Radiographic alignment outcomes after the single-position prone transpsoas approach: a multi-institutional retrospective review of 363 cases

Luis Diaz-AguilarDepartment of Neurological Surgery, University of California, San Diego, La Jolla, California;

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Lauren E. StoneDepartment of Neurological Surgery, University of California, San Diego, La Jolla, California;

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Mohamed A. R. SolimanDepartment of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt;
Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, New York;

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Alexander PadovanoDepartment of Orthopaedic Surgery, WakeMed, Raleigh, North Carolina;

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Jeff EhresmanDepartment of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona;

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Nolan J. BrownDepartment of Neurological Surgery, University of Irvine, California;

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Gautam ProduturiDepartment of Neurological Surgery, University of California, San Diego, La Jolla, California;

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Madison BattistaDepartment of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona;

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Asham KhanDepartment of Neurological Surgery, University at Buffalo, New York;

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John PollinaDepartment of Neurological Surgery, University at Buffalo, New York;

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Rodrigo AmaralDepartment of Neurological Surgery, Instituto de Patologia da Coluna, São Paulo Sul, Brazil;

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Muhammad M. Abd-El-BarrDepartment of Neurological Surgery, Duke University, Durham, North Carolina;

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Isaac MossDepartment of Orthopedic Surgery, University of Connecticut, Farmington, Connecticut;

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Tyler SmithSpine Institute, Roseville, California;

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Gurvinder S. DeolDepartment of Orthopaedic Surgery, WakeMed, Raleigh, North Carolina;

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Bryan S. LeeDepartment of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona;

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M. Craig McMainsMcMains Spine, Indianapolis, Indiana;

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Samuel A . Joseph Jr.Joseph Spine Institute, Tampa, Florida; and

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David SchwartzOrthoIndy, Indianapolis, Indiana

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Luiz PimentaDepartment of Neurological Surgery, Instituto de Patologia da Coluna, São Paulo Sul, Brazil;

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Andrew D. NguyenDepartment of Neurological Surgery, University of California, San Diego, La Jolla, California;

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William R. TaylorDepartment of Neurological Surgery, University of California, San Diego, La Jolla, California;

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OBJECTIVE

The aim of this paper was to evaluate the changes in radiographic spinopelvic parameters in a large cohort of patients undergoing the prone transpsoas approach to the lumbar spine.

METHODS

A multicenter retrospective observational cohort study was performed for all patients who underwent lateral lumber interbody fusion via the single-position prone transpsoas (PTP) approach. Spinopelvic parameters from preoperative and first upright postoperative radiographs were collected, including lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt (PT). Functional indices (visual analog scale score), and patient-reported outcomes (Oswestry Disability Index) were also recorded from pre- and postoperative appointments.

RESULTS

Of the 363 patients who successfully underwent the procedure, LL after fusion was 50.0° compared with 45.6° preoperatively (p < 0.001). The pelvic incidence–lumbar lordosis mismatch (PI-LL) was 10.5° preoperatively versus 2.9° postoperatively (p < 0.001). PT did not significantly change (0.2° ± 10.7°, p > 0.05).

CONCLUSIONS

The PTP approach allows significant gain in lordotic augmentation, which was associated with good functional results at follow-up.

ABBREVIATIONS

LL = lumbar lordosis; LLIF = lateral lumbar interbody fusion; MIS = minimally invasive surgery; ODI = Oswestry Disability Index; PI = pelvic incidence; PI-LL = PI-LL mismatch; PT = pelvic tilt; PTP = prone transpsoas; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale.

OBJECTIVE

The aim of this paper was to evaluate the changes in radiographic spinopelvic parameters in a large cohort of patients undergoing the prone transpsoas approach to the lumbar spine.

METHODS

A multicenter retrospective observational cohort study was performed for all patients who underwent lateral lumber interbody fusion via the single-position prone transpsoas (PTP) approach. Spinopelvic parameters from preoperative and first upright postoperative radiographs were collected, including lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt (PT). Functional indices (visual analog scale score), and patient-reported outcomes (Oswestry Disability Index) were also recorded from pre- and postoperative appointments.

