Multilevel tandem spondylolisthesis associated with a reduced "safe zone" for a transpsoas lateral lumbar interbody fusion at L4–5

Anthony OyekanDepartment of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh;
Pittsburgh Orthopaedic Spine Research Group, Pittsburgh;

Search for other papers by Anthony Oyekan in
jns
Google Scholar
PubMed
Close
 MD
,
Jonathan DaltonDepartment of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh;
Pittsburgh Orthopaedic Spine Research Group, Pittsburgh;

Search for other papers by Jonathan Dalton in
jns
Google Scholar
PubMed
Close
 MD
,
Mitchell S. FourmanPittsburgh Orthopaedic Spine Research Group, Pittsburgh;
Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, New York

Search for other papers by Mitchell S. Fourman in
jns
Google Scholar
PubMed
Close
 MD, MPhil
,
Dominic RidolfiPittsburgh Orthopaedic Spine Research Group, Pittsburgh;
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and

Search for other papers by Dominic Ridolfi in
jns
Google Scholar
PubMed
Close
 BS
,
Landon ClutsPittsburgh Orthopaedic Spine Research Group, Pittsburgh;
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and

Search for other papers by Landon Cluts in
jns
Google Scholar
PubMed
Close
 BS
,
Brandon CouchDepartment of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh;
Pittsburgh Orthopaedic Spine Research Group, Pittsburgh;

Search for other papers by Brandon Couch in
jns
Google Scholar
PubMed
Close
 MD
,
Jeremy D. ShawDepartment of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh;
Pittsburgh Orthopaedic Spine Research Group, Pittsburgh;

Search for other papers by Jeremy D. Shaw in
jns
Google Scholar
PubMed
Close
 MD
,
William DonaldsonDepartment of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh;
Pittsburgh Orthopaedic Spine Research Group, Pittsburgh;

Search for other papers by William Donaldson in
jns
Google Scholar
PubMed
Close
 MD
, and
Joon Y. LeeDepartment of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh;
Pittsburgh Orthopaedic Spine Research Group, Pittsburgh;

Search for other papers by Joon Y. Lee in
jns
Google Scholar
PubMed
Close
 MD
Free access

OBJECTIVE

The aim of this study was to investigate the effect of degenerative spondylolisthesis (DS) on psoas anatomy and the L4–5 safe zone during lateral lumbar interbody fusion (LLIF).

METHODS

In this retrospective, single-institution analysis, patients managed for low-back pain between 2016 and 2021 were identified. Inclusion criteria were adequate lumbar MR images and radiographs. Exclusion criteria were spine trauma, infection, metastases, transitional anatomy, or prior surgery. There were three age and sex propensity-matched cohorts: 1) controls without DS; 2) patients with single-level DS (SLDS); and 3) patients with multilevel, tandem DS (TDS). Axial T2-weighted MRI was used to measure the apical (ventral) and central positions of the psoas relative to the posterior tangent line at the L4–5 disc. Lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and PI-LL mismatch were measured on lumbar radiographs. The primary outcomes were apical and central psoas positions at L4–5, which were calculated using stepwise multivariate linear regression including demographics, spinopelvic parameters, and degree of DS. Secondary outcomes were associations between single- and multilevel DS and spinopelvic parameters, which were calculated using one-way ANOVA with Bonferroni correction for between-group comparisons.

RESULTS

A total of 230 patients (92 without DS, 92 with SLDS, and 46 with TDS) were included. The mean age was 68.0 ± 8.9 years, and 185 patients (80.4%) were female. The mean BMI was 31.0 ± 7.1, and the mean age-adjusted Charlson Comorbidity Index (aCCI) was 4.2 ± 1.8. Age, BMI, sex, and aCCI were similar between the groups. Each increased grade of DS (no DS to SLDS to TDS) was associated with significantly increased PI (p < 0.05 for all relationships). PT, PI-LL mismatch, center psoas, and apical position were all significantly greater in the TDS group than in the no-DS and SLDS groups (p < 0.05). DS severity was independently associated with 2.4-mm (95% CI 1.1–3.8 mm) center and 2.6-mm (95% CI 1.2–3.9 mm) apical psoas anterior displacement per increased grade (increasing from no DS to SLDS to TDS).

CONCLUSIONS

TDS represents more severe sagittal malalignment (PI-LL mismatch), pelvic compensation (PT), and changes in the psoas major muscle compared with no DS, and SLDS and is a risk factor for lumbar plexus injury during L4–5 LLIF due to a smaller safe zone.

ABBREVIATIONS

aCCI = age-adjusted Charlson Comorbidity Index; ALIF = anterior lumbar interbody fusion; DS = degenerative spondylolisthesis; LL = lumbar lordosis; LLIF = lateral lumbar interbody fusion; PI = pelvic incidence; PLIF = posterior lumbar interbody fusion; PT = pelvic tilt; SLDS = single-level DS; SS = sacral slope; TDS = tandem DS; TLIF = transforaminal lumbar interbody fusion.

OBJECTIVE

The aim of this study was to investigate the effect of degenerative spondylolisthesis (DS) on psoas anatomy and the L4–5 safe zone during lateral lumbar interbody fusion (LLIF).

METHODS

In this retrospective, single-institution analysis, patients managed for low-back pain between 2016 and 2021 were identified. Inclusion criteria were adequate lumbar MR images and radiographs. Exclusion criteria were spine trauma, infection, metastases, transitional anatomy, or prior surgery. There were three age and sex propensity-matched cohorts: 1) controls without DS; 2) patients with single-level DS (SLDS); and 3) patients with multilevel, tandem DS (TDS). Axial T2-weighted MRI was used to measure the apical (ventral) and central positions of the psoas relative to the posterior tangent line at the L4–5 disc. Lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and PI-LL mismatch were measured on lumbar radiographs. The primary outcomes were apical and central psoas positions at L4–5, which were calculated using stepwise multivariate linear regression including demographics, spinopelvic parameters, and degree of DS. Secondary outcomes were associations between single- and multilevel DS and spinopelvic parameters, which were calculated using one-way ANOVA with Bonferroni correction for between-group comparisons.

RESULTS

A total of 230 patients (92 without DS, 92 with SLDS, and 46 with TDS) were included. The mean age was 68.0 ± 8.9 years, and 185 patients (80.4%) were female. The mean BMI was 31.0 ± 7.1, and the mean age-adjusted Charlson Comorbidity Index (aCCI) was 4.2 ± 1.8. Age, BMI, sex, and aCCI were similar between the groups. Each increased grade of DS (no DS to SLDS to TDS) was associated with significantly increased PI (p < 0.05 for all relationships). PT, PI-LL mismatch, center psoas, and apical position were all significantly greater in the TDS group than in the no-DS and SLDS groups (p < 0.05). DS severity was independently associated with 2.4-mm (95% CI 1.1–3.8 mm) center and 2.6-mm (95% CI 1.2–3.9 mm) apical psoas anterior displacement per increased grade (increasing from no DS to SLDS to TDS).

CONCLUSIONS

TDS represents more severe sagittal malalignment (PI-LL mismatch), pelvic compensation (PT), and changes in the psoas major muscle compared with no DS, and SLDS and is a risk factor for lumbar plexus injury during L4–5 LLIF due to a smaller safe zone.

Interbody fusion can improve local sagittal alignment and provide an adjunct fusion surface in the management of degenerative spondylolisthesis (DS). Ha et al.1 reported improved function and greater pain relief in patients with unstable DS treated with interbody fusion compared with posterolateral fusion alone. Interbody fusions are particularly useful in patients with multilevel, or "tandem," DS (TDS), which frequently requires longer fusion constructs and anterior column supplementation.2 However, limited data exist as to the efficacy, safety, and benefit of specific anterior column lumbar fusion techniques and approaches.35

Lateral lumbar interbody fusion (LLIF) is a popular technique for achieving improved sagittal alignment while producing a broad-based anterior fusion surface.6,7 Pawar et al. reported that LLIF in patients with DS at L3–4 or L4–5 resulted in improved restoration of disc height, foraminal height, and sagittal alignment with reduced blood loss compared with posterolateral fusion.8 LLIF utilizes a retroperitoneal window to access the anterior column of the spine, thereby avoiding the visceral structures and accompanying scar risk incurred by accessing the peritoneum.6,9 The most common complications from LLIF relate to its transpsoas approach, which predisposes patients to iatrogenic injury to the neighboring lumbar plexus.6,1013 While cadaveric, electrical, and radiographic studies have identified a relatively safe transpsoas working zone located roughly in the anterior one-third of the vertebral body, the incidence of femoral nerve weakness following LLIF is up to 75%.1417 This risk is particularly prominent at the L4–5 level, which has been associated with a smaller "safe zone."18 A ventrally positioned psoas major muscle—referred to radiographically as the "rising psoas" or "Mickey Mouse" sign—has also been correlated with an increased risk of nerve damage during LLIF.19

While it is established that LLIF is useful in the management of DS, it is unclear if the presence of DS impacts the risk of femoral nerve injury during this approach. There are some data associating a rising psoas sign with elevated pelvic incidence (PI; > 54°) and coronal malalignment that improves following LLIF.20,21 However, to our knowledge the impact of sagittal malalignment and single- versus multilevel DS on anterior psoas position has not been evaluated. We hypothesized that the psoas major muscle would be positioned ventrally in patients with single-level DS (SLDS) and TDS compared with those without DS and that sagittal alignment parameters would correlate with psoas major muscle position.

Methods

This study was performed after receiving University of Pittsburgh Institutional Review Board approval and provides a level III analysis of a retrospectively collected cohort.

