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Mini-Open Access for Lateral Lumbar Interbody Fusion

Indications, Technique, and Outcomes

Salzmann, Stephan N. MD1; Fantini, Gary A. MD1; Okano, Ichiro MD1; Sama, Andrew A. MD1; Hughes, Alexander P. MD1; Girardi, Federico P. MD1

JBJS Essential Surgical Techniques: October-December 2019 - Volume 9 - Issue 4 - p e37
doi: 10.2106/JBJS.ST.19.00013
Subspecialty Procedures

Background: Lateral lumbar interbody fusion (LLIF) is a relatively new procedure. It was established as a minimally invasive alternative to traditional open interbody fusion. LLIF allows the surgeon to access the disc space via a retroperitoneal transpsoas muscle approach. Theoretical advantages of the LLIF technique include preservation of the longitudinal ligaments, augmentation of disc height with indirect decompression of neural elements, and insertion of large footprint cages spanning the dense apophyseal ring bilaterally1,2. The original 2-incision LLIF technique described by Ozgur et al., in 2006, had some inherent limitations3. First, it substantially limited direct visualization of the surgical field and may have endangered nerve and vascular structures. Additionally, it often required multiple separated incisions for multilevel pathologies. Finally, for surgeons with experience in traditional open retroperitoneal surgery, utilization of their previously acquired skills may have been difficult with this approach. To overcome these limitations, we adopted the mini-open lateral approach, which allows for visualization, palpation, and electrophysiologic neurologic confirmation during the procedure4.

Description: As detailed below, the patient is positioned in the lateral decubitus position and a single incision is carried out centered between the target discs. For single-level LLIF, the incision spans approximately 3 cm and can be lengthened in small increments for multilevel procedures. After blunt dissection, the retroperitoneal space is entered. The psoas muscle is split under direct visualization, carefully avoiding the traversing nerves with neurosurveillance5. A self-retaining retractor is used, and after thorough discectomy, the disc space is sized with trial components. The implant is filled with bone graft materials and is introduced using intraoperative fluoroscopy.

Alternatives: The 2-incision LLIF technique or traditional anterior or posterior lumbar spine interbody fusion techniques might be used instead.

Rationale: LLIF offers the reported advantages of minimally invasive surgery, such as reduced tissue trauma during the approach, low blood loss, shorter length of stay, decreased recovery time, and less postoperative pain. LLIF allows for the placement of a relatively larger interbody cage spanning the dense apophyseal ring bilaterally. The lateral approach preserves the anterior longitudinal ligament and posterior longitudinal ligament. These structures allow for powerful ligamentotaxis and provide extra stability for the construct. Compared with other approaches, LLIF has a reduced risk of visceral and vascular injuries, incidental dural tears, and perioperative infections. Although associated with approach-related complications such as motor and sensory deficits, LLIF can be a safe and versatile procedure1,2.

1Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY

Email address for F.P. Girardi: girardif@hss.edu

Investigation performed at the Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY

Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work and “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadly relevant to this work (http://links.lww.com/JBJSEST/A268).

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated