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Juan S. Uribe, Edwin Ramos, Sammy Youssef, Fernando L. Vale and Ali A. Baaj

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Armen R. Deukmedjian, Tien V. Le, Ali A. Baaj, Elias Dakwar, Donald A. Smith and Juan S. Uribe

Object

Traditional procedures for correction of sagittal imbalance via shortening of the posterior column include the Smith-Petersen osteotomy, pedicle subtraction osteotomy, and vertebral column resection. These procedures require wide exposure of the spinal column posteriorly, and may be associated with significant morbidity. Anterior longitudinal ligament (ALL) release using the minimally invasive lateral retroperitoneal approach with a resultant net lengthening of the anterior column has been performed as an alternative to increase lordosis. The objective of this study was to demonstrate the feasibility and early clinical experience of ALL release through a minimally invasive lateral retroperitoneal transpsoas approach, as well as to describe its surgical anatomy in the lumbar spine.

Methods

Forty-eight lumbar levels were dissected in 12 fresh-frozen cadaveric specimens to study the anatomy of the ALL as well as its surrounding structures, and to determine the feasibility of the technique. The lumbar disc spaces and ALL were accessed via the lateral transpsoas approach and confirmed with fluoroscopy in each specimen. As an adjunct, 4 clinical cases of ALL release through the minimally invasive lateral retroperitoneal transpsoas approach were reviewed. Operative technique, results, complications, and early outcomes were assessed.

Results

In the cadaveric study, sectioning of the ALL proved to be feasible from the minimally invasive lateral retroperitoneal transpsoas approach. The structures at most immediate risk during this procedure were the aorta, inferior vena cava, iliac vessels, and sympathetic plexus. The mean increase in segmental lumbar lordosis per level of ALL release was 10.2°, while global lumbar lordosis improved by 25°. Each level of ALL release took 56 minutes and produced 40 ml of blood loss on average. Visual analog scale and Oswestry Disability Index scores improved by 9 and 35 points, respectively. There were no cases of hardware failure, and as of yet no complications to report.

Conclusions

This initial experience suggests that ALL release through the minimally invasive lateral retroperitoneal transpsoas approach may be feasible, allows for improvement of lumbar lordosis without the need of an open laparotomy/thoracotomy, and minimizes the tissue disruption and morbidity associated with posterior osteotomies.

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Juan S. Uribe, Donald A. Smith, Elias Dakwar, Ali A. Baaj, Gregory M. Mundis, Alexander W. L. Turner, G. Bryan Cornwall and Behrooz A. Akbarnia

Object

In the surgical treatment of spinal deformities, the importance of restoring lumbar lordosis is well recognized. Smith-Petersen osteotomies (SPOs) yield approximately 10° of lordosis per level, whereas pedicle subtraction osteotomies result in as much as 30° increased lumbar lordosis. Recently, selective release of the anterior longitudinal ligament (ALL) and placement of lordotic interbody grafts using the minimally invasive lateral retroperitoneal transpsoas approach (XLIF) has been performed as an attempt to increase lumbar lordosis while avoiding the morbidity of osteotomy. The objective of the present study was to measure the effect of the selective release of the ALL and varying degrees of lordotic implants placed using the XLIF approach on segmental lumbar lordosis in cadaveric specimens between L-1 and L-5.

Methods

Nine adult fresh-frozen cadaveric specimens were placed in the lateral decubitus position. Lateral radiographs were obtained at baseline and after 4 interventions at each level as follows: 1) placement of a standard 10° lordotic cage, 2) ALL release and placement of a 10° lordotic cage, 3) ALL release and placement of a 20° lordotic cage, and 4) ALL release and placement of a 30° lordotic cage. All four cages were implanted sequentially at each interbody level between L-1 and L-5. Before and after each intervention, segmental lumbar lordosis was measured in all specimens at each interbody level between L-1 and L-5 using the Cobb method on lateral radiography.

Results

The mean baseline segmental lordotic angles at L1–2, L2–3, L3–4, and L4–5 were –3.8°, 3.8°, 7.8°, and 22.6°, respectively. The mean lumbar lordosis was 29.4°. Compared with baseline, the mean postimplantation increase in segmental lordosis in all levels combined was 0.9° in Intervention 1 (10° cage without ALL release); 4.1° in Intervention 2 (ALL release with 10° cage); 9.5° in Intervention 3 (ALL release with 20° cage); and 11.6° in Intervention 4 (ALL release with 30° cage). Foraminal height in the same sequence of conditions increased by 6.3%, 4.6%, 8.8% and 10.4%, respectively, while central disc height increased by 16.1%, 22.3%, 52.0% and 66.7%, respectively. Following ALL release and placement of lordotic cages at all 4 lumbar levels, the average global lumbar lordosis increase from preoperative lordosis was 3.2° using 10° cages, 12.0° using 20° cages, and 20.3° using 30° cages. Global lumbar lordosis with the cages at 4 levels exhibited a negative correlation with preoperative global lordosis (10°, R = −0.756; 20°, −0.730; and 30°, R = −0.437).

Conclusions

Combined ALL release and placement of increasingly lordotic lateral interbody cages leads to progressive gains in segmental lordosis in the lumbar spine. Mean global lumbar lordosis similarly increased with increasingly lordotic cages, although the effect with a single cage could not be evaluated. Greater global lordosis was achieved with smaller preoperative lordosis. The mean maximum increase in segmental lordosis of 11.6° followed ALL release and placement of the 30° cage.