Participants

The electronic medical record was used to identify patients managed for low-back pain with or without neurogenic claudication at a single institution from July 2016 to July 2021. Inclusion criteria were patients with lumbar spine MR images and adequate standing lumbar spine radiographs for analysis of spinopelvic parameters, previously defined as radiographs that include the upper endplate of the L1 vertebra, the sacral dome, and both femoral heads.22 Exclusion criteria were patients who were being managed for lumbar spine trauma or metastatic disease to the lumbar spine, had a prior history of lumbar or abdominal surgery, presented with inadequate radiographic data, had transitional anatomy, or were previously managed for a spinal infection. Three cohorts were established: 1) single-level grade 1 (SLDS), 2) TDS, and 3) controls without DS. Cohorts were propensity matched for age and sex. DS was defined on neutral lateral lumbar radiographs as anterior slippage without pars interarticularis injury of the superior vertebral body greater than 3 mm relative to the inferior vertebral body as measured along the posterior edge of the caudal endplate.23 Grade 1 DS was defined according to the Meyerding classification as a ratio of overhang from the superior vertebral body to the anteroposterior length of the adjacent inferior vertebral body of ≤ 25%.24 TDS was defined as degenerative grade 1 anterolisthesis of two or more contiguous or noncontiguous segments.

Radiographic Measurements

Two authors (J.D. and A.O.) reviewed the most recently available preoperative MR images and plain radiographs for each patient. Cases of inadequate radiographic or MRI quality were excluded after agreement between both readers. Philips DICOM Viewer software (Koninklijke Philips N.V.) was used for MRI and radiographic measurements. Axial T2-weighted MR images were used to identify a tangent line at the posterior aspect of the L4–5 intervertebral disc space. Measurements were made from this tangent line to both the apical (ventral) and central points of the psoas major muscle belly (Fig. 1). Spinopelvic parameters including lumbar lordosis (LL), PI, pelvic tilt (PT), sacral slope (SS), and PI-LL mismatch were recorded for all patients using lateral lumbar spine radiographs (Fig. 2).

FIG. 1.
FIG. 1.

A: Sagittal and axial T2-weighted MR images obtained at the L4–5 disc level in a patient without DS. The sagittal image (left) shows the scout line confirming the position of the axial image. The axial image (right) shows the center and apical (ventral) psoas major muscle. The measurement is taken from a tangent line at the posterior (dorsal) aspect of the L4–5 disc space. Measurements are averaged between the right and left psoas major muscles. B: Sagittal and axial T2-weighted MR images obtained at the L4–5 disc level in a patient with SLDS. C: Sagittal and axial T2-weighted MR images obtained at the L4–5 disc level in a patient with TDS.

FIG. 2.
FIG. 2.

Lumbar spine radiographs that include the upper endplate of the L1 vertebra, the sacral dome, and both femoral heads, showing spinopelvic parameter measurements in a patient with TDS. A: SS. B: PI. C: PT.

Clinical Data

Medical records were retrospectively reviewed for demographic variables, including age, sex, BMI, and comorbidities as defined by the age-adjusted Charlson Comorbidity Index (aCCI).

Statistical Analysis

Analysis was performed using IBM SPSS version 24 (IBM Corp.). The primary outcome was apical and central psoas major position at the L4–5 disc space, for which independent associations were identified using stepwise multivariate linear regressions that included patient demographics, spinopelvic parameters, and degree of spondylolisthesis (no DS, SLDS, and TDS). Secondary outcomes were associations between degree of spondylolisthesis (no DS, SLDS, and TDS) and spinopelvic parameters, which were identified using a one-way ANOVA with a Bonferroni correction for between-group comparisons. Statistical significance was defined as p < 0.05. Data are presented as percentages for categorical variables and mean ± standard deviation for continuous variables. Regressions are reported as coefficient (95% CI).

Results

Demographics

A total of 230 patients (92 without DS, 92 with SLDS, and 46 with TDS) were included in this study. The mean cohort age was 68.0 ± 8.9 years, 185 patients (80.4%) were female, the mean BMI was 31.0 ± 7.1, and the mean aCCI was 4.2 ± 1.8. Age, BMI, sex, and aCCI were similar between groups. The mean spinopelvic parameters were PI 58.6° ± 13.2°, PT 22.3° ± 9.0°, PI-LL mismatch 9.8° ± 13.1°, and LL 48.8° ± 14.1° (Table 1).

TABLE 1.

Demographics, spinopelvic parameters, and psoas measurements compared between groups

Control GroupSLDS GroupTDS Groupp Value
No. of patients929246
Sex, n (%)>0.05
 Male18 (19.6)18 (19.6)9 (19.6)
 Female74 (80.4)74 (80.4)37 (80.4)
Comorbidities
 Mean BMI30.9 ± 7.131.4 ± 7.129.8 ± 6.8>0.05
 Mean age, yrs67.9 ± 8.567.8 ± 9.468.5 ± 8.5>0.05
 Mean aCCI4.2 ± 1.74.3 ± 1.94.1 ± 1.7>0.05
Mean spinopelvic parameters, °
 PI54.3 ± 13.059.3 ± 12.466.0 ± 11.8<0.05
 PT19.8 ± 9.022.4 ± 7.727.2 ± 9.3<0.05
 SS34.2 ± 12.836.3 ± 11.239.5 ± 10.7<0.05
 PI-LL mismatch8.7 ± 12.48.1 ± 12.515.4 ± 14.4<0.05
Mean psoas measurement, mm
 Center23.4 ± 7.424.2 ± 7.829.7 ± 8.8<0.05
 Apex43.5 ± 8.444.9 ± 7.850.7 ± 10.5<0.05

Boldface type indicates statistical significance.