RESULTS

Of the 363 patients who successfully underwent the procedure, LL after fusion was 50.0° compared with 45.6° preoperatively (p < 0.001). The pelvic incidence–lumbar lordosis mismatch (PI-LL) was 10.5° preoperatively versus 2.9° postoperatively (p < 0.001). PT did not significantly change (0.2° ± 10.7°, p > 0.05).

CONCLUSIONS

The PTP approach allows significant gain in lordotic augmentation, which was associated with good functional results at follow-up.

The evolution of approaches, techniques, and concomitant technological advancements for the surgical treatment of lumbar spinal instability and neural compression reflect a growing trend toward precision surgical intervention.1 Open correction via posterolateral fusion, anterior lumbar interbody fusion, and posterior lumbar interbody fusion were the earliest developed reliable techniques and therefore remain staple approaches for lumbar spinal disease. More recently, the advent of minimally invasive surgery (MIS), coupled with improvements in specialized equipment (including robotics), has permitted the development of new corridors, including lateral lumbar interbody fusion (LLIF), transforaminal lumbar interbody fusion (TLIF), and oblique lateral interbody fusion, among others. These approaches have become associated with less estimated blood loss, shorter recovery times, and improved functional outcomes compared with traditional open correction.24

The development of single-position MIS procedures followed a history of repositioning for circumferential access.5 This repositioning irrevocably added nonsurgical time to the procedure, negating a key tenant of MIS approaches. While single-position procedures in the lateral decubitus or modified lateral position have been described, these positions are less intuitive to surgeons and require extensive practice for positioning mastery.6,13 In order to circumvent this, the prone transpsoas (PTP) approach combines MIS access through a lateral psoas corridor with simultaneous access to the posterior spinal elements. Brief case series and feasibility studies have demonstrated decreased surgical times, greater lordotic correction, and retention of an MIS risk profile for PTP cases.7,9 However, no report on PTP to date has featured a longer follow-up length than that of our cohort, and no large-scale study has been conducted to formally evaluate the spinopelvic correction obtainable by this approach.

Methods

A multicenter retrospective observational cohort study was performed. Data were collected via chart review through the work of collaborators at all involved institutions. Patients aged > 18 years who had undergone LLIF via the single-position PTP approach, which we have extensively detailed in previous publications, were included.7,10

Patient demographic data and comorbidities were collected from medical records. Spinopelvic parameters from preoperative and first upright postoperative radiographs were collected by a neurosurgical resident at each institution. Results were verified by a senior surgeon. Collected variables included lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt (PT). Functional indices (visual analog scale [VAS] score) and patient-reported outcomes (Oswestry Disability Index [ODI]) were also recorded from pre- and postoperative appointments.

The homoscedastic t-test was used to compare preoperative and postoperative outcomes. All statistical analyses were performed using Python with the NumPy package (v.3.10.2, Python Software Foundation) and Microsoft Excel (Microsoft Corp.). IRB approval was obtained for this study.

Results

A total of 364 patients undergoing single-position PTP lumbar interbody fusion were evaluated. The mean age was 64.4 ± 10.7 years, and patients were predominantly female (56.8%) with a mean BMI of 32 ± 11.9. Fifty-three patients (16.1%) had diabetes, 41 (12.4%) had preexisting osteoporosis, and 25 (7.8%) were current smokers (Table 1). The preoperative VAS and ODI scores were 6.9 ± 1.9 and 20.7 ± 17.0, respectively (Table 2).

TABLE 1.

