral Incision ◽  
Oblique Lumbar Interbody Fusion ◽  
The Mean

Purpose: The purpose of this study was to assess the outcomes of a cohort of local Chinese patients who underwent oblique lumbar interbody fusion (OLIF) surgery for lumbar degenerative diseases. Methods: We adopted a minimally invasive anterior approach to the lumbar spine through retroperitoneal access. In the first part of the surgery, a 3- to 5-cm left lateral incision over the abdomen was made guided by imaging. L2–L5 disc space was approached via the corridor between the left psoas muscle and the great vessels. A specially designed interbody cage filled with bone substitute was utilized for interbody fusion. In the second part of the surgery, posterior instrumentation with or without decompression, was performed in a prone position. Efficacy and safety of the surgery were studied. Results: A total of 60 patients with the mean age of 68 years underwent OLIF at 83 surgical levels. Their mean operative time was 79 min, and the average blood loss was 84 ml for the OLIF part. The mean length of hospital stay was 5.5 days. Based on plain computed tomography scan obtained at post-operative 6 months, successful fusion was achieved in 82 of the 83 surgical levels. The Oswestry Disability Index for low back pain had a mean reduction of 22.3% after 6 months. Specific complications observed include transient thigh pain or numbness, retroperitoneal hematoma, post-operative ileus and Bone Morphogenetic Protein (BMP) osteolysis. None of the patients experienced infection, symptomatic pseudo-arthrosis, hardware failure, vascular injury, nerve injury, ureteral injury, bowel injury, incisional hernia or death. Conclusion: OLIF is an effective procedure to treat lumbar spinal stenosis and spondylolisthesis with excellent fusion rate and good functional outcome. Complications specific to this procedure are not uncommon, but majority are minor and self-recovery. Proper training is required to minimize potential surgical risks.

Single-Position Surgery: Prone Lateral Lumbar Interbody Fusion: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Ifije E Ohiorhenuan ◽  
Jakub Godzik ◽  
Juan S Uribe
Keyword(s):  
Informed Consent ◽  
Prone Position ◽  
Interbody Fusion ◽  
Operative Time ◽  
Illustrative Case ◽  
Anterior Fusion ◽  
Lumbar Interbody Fusion ◽  
Posterior Decompression ◽  
Lateral Lumbar Interbody Fusion ◽  
Lateral Decubitus

Abstract Lateral lumbar interbody fusion (LLIF) is a widely used technique for anterior fusion. However, posterior decompression or instrumentation often requires repositioning the patient, which increases operative time. This video describes the prone LLIF as a modification of the standard surgical technique. The prone LLIF facilitates simultaneous decompression and fusion, which avoids the need for repositioning the patient, increasing operative efficiency. Positioning, fluoroscopic considerations, and operative nuances involved in performing the LLIF in the prone position are described, and an illustrative case is presented. The patient provided informed consent for the procedure and videography. LLIF in the prone position can decrease operative time and increase operative efficiency. The prone position is a viable alternative to the conventional lateral decubitus position. Video used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Retroperitoneal oblique corridor to the L2–S1 intervertebral discs in the lateral position: an anatomic study

2014 ◽  
Vol 21 (5) ◽  
pp. 785-793 ◽  
Author(s):  
Timothy T. Davis ◽  
Richard A. Hynes ◽  
Daniel A. Fung ◽  
Scott W. Spann ◽  
Michael MacMillan ◽  
...  
Keyword(s):  
Intervertebral Discs ◽  
Lateral Decubitus Position ◽  
Lumbar Plexus ◽  
Intervertebral Disc Space ◽  
Disc Space ◽  
Static State ◽  
Iliac Vessel ◽  
Mean Values ◽  
Medial Border ◽  
Lateral Decubitus

Object Access to the intervertebral discs from L2–S1 in one surgical position can be challenging. The transpsoas minimally invasive surgical (MIS) approach is preferred by many surgeons, but this approach poses potential risk to neural structures of the lumbar plexus as they course through the psoas. The lumbar plexus and iliac crest often restrict the L4–5 disc access, and the L5–S1 level has not been a viable option from a direct lateral approach. The purpose of the present study was to investigate an MIS oblique corridor to the L2–S1 intervertebral disc space in cadaveric specimens while keeping the specimens in a lateral decubitus position with minimal disruption of the psoas and lumbar plexus. Methods Twenty fresh-frozen full-torso cadaveric specimens were dissected, and an oblique anatomical corridor to access the L2–S1 discs was examined. Measurements were taken in a static state and with mild retraction of the psoas. The access corridor was defined at L2–5 as the left lateral border of the aorta (or iliac artery) and the anterior medial border of the psoas. The L5–S1 corridor of access was defined transversely from the midsagittal line of the inferior endplate of L-5 to the medial border of the left common iliac vessel and vertically to the first vascular structure that crosses midline. Results The mean access corridor diameters in the static state and with mild psoas retraction, respectively, were as follows: at L2–3, 18.60 mm and 25.50 mm; at L3–4, 19.25 mm and 27.05 mm; and at L4–5, 15.00 mm and 24.45 mm. The L5–S1 corridor mean values were 14.75 mm transversely, from midline to the left common iliac vessel and 23.85 mm from the inferior endplate of L-5 cephalad to the first midline vessel. Conclusions The oblique corridor allows access to the L2–S1 discs while keeping the patient in a lateral decubitus position without a break in the table. Minimal psoas retraction without significant tendon disruption allowed for a generous corridor to the disc space. The L5–S1 disc space can be accessed from an oblique angle consistently with gentle retraction of the iliac vessels. This study supports the potential of an MIS oblique retroperitoneal approach to the L2–S1 discs.