Primary Outcome: Position of the Psoas Major Muscle

Increased PI-LL mismatch (0.1, 95% CI 0.1–0.2) was independently associated with a more anterior position of the center of the psoas muscle. Severity of spondylolisthesis (no DS, then SLDS, then TDS) was also associated with anterior displacement of the psoas muscle by 2.4 mm (95% CI 1.1–3.8 mm). In other words, the center of the psoas muscle was on average 2.4 mm more anterior in the SLDS group than in the no-DS group and 4.8 mm more anterior in the TDS group than in the no-DS group. Increased PI-LL mismatch (0.2, 95% CI 0.1–0.3) was independently associated with a more anterior position of the apex of the psoas muscle. Severity of spondylolisthesis (no DS, then SLDS, then TDS) was also associated with anterior displacement of the apex of the psoas muscle by 2.6 mm (95% CI 1.2–3.9 mm). In other words, the apex of the psoas muscle was on average 2.6 mm more anterior in the SLDS group than in the no-DS group and 5.2 mm more anterior in the TDS group than in the no-DS group. Additionally, female sex was found to be associated with a more posterior apex psoas position (−5.0 mm, 95% CI −7.6 to −2.4).

Secondary Outcome: Association Between Degree of DS and Spinopelvic Parameters

Each increased grade of spondylolisthesis (no DS to DSLS to TDS) was associated with significantly increased PI (no DS 54.3° ± 13.0°, SLDS 59.3° ± 12.4°, and TDS 66.0° ± 11.8°), PT (no DS 19.8° ± 9.0°, SLDS 22.4° ± 7.7°, and TDS 27.2° ± 9.3°), and PI-LL mismatch (no DS 8.7° ± 12.4°, SLDS 8.1° ± 12.5°, and TDS 15.4° ± 14.4°). Additionally, center psoas position (no DS 23.4 ± 7.4 mm, SLDS 24.2 ± 7.8 mm, and TDS 29.7 ± 8.8 mm) and apical psoas position (no DS 43.5 ± 8.4 mm, SLDS 44.9 ± 7.8 mm, and TDS 50.7 ± 10.5 mm) were both significantly greater in the TDS group than the no-DS and SLDS groups (p < 0.05 all comparisons).

Discussion

The purpose of this study was to assess the safety of LLIF in the setting of sagittal malalignment by evaluating how the position of the psoas major muscle changes with increasing severity of DS and increasing aberrance of spinopelvic parameters. Increased PI-LL mismatch was independently associated with a more anterior position of both the center and apex of the psoas muscle. Severity of spondylolisthesis (no DS, then SLDS, then TDS) was associated with anterior displacement of both the center and apex of the psoas muscle. The center of the psoas muscle was on average 2.4 mm more anterior in the SLDS group than in the no-DS group, and 4.8 mm more anterior in the TDS group compared with the no-DS group. The apex of the psoas muscle was on average 2.6 mm more anterior in the SLDS group than in the no-DS group, and 5.2 mm more anterior in the TDS group than in the no-DS group. Interestingly, female sex was the only demographic factor associated with psoas position, predicting a significantly more posterior center and apex position of the psoas major muscle.

The psoas major muscle originates from the transverse processes of T12 to L1. Over its course it broadens from L3 to L5, then thins starting at the lumbosacral junction.19 As the psoas muscle becomes thinner, it tends to move laterally and ventrally, or "rise" in relation to the vertebral column.19 The lumbar plexus and femoral nerves, which are classically encountered in the dorsal aspect of the psoas muscle belly, also migrate ventrally.10,25,26 The peak of the psoas major muscle’s ventral movement is at the L4–5 or L5–S1 level.10,19 It is therefore unsurprising that previous work has identified the L4–5 level as at the highest risk for LLIF.10,16,26 Kepler et al., in their retrospective review of the MR images obtained in 43 adults, reported lumbar plexus and femoral nerve vulnerability in 21% and 44% of patients when a standard left- and right-sided lateral approach was considered, respectively.10 However, this study did not specifically comment on the impact of spondylolisthesis on these measurements. Another recent work on neurovascular injury during the lateral approach to the spine noted 3 aborted cases in the setting of a relatively ventrally oriented psoas.19 However, all were the result of aberrant anatomy (lumbarized proximal sacral segment—6 lumbar vertebrae) or an asymmetrical psoas.19 To our knowledge, the only study in the literature that directly correlates the rising psoas sign with spondylolisthesis is a single case report that details the resolution of a ventrally displaced psoas muscle following correction of DS in a 62-year-old woman.27 The connection between sagittal malalignment, worsening spondylolisthesis, and the rising psoas sign has not been well studied but may portend potential adverse consequences for patients undergoing LLIF. Findings from the present work indicate that the safe zone available for LLIF is smaller with increasing PI-LL mismatch and with increasing severity of spondylolisthesis.