Patient demographics

ParameterValue
No. of patients364
Mean age, yrs64.5 ± 10.7
Female sex207 (57.0)
Mean BMI31.9 ± 11.9
Diabetes (n = 330)53 (16.1)
Osteoporosis (n = 330)41 (12.4)
Current smoker (n = 322)25 (7.8)
No. of levels involved (n = 363)
 1229 (63.1)
 292 (25.3)
 339 (10.7)
 42 (0.6)
 51 (0.3)
Mean follow-up time, mos (n = 262)7.3 ± 5.0

Values are presented as the number of patients (%) or mean ± SD.

TABLE 2.

Functional and radiographic outcomes

ParameterMean ± SDp Value
Preop VAS back pain score6.9 ± 1.9<0.001
Postop VAS back pain score2.4 ± 2.2
Change in VAS back pain score4.5 ± 2.6
Preop ODI20.7 ± 17.00.146
Postop ODI18.3 ± 23.4
Change in ODI3.3 ± 13.9
Preop LL, °45.6 ± 14<0.001
Postop LL, °50.0 ± 14.1
Change in LL, °4.8 ± 10.8
Preop PI, °55.9 ± 14.10.008
Postop PI, °52.8 ± 13.4
Change in PI, °3.0 ± 12.0
Preop PT, °22.7 ± 8.90.37
Postop PT, °22.3 ± 12.5
Change in PT, °0.2 ± 10.7
Preop PI-LL, °10.5 ± 15.0<0.001
Postop PI-LL, °2.9 ± 13.5
Change in PI-LL, °7.9 ± 11.0

Boldface type indicates statistical significance.

One patient was excluded because the case was aborted due to poor preoperative neuromonitoring signals. Of the 363 patients who successfully underwent the procedure, the majority of cases were single level (63.1%). Across all cases, the LL after fusion was 50.0° compared with 45.6° preoperatively (p < 0.001). The pelvic incidence–lumbar lordosis mismatch (PI-LL) was 10.5° preoperatively compared with 2.9° postoperatively (p < 0.001). PT did not significantly change (0.2 ± 10.7, p > 0.05) (Table 2).

The mean follow-up was 7.3 ± 5.0 months (Table 1). At the time of follow-up, patients reported a significant improvement in their VAS back pain score (6.9 vs 2.4, p < 0.001). No similar improvement was noted for the ODI score (20.7 vs 18.3, p = 0.146).

Discussion

The LLIF has been a staple in the armamentarium of spine surgeons for more than 2 decades. As an established MIS technique, this approach confers benefits such as reduced blood loss, operative duration, and hospitalization times, as well as decreased posterior muscle damage and shorter recovery times. Single-position lateral fusion approaches in the lateral decubitus position have been performed and studied, with some reports documenting a nearly 1-hour decrease in the mean operative time compared with two-stage procedures without compromising spinopelvic parameters.1012 However, this approach is associated with a higher rate of facet joint violation, leading to unnecessary repeat reoperation.13

The PTP technique addresses certain drawbacks associated with both staged and lateral decubitus LLIF techniques. By using the more familiar prone approach to the lumbar spine, spine surgeons enjoy the familiarity of the prone view while maintaining an optimized single-position surgical workflow and thus far reported in the literature equivalent or better outcomes.7,8,10,14,15

Our retrospective study adds to the known limited published radiographic outcomes of PTP in the literature from smaller studies. Soliman et al. compared 26 patients who underwent PTP with patients who underwent traditional TLIF and found significant differences between achieved LL (11.5° ± 9.5° PTP vs 0.1° ± 15.1° TLIF) and PI-LL mismatch (3° ± 10.3° PTP vs 14.9° ± 14.1° TLIF).16 Our observed change in LL and the postoperative PI-LL mismatch were 4.8° ± 10.8° and 2.9° ± 13.5°, respectively, comparable to these findings. In offering an explanation for these radiographic improvements, Soliman and colleagues pointed out that PTP enables more anterior placement of interbody cages compared with TLIF. PTP therefore enables increased correction angles because cage depth ratio, a measure indicative of the degree of anterior advancement during cage placement, is greater for PTP than for anterior lumbar interbody fusion and allows for insertion of more lordotic cages. By contrast, PT did not significantly change in our cohort, possibly because the average preoperative PT was not grossly pathologic. This finding is similar to that of Soliman et al.16

Our cohort found significant improvements in VAS back pain reporting but not ODI. There are limited studies for comparison in the PTP literature. Farber et al. similarly reported a 3.7-point decrease in VAS back pain scores, however, with a 12.1-point decrease in ODI in their cohort of 29 patients at 3 months.10 Furthermore, the significant range in postoperative ODI reporting may suggest heterogeneous cohorts of outliers. Future analysis of ODI subcategories is warranted.