scholarly journals Use of 3D CT-based navigation in minimally invasive lateral lumbar interbody fusion

2016 ◽  
Vol 25 (3) ◽  
pp. 339-344 ◽  
Author(s):  
Jacob R. Joseph ◽  
Brandon W. Smith ◽  
Rakesh D. Patel ◽  
Paul Park
Keyword(s):  
Interbody Fusion ◽  
Cone Beam Ct ◽  
Psoas Muscle ◽  
Lumbar Interbody Fusion ◽  
Related Complication ◽  
Disc Space ◽  
Image Guided ◽  
Lateral Lumbar Interbody Fusion ◽  
Intraoperative Fluoroscopy ◽  
Spinal Navigation

OBJECTIVE Lateral lumbar interbody fusion (LLIF) is an increasingly popular technique used to treat degenerative lumbar disease. The technique of using an intraoperative cone-beam CT (iCBCT) and an image-guided navigation system (IGNS) for LLIF cage placement has been previously described. However, other than a small feasibility study, there has been no clinical study evaluating its accuracy or safety. Therefore, the purpose of this study was to evaluate the accuracy and safety of image-guided spinal navigation in LLIF. METHODS An analysis of a prospectively acquired database was performed. Thirty-one consecutive patients were identified. Accuracy was initially determined by comparison of the planned trajectory of the IGNS with post–cage placement intraoperative fluoroscopy. Accuracy was subsequently confirmed by postprocedural CT and/or radiography. Cage placement was graded based on a previously described system separating the disc space into quarters. RESULTS The mean patient age was 63.9 years. A total of 66 spinal levels were treated, with a mean of 2.1 levels (range 1–4) treated per patient. Cage placement was noted to be accurate using IGNS in each case, as confirmed with intraoperative fluoroscopy and postoperative imaging. Sixty-four (97%) cages were placed within Quarters 1 to 2 or 2 to 3, indicating placement of the cage in the anterior or middle portions of the disc space. There were no instances of misguidance by IGNS. There was 1 significant approach-related complication (psoas muscle abscess) that required intervention, and 8 patients with transient, mild thigh paresthesias or weakness. CONCLUSIONS LLIF can be safely and accurately performed utilizing iCBCT and IGNS. Accuracy is acceptable for multilevel procedures.

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

2020 ◽  
Vol 49 (3) ◽  
pp. E5
Author(s):  
J. Alex Thomas ◽  
Christopher I. M. Thomason ◽  
Brett A. Braly ◽  
Cristiano M. Menezes
Keyword(s):  
Interbody Fusion ◽  
Lateral Decubitus Position ◽  
Foraminal Stenosis ◽  
Lumbar Interbody Fusion ◽  
Number Of Patients ◽  
Indirect Decompression ◽  
Surgical Data ◽  
Lateral Decubitus ◽  
The Mean ◽  
Rate Of Failure

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.

scholarly journals Changes in the Operative Corridor in Oblique Lumbar Interbody Fusion Between Preoperative Imaging and Intraoperative Cone-Beam Computed Tomography Using Morphometric Analysis

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Aqib Zehri ◽  
Hector Enrique Soriano-Baron ◽  
Wesley Hsu ◽  
Matthew Neal ◽  
Jonathan L Wilson
Keyword(s):  
Computed Tomography ◽  
Mr Imaging ◽  
Interbody Fusion ◽  
Lateral Decubitus Position ◽  
Cone Beam ◽  
Preoperative Imaging ◽  
Invasive Technique ◽  
Lumbar Interbody Fusion ◽  
Oblique Lumbar Interbody Fusion ◽  
Lateral Decubitus