The use of an interbody implant has been associated with a higher rate of fusion in patients with DS with preoperative instability.2830 Approaching the lumbar spine laterally via LLIF has several advantages, including obviating the need for an anterior-approach surgeon while still allowing for large intervertebral graft placement.3133 Benefits of LLIF include reduced operative time, postoperative pain, and length of hospital stay.12,32,34,35 However, the corridor used for LLIF risks injury to the nerves of the lumbar plexus, which lie within the psoas muscle. Rates of lumbar plexus injury as high as 54.9% for muscle weakness and up to 25% for sensory deficits have been reported, although the vast majority of cases resolve over medium-term (6–9 months) follow-up.12,32,36,37 A recent paper reported significant differences in psoas muscle and lumbar plexus positioning when a patient transitioned between sitting and supine MRI that were more pronounced at caudal levels.38 This highlights the dynamic nature of psoas anatomy and supports the influence of factors such as degenerative disease and malalignment on its position. We recommend a high index of suspicion that patients with DS, and especially those with TDS, will have an anteriorly located psoas position. Anticipating this challenging anatomy of the psoas and responding accordingly with a more cautious or alternative surgical approach may reduce the incidence of lumbar plexus injuries.

If the anticipated risk to the lumbar plexus via LLIF is considered too great, commonly used alternative interbody fusion surgical approaches in the treatment of DS include anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF). In contrast to the LLIF approach, the ALIF approach does not encounter the lumbar plexus and thus does not require neuromonitoring during cases.39 The major neurological injury concern with the ALIF approach is damage to the sympathetic trunk that descends along the anterior lumbar spine. The incidence of injury to this structure and subsequent sympathetic dysfunction has been reported in prior literature ranging from 9% to 43%.18 Other alternative approaches to LLIF include TLIF and PLIF. In prior literature, the incidences of lumbar plexus–related motor deficits persisting longer than 1 year have been reported as 4.1% and 6.1% for these two approaches, respectively.40,41 Both of these rates are higher than the 2.9% incidence of lumbar plexus injuries that persist longer than 1 year reported in a recent study on LLIF.18

Prior work has noted that the ALIF approach provides excellent exposure for a thorough discectomy and placement of a large cage for fusion while also reducing anterolisthesis and improving lordosis.4245 The major drawback of the ALIF approach is the morbidity and risk associated with transperitoneal dissection. Prior systematic reviews have reported vascular complication rates ranging from 0% to 18%.46,47 Additional complications after ALIF include retrograde ejaculation, sexual dysfunction, and urinary incontinence.4850 In contrast, TLIF through a minimally invasive or open approach avoids the morbidity of the transperitoneal ALIF approach but permits the placement of a substantially smaller graft, thereby decreasing the total surface area available for fusion. Dural tears were also more common during TLIF than ALIF in a recent study.50 Patient-reported outcomes comparing ALIF and TLIF have not been extensively studied. In a recent retrospective review, an ALIF subgroup had a superior reduction in both the Short Form–36 and Oswestry Disability Index scores compared with the TLIF subgroup.51 However, this study was limited by the differing surgical indications between the groups.5,51 A recent prospective, randomized controlled trial compared minimally invasive TLIF and LLIF in terms of a number of patient-reported outcomes, including visual analog scores for back and leg pain, Short Form–36 scores, and Oswestry Disability Index scores.52 Both approaches demonstrated significant improvements in all tests from preoperative to postoperative scores, but there were no significant differences between the two approaches.52

The pathogenesis of the findings of this study that correlate increasingly severe DS with an anterior psoas muscle position warrants thoughtful interpretation, as we believe that it is less likely that the spondylolisthesis itself impacts psoas position rather than the sagittal malalignment that it represents. Prior work has hypothesized that increased PI, which is largely set at birth, requires increased initial LL to maintain a neutral sagittal alignment.5355 This LL "demand" is thought to predispose one to increased mechanical stress on the posterior facets, accelerated posterior arthritis, and ultimately an increased risk of vertebral slippage.56,57 Progression of vertebral slippage ultimately leads to flattening of the LL and increased PI-LL mismatch.53,58 PI-LL mismatch was found to be independently associated with a ventrally displaced psoas position in the present work. This may suggest that as the lumbar spine flattens and flexes throughout the natural history of DS, the psoas major muscle at L4–5 is pulled forward along with the vertebral anterolisthesis. Further biomechanical studies may be warranted to confirm this speculation and to explore other related local and global anatomical changes.

Limitations

There are several limitations to this study beyond those intrinsic to retrospective analyses. First is the lack of comparison seated or standing MRI, which would potentially provide us with an understanding of the impact of gravity on psoas position and a more accurate correlate to the standing lumbar radiographs used in the present work. However, the multilevel attachments of the psoas muscle suggest that its position in the supine versus the standing position is only marginally different. Second, the lack of supine lumbar radiographs does not permit an assessment of the importance of supine sagittal alignment or lumbar flexibility with respect to psoas position. Given the importance of flexibility to adult spinal deformity management, this needs to be evaluated in future work. Finally, our institution at the time of this study did not routinely obtain 36-inch radiographs in patients with DS, precluding the measurement of sagittal vertical axis and T1–pelvis angles. Future prospective works will include these additional imaging studies as well as clinical correlates, such as patient-reported outcomes.