Limitations of this study include its retrospective design, thereby introducing the risk of bias in the selection of patients for data analysis. We attempted to address this via predefined inclusion and exclusion criteria, although the lack of defined indications and contraindications for single-position PTP versus LLIF do serve as a source of subjectivity in patient selection. Additionally, as an observational study, there is no control group for comparison, either against traditional two-position LLIF or the more recent single-position lateral decubitus approach. This study also did not evaluate segmental alignment or global sagittal alignment given the heterogeneity of surgical indications and levels performed. The efficacy of PTP for deformity versus single-level degenerative cases may be reflected differently when disaggregated.

Conclusions

The single-position PTP approach has previously demonstrated feasibility, safety, and an association with good short-term outcomes. In this multicenter retrospective cohort study, we further demonstrated that this procedure is well tolerated and associated with minimal complications. Additionally, patients experienced a significant gain in lordotic augmentation, which was associated with good functional results at follow-up. Future work comparing PTP with existing techniques will be necessary to further elucidate the radiographic outcomes and advantages associated with this approach.

Disclosures

Dr. Pollina reported surgical training from Medtronic; consultant for and royalties from ATEC Spine; and stock ownership in REMI outside the submitted work. Dr. Amaral reported personal fees from ATEC during the conduct of the study. Dr. Abd-El-Barr reported being a consultant for Spineology, DePuy Synthes, and Trackx; and research support from NIH, Abbvie, and the Dana and Christopher Reeve Foundation outside the submitted work. Dr. Moss reported personal fees from Stryker and Biedermann; medical advisory board and stock ownership in Spinal Simplicity and Orthozon; personal fees from NuVasive, Spinewave, and ATEC outside the submitted work; and a patent for ATEC with royalties paid. Dr. Smith reported personal fees from ATEC outside the submitted work. Dr. Deol reported royalties from NuVasive, Globus Medical, SeaSpine, and Alphatec; and consultant for Cerapedics and Alphatec outside the submitted work. Dr. Lee reported personal fees from ATEC outside the submitted work. Dr. McMains reported personal fees from Alphatec, Medtronic, and Cerapedics outside the submitted work; and a patent for Expandable Interbody Device issued. Dr. Schwartz reported personal fees from ATEC, NuVasive, and Medtronic; and grants from Cerapedics outside the submitted work. Dr. Pimenta reported personal fees from ATEC during the conduct of the study. Dr. Nguyen reported consulting honoraria from Globus Medical for surgeon training/education related to the prone lateral surgical technique.

Author Contributions

Conception and design: Stone, Diaz-Aguilar, Soliman, Khan, Pollina, Amaral, Abd-El-Barr, Smith, Lee, McMains, Schwartz, Pimenta, Taylor. Acquisition of data: Diaz-Aguilar, Soliman, Padovano, Ehresman, Brown, Battista, Khan, Amaral, Abd-El-Barr, Moss, Smith, Deol, Lee, McMains, Joseph, Schwartz, Nguyen, Taylor. Analysis and interpretation of data: Stone, Soliman, Brown, Produturi, Khan, Lee, McMains, Joseph, Schwartz, Taylor. Drafting the article: Stone, Diaz-Aguilar, Brown, Produturi, Abd-El-Barr, Moss, Schwartz. Critically revising the article: Stone, Soliman, Padovano, Produturi, Khan, Pollina, Abd-El-Barr, Smith, McMains, Schwartz, Nguyen, Taylor. Reviewed submitted version of manuscript: Stone, Soliman, Padovano, Produturi, Khan, Pollina, Moss, Smith, Deol, Lee, McMains, Joseph, Schwartz, Pimenta, Taylor. Approved the final version of the manuscript on behalf of all authors: Stone. Statistical analysis: Soliman. Administrative/technical/material support: Stone, Schwartz. Study supervision: Pollina, Schwartz, Nguyen.