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Tien V. Le, Donald A. Smith, Mark S. Greenberg, Elias Dakwar, Ali A. Baaj and Juan S. Uribe

Object

The aim of this study was to review the authors' experience with 101 cases over the past 3 years with minimally invasive lateral interbody fusion using a lateral plate. Their main goal was to specifically look for hardware-associated complications. Three cases of hardware failure and 3 cases of vertebral body (VB) fractures associated with lateral plate placement are reported. The authors also review the literature pertaining to lateral plates and related complications.

Methods

This study is a retrospective review of a database of patients who underwent minimally invasive lateral interbody fusion in the thoracolumbar spine during a 3-year period.

Results

Six complications were identified, resulting in an incidence of 5.9%. Three hardware failures, 2 coronal plane VB fractures, and 1 lateral VB fracture were identified. All complications occurred in multilevel cases. All cases presented with recurrent back pain except one, which was identified incidentally.

Conclusions

Minimally invasive lateral interbody fusion is a safe and direct technique that is practical, especially when trying to avoid other approaches for hardware insertion, and it also avoids the complications associated with other types of instrumentation such as pedicle screws. Careful consideration during patient selection and during the operation will aid in the avoidance of complications.

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Elias Dakwar, Tien V. Le, Ali A. Baaj, Anh X. Le, William D. Smith, Behrooz A. Akbarnia and Juan S. Uribe

Object

The minimally invasive lateral transpsoas approach for interbody fusion has been increasingly employed to treat various spinal pathological entities. Gaining access to the retroperitoneal space and traversing the abdominal wall poses a risk of injury to the major nervous structures. Nerve injury of the abdominal wall can potentially lead to paresis of the abdominal musculature and bulging of the abdominal wall. Abdominal wall nerve injury resulting from the minimally invasive lateral retroperitoneal transpsoas approach has not been previously reported. The authors describe a case series of patients presenting with paresis and bulging of the abdominal wall after undergoing a minimally invasive lateral retroperitoneal approach.

Methods

The authors retrospectively reviewed all patients who underwent a minimally invasive lateral transpsoas approach for interbody fusion and in whom development of abdominal paresis developed; the patients were treated at 4 institutions between 2006 and 2010. All data were recorded including demographics, diagnosis, operative procedure, positioning, hospital course, follow-up, and complications. The onset, as well as resolution of the abdominal paresis, was reviewed.

Results

The authors identified 10 consecutive patients in whom abdominal paresis developed after minimally invasive lateral transpsoas spine surgery out of a total of 568 patients. Twenty-nine interbody levels were fused (range 1–4 levels/patient). There were 4 men and 6 women whose mean age was 54.1 years (range 37–66 years). All patients presented with abdominal paresis 2–6 weeks postoperatively. In 8 of the 10 patients, abdominal wall paresis had resolved by the 6-month follow-up visit. Two patients only had 1 and 4 months of follow-up. No long-term sequelae were identified.

Conclusions

Abdominal wall paresis is a rare but known potential complication of abdominal surgery. The authors report the first case series associated with the minimally invasive lateral transpsoas approach.

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Ali A. Baaj, Katheryne Downes, Alexander R. Vaccaro, Juan S. Uribe and Fernando L. Vale

Object

The objective of this study was to investigate a national health care database and analyze demographics, hospital charges, and treatment trends of patients diagnosed with lumbar spine fractures in the US over a 5-year period.

Methods

Clinical data were derived from the Nationwide Inpatient Sample (NIS) for the years 2003 through 2007. The NIS is maintained by the Agency for Healthcare Research and Quality and represents a 20% random stratified sample of all discharges from nonfederal hospitals within the US. Patients with lumbar spine fractures were identified using the appropriate ICD-9-CM code. Data on the number of vertebral body augmentation procedures were also retrieved. National estimates of discharges, hospital charges, discharge patterns, and treatment with spinal fusion trends were retrieved and analyzed.

Results

More than 190,000 records of patients with lumbar spine fractures were abstracted from the database. During the 5-year period, there was a 17% increase in hospitalizations for lumbar spine fractures. This was associated with a 27% increase in hospital charges and a 55% increase in total national charges (both adjusted for inflation). The total health care bill associated with lumbar spine fractures in 2007 exceeded 1 billion US dollars. During this same time period, there was a 24% increase in spinal fusions for lumbar fractures, which was associated with a 15% increase in hospital charges. The ratio of spinal fusions to hospitalizations (surgical rate) during this period, however, was stable with an average of 7.4% over the 5-year period. There were an estimated 13,000 vertebral body augmentation procedures for nonpathological fractures performed in 2007 with a total national bill of 450 million US dollars.

Conclusions

An increasing trend of hospitalizations, surgical treatment, and charges associated with lumbar spine fractures was observed between 2003 and 2007 on a national level. This trend, however, does not appear to be as steep as that of surgical utilization in degenerative spine disease. Furthermore, the ratio of spinal fusions to hospitalizations for lumbar fractures appears to be stable, possibly indicating no significant changes in indications for surgical intervention over the time period studied.