Conclusions

In the first large, single-institution examination of a correlation between an anteriorly located psoas muscle and sagittal malalignment, increased PI-LL mismatch and more severe spondylolisthesis (SLDS followed by TDS) were independently associated with a smaller LLIF safe zone at L4–5, and female sex was associated with a larger safe zone. TDS patients had a greater degree of sagittal malalignment (PI-LL mismatch) and pelvic compensation (PT) than both patients with SLDS and individuals without spondylolisthesis. Our findings suggest that TDS represents a more severe degree of sagittal malalignment and is a risk factor for lumbar plexus injury during LLIF at L4–5. These findings may have significant implications for TDS patients undergoing LLIF. However, further work is needed to explore the clinical outcomes of this patient population after LLIF.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Dalton, Oyekan, Ridolfi, Couch, Shaw, Donaldson, Lee. Acquisition of data: Dalton, Oyekan, Ridolfi, Couch, Shaw. Analysis and interpretation of data: Dalton, Oyekan, Fourman, Ridolfi, Cluts, Couch, Shaw, Donaldson. Drafting the article: Dalton, Oyekan, Fourman, Ridolfi, Cluts, Couch, Shaw, Lee. Critically revising the article: Dalton, Fourman, Ridolfi, Cluts, Couch, Shaw, Lee. Reviewed submitted version of manuscript: Dalton, Fourman, Ridolfi, Couch, Shaw. Approved the final version of the manuscript on behalf of all authors: Dalton. Statistical analysis: Dalton, Oyekan, Fourman, Cluts. Administrative/technical/material support: Shaw. Study supervision: Dalton, Shaw, Lee.

Supplemental Information

Previous Presentations

Portions of this work were presented at the Global Spine Congress, Las Vegas, Nevada, June 4, 2022; and the International Society for the Study of the Lumbar Spine Annual Meeting, Boston, Massachusetts, May 9, 2022.

References

  • 1

    Ha KY, Na KH, Shin JH, Kim KW. Comparison of posterolateral fusion with and without additional posterior lumbar interbody fusion for degenerative lumbar spondylolisthesis. J Spinal Disord Tech. 2008;21(4):229234.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Moo IH, Tan SW, Kasat N, Thng LK. A case report of 3-level degenerative spondylolisthesis with spinal canal stenosis. Int J Surg Case Rep. 2015;8C:120-123.

  • 3

    Fritzell P, Hägg O, Wessberg P, Nordwall A. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976). 2001;26(23):25212534.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Deluzio KJ, Lucio JC, Rodgers WB. Value and cost in less invasive spinal fusion surgery: lessons from a community hospital. SAS J. 2010;4(2):3740.

  • 5

    Spiker WR, Goz V, Brodke DS. Lumbar interbody fusions for degenerative spondylolisthesis: review of techniques, indications, and outcomes. Global Spine J. 2019;9(1):7784.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Arnold PM, Anderson KK, McGuire RA Jr. The lateral transpsoas approach to the lumbar and thoracic spine: a review. Surg Neurol Int. 2012;3(suppl 3):S198-S215.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Acosta FL, Liu J, Slimack N, Moller D, Fessler R, Koski T. Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. J Neurosurg Spine. 2011;15(1):9296.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Pawar AY, Hughes AP, Sama AA, Girardi FP, Lebl DR, Cammisa FP. A comparative study of lateral lumbar interbody fusion and posterior lumbar interbody fusion in degenerative lumbar spondylolisthesis. Asian Spine J. 2015;9(5):668674.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    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
  • 10

    Kepler CK, Bogner EA, Herzog RJ, Huang RC. Anatomy of the psoas muscle and lumbar plexus with respect to the surgical approach for lateral transpsoas interbody fusion. Eur Spine J. 2011;20(4):550556.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Houten JK, Alexandre LC, Nasser R, Wollowick AL. Nerve injury during the transpsoas approach for lumbar fusion. J Neurosurg Spine. 2011;15(3):280284.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Knight RQ, Schwaegler P, Hanscom D, Roh J. Direct lateral lumbar interbody fusion for degenerative conditions: early complication profile. J Spinal Disord Tech. 2009;22(1):3437.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Tohmeh AG, Rodgers WB, Peterson MD. Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine. 2011;14(1):3137.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Guérin P, Obeid I, Gille O, et al. Safe working zones using the minimally invasive lateral retroperitoneal transpsoas approach: a morphometric study. Surg Radiol Anat. 2011;33(8):665671.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Guérin P, Obeid I, Bourghli A, et al. The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach. Surg Radiol Anat. 2012;34(2):151157.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Regev GJ, Chen L, Dhawan M, Lee YP, Garfin SR, Kim CW. Morphometric analysis of the ventral nerve roots and retroperitoneal vessels with respect to the minimally invasive lateral approach in normal and deformed spines. Spine (Phila Pa 1976). 2009;34(12):13301335.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Ahmadian A, Deukmedjian AR, Abel N, Dakwar E, Uribe JS. Analysis of lumbar plexopathies and nerve injury after lateral retroperitoneal transpsoas approach: diagnostic standardization. J Neurosurg Spine. 2013;18(3):289297.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Pumberger M, Hughes AP, Huang RR, Sama AA, Cammisa FP, Girardi FP. Neurologic deficit following lateral lumbar interbody fusion. Eur Spine J. 2012;21(6):11921199.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19