References

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    Tarpada SP, Morris MT, Burton DA. Spinal fusion surgery: a historical perspective. J Orthop. 2016;14(1):134136.

  • 2

    Alhammoud A, Alborno Y, Baco AM, et al. Minimally invasive scoliosis surgery is a feasible option for management of idiopathic scoliosis and has equivalent outcomes to open surgery: a meta-analysis. Global Spine J. 2022;12(3):483492.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Goldstein CL, Macwan K, Sundararajan K, Rampersaud YR. Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review. J Neurosurg Spine. 2016;24(3):416427.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Abiola R, Rubery P, Mesfin A. Ossification of the posterior longitudinal ligament: etiology, diagnosis, and outcomes of nonoperative and operative management. Global Spine J. 2016;6(2):195204.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006;6(4):435443.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Hiyama A, Katoh H, Sakai D, Tanaka M, Sato M, Watanabe M. Facet joint violation after single-position versus dual-position lateral interbody fusion and percutaneous pedicle screw fixation: a comparison of two techniques. J Clin Neurosci. 2020;78:4752.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Pimenta L, Amaral R, Taylor W, et al. The prone transpsoas technique: preliminary radiographic results of a multicenter experience. Eur Spine J. 2021;30(1):108113.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Pimenta L, Pokorny G, Amaral R, et al. Single-position prone transpsoas lateral interbody fusion including L4L5: early postoperative outcomes. World Neurosurg. 2021;149:e664e668.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Pimenta L, Taylor WR, Stone LE, Wali AR, Santiago-Dieppa DR. Prone transpsoas technique for simultaneous single-position access to the anterior and posterior lumbar spine. Oper Neurosurg (Hagerstown). 2020;20(1):E5E12.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Farber SH, Naeem K, Bhargava M, Porter RW. Single-position prone lateral transpsoas approach: early experience and outcomes. J Neurosurg Spine. 2022;36(3):358365.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Stone LE, Wali AR, Santiago-Dieppa DR, Taylor WR. Prone-transpsoas as single-position, circumferential access to the lumbar spine: a brief survey of index cases. N Am Spine Soc J. 2021;6:100053.

    • Search Google Scholar
    • Export Citation
  • 12

    Ouchida J, Kanemura T, Satake K, Nakashima H, Ishikawa Y, Imagama S. Simultaneous single-position lateral interbody fusion and percutaneous pedicle screw fixation using O-arm-based navigation reduces the occupancy time of the operating room. Eur Spine J. 2020;29(6):12771286.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Hiyama A, Katoh H, Sakai D, Sato M, Tanaka M, Watanabe M. Comparison of radiological changes after single- position versus dual- position for lateral interbody fusion and pedicle screw fixation. BMC Musculoskelet Disord. 2019;20(1):601.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Godzik J, Ohiorhenuan IE, Xu DS, et al. Single-position prone lateral approach: cadaveric feasibility study and early clinical experience. Neurosurg Focus. 2020;49(3):E15.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Shahrestani S, Brown NJ, Acharya N, Diaz-Aguilar LD, Pham MH, Taylor WR. A case report of robotic-guided prone transpsoas lumbar fusion in a patient with lumbar pseudarthrosis, adjacent segment disease, and degenerative scoliosis. Int J Surg Case Rep. 2022;94:106999.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Soliman MAR, Aguirre AO, Ruggiero N, et al. Comparison of prone transpsoas lateral lumbar interbody fusion and transforaminal lumbar interbody fusion for degenerative lumbar spine disease: a retrospective radiographic propensity score-matched analysis. Clin Neurol Neurosurg. 2022;213:107105.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand

Illustration from Chan et al. (E2). © Andrew K. Chan, published with permission.