Abstract INTRODUCTION Oblique lumbar interbody fusion (OLIF) is a minimally-invasive technique that relies on a sufficient corridor anterior to the psoas and posterior to vascular structures.This intraoperative corridor is evaluated on preoperative computed tomography (CT) and/or magnetic resonance (MR) imaging to guide patient selection.Previous cadaveric studies and preoperative MR imaging analysis have examined this corridor to determine corridor variations along right- and left-sided approaches and among patient characteristics.This is the first study that directly evaluates the true intraoperative corridor in the lateral decubitus position based on intraoperative 3D imaging. METHODS We performed a retrospective evaluation identifying patients > 18 yr old who had undergone an OLIF via a left-sided approach at 2 tertiary care centers from 2016 to 2018. Patients with scoliosis greater than 20 degrees, transitional anatomy, and psoas abnormalities were excluded.We recorded demographics and the intraoperative corridor defined by the distance between the left lateral border of the aorta or iliac vessels and anteromedial border of the psoas from L1-L2 through L4-5 disc spaces.This corridor was measured on supine, preoperative MR axial imaging and subsequent intraoperative 3D cone beam CT acquired in the right lateral decubitus position. RESULTS A total of 33 patients, 15 of whom were female, were included in this study.The average age was 65.4 and body mass index (BMI) was 31 kg/m2.There was a statistically significant increase (P < .05) in the intraoperative corridor from supine to lateral decubitus positioning at all levels.The greatest increase in corridor size was noted at L1-2 (3.1 cm) and least at L4-5 (2.1 cm).There was no statistically significant difference between age, BMI, or gender in the preoperative versus intraoperative corridor. CONCLUSION This is the first study to provide objective evidence to support that lateral decubitus positioning increases the intraoperative corridor for anterior to the psoas techniques.This information should increase confidence with an anterior to the psoas approach if there is adequate corridor size on supine preoperative imaging evaluation.

scholarly journals Microendoscopy-assisted extraforaminal lumbar interbody fusion for treating single-level spondylodesis

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Motohide Shibayama ◽  
Guang Hua Li ◽  
Li Guo Zhu ◽  
Zenya Ito ◽  
Fujio Ito
Keyword(s):  
Minimally Invasive ◽  
Spinal Canal ◽  
Interbody Fusion ◽  
Facet Joint ◽  
Clinical Results ◽  
Invasive Technique ◽  
Clinical Effects ◽  
Lumbar Interbody Fusion ◽  
Disc Space ◽  
Single Level

Abstract Background Lumbar interbody fusion is a standard technique for treating degenerative lumbar disorders involving instability. Due to its invasiveness, a minimally invasive technique, extraforaminal lumbar interbody fusion (ELIF), was introduced. On surgically approaching posterolaterally, the posterior muscles and spinal canal are barely invaded. Despite its theoretical advantage, ELIF is technically demanding and has not been popularised. Therefore, we developed a microendoscopy-assisted ELIF (mELIF) technique which was designed to be safe and less invasive. Here, we aimed to report on the surgical technique and clinical results. Methods Using a posterolateral approach similar to that of lateral disc herniation surgery, a tubular retractor, 16 or 18 mm in diameter, was placed at the lateral aspect of the facet joint. The facet joint was partially excised, and the disc space was cleaned. A cage and local bone graft were inserted into the disc space. All disc-related procedures were performed under microendoscopy. The spinal canal was not invaded. Bilateral percutaneous screw-rod constructs were inserted and fixed. Results Fifty-five patients underwent the procedure. The Oswestry Disability Index and visual analogue scale scores greatly improved. Over 90% of the patients obtained excellent or good results based on Macnab’s criteria. There were neither major adverse clinical effects nor the need for additional surgery. Conclusions mELIF is minimally invasive because the spinal canal and posterior muscles are barely invaded. It produces good clinical results with fewer complications. This technique can be applied in most single-level spondylodesis cases, including those involving L5/S1 disorders.

scholarly journals Computerized tomography evaluation of a resorbable implant after transforaminal lumbar interbody fusion

2004 ◽  
Vol 16 (3) ◽  
pp. 1-6 ◽  
Author(s):  
Timothy R. Kuklo ◽  
Michael K. Rosner ◽  
David W. Polly
Keyword(s):  
Computerized Tomography ◽  
Interbody Fusion ◽  
Case Series ◽  
Ct Scanning ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Delayed Union ◽  
Lumbar Interbody Fusion ◽  
Disc Space ◽  
Screw Breakage

Object Synthetic bioabsorbable implants have recently been introduced in spinal surgery; consequently, the indications, applications, and results are still evolving. The authors used absorbable interbody spacers (Medtronic Sofamor Danek, Memphis, TN) packed with recombinant bone morphogenetic protein (Infuse; Medtronic Sofamor Danek) for single- and multiple-level transforaminal lumbar interbody fusion (TLIF) procedures over a period of 18 months. This is a consecutive case series in which postoperative computerized tomography (CT) scanning was used to assess fusion status. Methods There were 22 patients (17 men, five women; 39 fusion levels) whose mean age was 41.6 years (range 23–70 years) and in whom the mean follow-up duration was 12.4 months (range 6–18 months). Bridging bone was noted as early as the 3-month postoperative CT scan when obtained; solid arthrodesis was routinely noted between 6 and 12 months in 38 (97.4%) of 39 fusion levels. In patients who underwent repeated CT scanning, the fusion mass appeared to increase with time, whereas the disc space height remained stable. Although the results are early (mean 12-month follow-up duration), there was only one noted asymptomatic delayed union/nonunion at L5–S1 in a two-level TLIF with associated screw breakage. There were no infections or complications related to the cages. Conclusions The bioabsorbable cages appear to be a viable alternative to metal interbody spacers, and may be ideally suited to spinal interbody applications because of their progressive load-bearing properties.

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