    Voyadzis JM, Felbaum D, Rhee J. The rising psoas sign: an analysis of preoperative imaging characteristics of aborted minimally invasive lateral interbody fusions at L4-5. J Neurosurg Spine. 2014;20(5):531537.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Tanida S, Fujibayashi S, Otsuki B, Matsuda S. The spontaneous restoration of the course of psoas muscles after corrective surgery for adult spinal deformity. J Orthop Sci. 2020;25(1):7381.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Tanida S, Fujibayashi S, Otsuki B, Masamoto K, Matsuda S. Influence of spinopelvic alignment and morphology on deviation in the course of the psoas major muscle. J Orthop Sci. 2017;22(6):10011008.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Chung NS, Jeon CH, Lee HD, Won SH. Measurement of spinopelvic parameters on standing lateral lumbar radiographs: validity and reliability. Clin Spine Surg. 2017;30(2):E119E123.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Iguchi T, Wakami T, Kurihara A, Kasahara K, Yoshiya S, Nishida K. Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis. J Spinal Disord Tech. 2002;15(2):9399.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24

    Koslosky E, Gendelberg D. Classification in brief: the Meyerding classification system of spondylolisthesis. Clin Orthop Relat Res. 2020;478(5):11251130.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Park DK, Lee MJ, Lin EL, Singh K, An HS, Phillips FM. The relationship of intrapsoas nerves during a transpsoas approach to the lumbar spine: anatomic study. J Spinal Disord Tech. 2010;23(4):223228.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Benglis DM, Vanni S, Levi AD. An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 2009;10(2):139144.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27

    Syed HR, Yaeger K, Sandhu FA. Resolution of the more anteriorly positioned psoas muscle following correction of spinal sagittal alignment from spondylolisthesis: case report. J Neurosurg Spine. 2017;26(4):441447.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28

    Gandhoke GS, Kasliwal MK, Smith JS, et al. A multicenter evaluation of clinical and radiographic outcomes following high-grade spondylolisthesis reduction and fusion. Clin Spine Surg. 2017;30(4):E363E369.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29

    Mummaneni PV, Dhall SS, Eck JC, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 11: Interbody techniques for lumbar fusion. J Neurosurg Spine. 2014;21(1):6774.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Park P, Wang MY, Lafage V, et al. Comparison of two minimally invasive surgery strategies to treat adult spinal deformity. J Neurosurg Spine. 2015;22(4):374380.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31

    Dahdaleh NS, Smith ZA, Snyder LA, Graham RB, Fessler RG, Koski TR. Lateral transpsoas lumbar interbody fusion: outcomes and deformity correction. Neurosurg Clin N Am. 2014;25(2):353360.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32

    Dakwar E, Cardona RF, Smith DA, Uribe JS. Early outcomes and safety of the minimally invasive, lateral retroperitoneal transpsoas approach for adult degenerative scoliosis. Neurosurg Focus. 2010;28(3):E8.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33

    Isaacs RE, Hyde J, Goodrich JA, Rodgers WB, Phillips FM. A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine (Phila Pa 1976). 2010;35(26 suppl):S322S330.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Graham RB, Wong AP, Liu JC. Minimally invasive lateral transpsoas approach to the lumbar spine: pitfalls and complication avoidance. Neurosurg Clin N Am. 2014;25(2):219231.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35

    Moller DJ, Slimack NP, Acosta FL Jr, Koski TR, Fessler RG, Liu JC. Minimally invasive lateral lumbar interbody fusion and transpsoas approach-related morbidity. Neurosurg Focus. 2011;31(4):E4.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976). 2013;38(1):E13E20.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37

    Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 2011;36(1):2632.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38

    Buckland AJ, Beaubrun BM, Isaacs E, et al. Psoas morphology differs between supine and sitting magnetic resonance imaging lumbar spine: implications for lateral lumbar interbody fusion. Asian Spine J. 2018;12(1):2936.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39

    Winder MJ, Gambhir S. Comparison of ALIF vs. XLIF for L4/5 interbody fusion: pros, cons, and literature review. J Spine Surg. 2016;2(1):28.

  • 40

    Barnes B, Rodts GE Jr, Haid RW Jr, Subach BR, McLaughlin MR. Allograft implants for posterior lumbar interbody fusion: results comparing cylindrical dowels and impacted wedges. Neurosurgery. 2002;51(5):11911198.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 41

    Villavicencio AT, Burneikiene S, Bulsara KR, Thramann JJ. Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability. J Spinal Disord Tech. 2006;19(2):9297.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42

    Rao PJ, Loganathan A, Yeung V, Mobbs RJ. Outcomes of anterior lumbar interbody fusion surgery based on indication: a prospective study. Neurosurgery. 2015;76(1):724.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 43

    Burke PJ. Anterior lumbar interbody fusion. Radiol Technol. 2001;72(5):423430.