  • 1

    Tarpada SP, Morris MT, Burton DA. Spinal fusion surgery: a historical perspective. J Orthop. 2016;14(1):134136.

  • 2

    Alhammoud A, Alborno Y, Baco AM, et al. Minimally invasive scoliosis surgery is a feasible option for management of idiopathic scoliosis and has equivalent outcomes to open surgery: a meta-analysis. Global Spine J. 2022;12(3):483492.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Goldstein CL, Macwan K, Sundararajan K, Rampersaud YR. Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review. J Neurosurg Spine. 2016;24(3):416427.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Abiola R, Rubery P, Mesfin A. Ossification of the posterior longitudinal ligament: etiology, diagnosis, and outcomes of nonoperative and operative management. Global Spine J. 2016;6(2):195204.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006;6(4):435443.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Hiyama A, Katoh H, Sakai D, Tanaka M, Sato M, Watanabe M. Facet joint violation after single-position versus dual-position lateral interbody fusion and percutaneous pedicle screw fixation: a comparison of two techniques. J Clin Neurosci. 2020;78:4752.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Pimenta L, Amaral R, Taylor W, et al. The prone transpsoas technique: preliminary radiographic results of a multicenter experience. Eur Spine J. 2021;30(1):108113.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Pimenta L, Pokorny G, Amaral R, et al. Single-position prone transpsoas lateral interbody fusion including L4L5: early postoperative outcomes. World Neurosurg. 2021;149:e664e668.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Pimenta L, Taylor WR, Stone LE, Wali AR, Santiago-Dieppa DR. Prone transpsoas technique for simultaneous single-position access to the anterior and posterior lumbar spine. Oper Neurosurg (Hagerstown). 2020;20(1):E5E12.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Farber SH, Naeem K, Bhargava M, Porter RW. Single-position prone lateral transpsoas approach: early experience and outcomes. J Neurosurg Spine. 2022;36(3):358365.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Stone LE, Wali AR, Santiago-Dieppa DR, Taylor WR. Prone-transpsoas as single-position, circumferential access to the lumbar spine: a brief survey of index cases. N Am Spine Soc J. 2021;6:100053.

    • Search Google Scholar
    • Export Citation
  • 12

    Ouchida J, Kanemura T, Satake K, Nakashima H, Ishikawa Y, Imagama S. Simultaneous single-position lateral interbody fusion and percutaneous pedicle screw fixation using O-arm-based navigation reduces the occupancy time of the operating room. Eur Spine J. 2020;29(6):12771286.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Hiyama A, Katoh H, Sakai D, Sato M, Tanaka M, Watanabe M. Comparison of radiological changes after single- position versus dual- position for lateral interbody fusion and pedicle screw fixation. BMC Musculoskelet Disord. 2019;20(1):601.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Godzik J, Ohiorhenuan IE, Xu DS, et al. Single-position prone lateral approach: cadaveric feasibility study and early clinical experience. Neurosurg Focus. 2020;49(3):E15.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Shahrestani S, Brown NJ, Acharya N, Diaz-Aguilar LD, Pham MH, Taylor WR. A case report of robotic-guided prone transpsoas lumbar fusion in a patient with lumbar pseudarthrosis, adjacent segment disease, and degenerative scoliosis. Int J Surg Case Rep. 2022;94:106999.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Soliman MAR, Aguirre AO, Ruggiero N, et al. Comparison of prone transpsoas lateral lumbar interbody fusion and transforaminal lumbar interbody fusion for degenerative lumbar spine disease: a retrospective radiographic propensity score-matched analysis. Clin Neurol Neurosurg. 2022;213:107105.

    • Crossref
    • Search Google Scholar
    • Export Citation

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