  • 44

    Mummaneni PV, Haid RW, Rodts GE. Lumbar interbody fusion: state-of-the-art technical advances. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine. 2004;1(1):2430.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45

    Rao PJ, Ghent F, Phan K, Lee K, Reddy R, Mobbs RJ. Stand-alone anterior lumbar interbody fusion for treatment of degenerative spondylolisthesis. J Clin Neurosci. 2015;22(10):16191624.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 46

    Inamasu J, Guiot BH. Vascular injury and complication in neurosurgical spine surgery. Acta Neurochir (Wien). 2006;148(4):375387.

  • 47

    Wood KB, Devine J, Fischer D, Dettori JR, Janssen M. Vascular injury in elective anterior lumbosacral surgery. Spine (Phila Pa 1976)s. 2010;35(9 suppl):S66S75.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 48

    Wuertz-Kozak K, Bleisch D, Nadi N, et al. Sexual and urinary function following anterior lumbar surgery in females. Neurourol Urodyn. 2019;38(2):632636.

  • 49

    Malham GM, Parker RM, Ellis NJ, Blecher CM, Chow FY, Claydon MH. Anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2: a prospective study of complications. J Neurosurg Spine. 2014;21(6):851860.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 50

    Phan K, Thayaparan GK, Mobbs RJ. Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion—systematic review and meta-analysis. Br J Neurosurg. 2015;29(5):705711.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 51

    Glassman S, Gornet MF, Branch C, et al. MOS Short Form 36 and Oswestry Disability Index outcomes in lumbar fusion: a multicenter experience. Spine J. 2006;6(1):2126.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 52

    Sembrano JN, Tohmeh A, Isaacs R. Two-year comparative outcomes of MIS lateral and MIS transforaminal interbody fusion in the treatment of degenerative spondylolisthesis: Part I: Clinical findings. Spine (Phila Pa 1976). 2016;41(suppl 8):S123-S132.

    • Search Google Scholar
    • Export Citation
  • 53

    Barrey C, Jund J, Noseda O, Roussouly P. Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases. Eur Spine J. 2007;16(9):14591467.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 54

    Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976). 2005;30(3):346353.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 55

    Labelle H, Roussouly P, Berthonnaud E, et al. Spondylolisthesis, pelvic incidence, and spinopelvic balance: a correlation study. Spine (Phila Pa 1976). 2004;29(18):20492054.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 56

    Berlemann U, Jeszenszky DJ, Bühler DW, Harms J. Facet joint remodeling in degenerative spondylolisthesis: an investigation of joint orientation and tropism. Eur Spine J. 1998;7(5):376380.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 57

    Matsunaga S, Sakou T, Morizono Y, Masuda A, Demirtas AM. Natural history of degenerative spondylolisthesis. Pathogenesis and natural course of the slippage. Spine (Phila Pa 1976). 1990;15(11):12041210.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 58

    Le Huec JC, Aunoble S, Philippe L, Nicolas P. Pelvic parameters: origin and significance. Eur Spine J. 2011;20(suppl 5):564-571.

  • Collapse
  • Expand

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

  • View in gallery
    FIG. 1.

    A: Sagittal and axial T2-weighted MR images obtained at the L4–5 disc level in a patient without DS. The sagittal image (left) shows the scout line confirming the position of the axial image. The axial image (right) shows the center and apical (ventral) psoas major muscle. The measurement is taken from a tangent line at the posterior (dorsal) aspect of the L4–5 disc space. Measurements are averaged between the right and left psoas major muscles. B: Sagittal and axial T2-weighted MR images obtained at the L4–5 disc level in a patient with SLDS. C: Sagittal and axial T2-weighted MR images obtained at the L4–5 disc level in a patient with TDS.

  • View in gallery
    FIG. 2.

    Lumbar spine radiographs that include the upper endplate of the L1 vertebra, the sacral dome, and both femoral heads, showing spinopelvic parameter measurements in a patient with TDS. A: SS. B: PI. C: PT.

  • 1

    Ha KY, Na KH, Shin JH, Kim KW. Comparison of posterolateral fusion with and without additional posterior lumbar interbody fusion for degenerative lumbar spondylolisthesis. J Spinal Disord Tech. 2008;21(4):229234.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Moo IH, Tan SW, Kasat N, Thng LK. A case report of 3-level degenerative spondylolisthesis with spinal canal stenosis. Int J Surg Case Rep. 2015;8C:120-123.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Fritzell P, Hägg O, Wessberg P, Nordwall A. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976). 2001;26(23):25212534.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Deluzio KJ, Lucio JC, Rodgers WB. Value and cost in less invasive spinal fusion surgery: lessons from a community hospital. SAS J. 2010;4(2):3740.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Spiker WR, Goz V, Brodke DS. Lumbar interbody fusions for degenerative spondylolisthesis: review of techniques, indications, and outcomes. Global Spine J. 2019;9(1):7784.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Arnold PM, Anderson KK, McGuire RA Jr. The lateral transpsoas approach to the lumbar and thoracic spine: a review. Surg Neurol Int. 2012;3(suppl 3):S198-S215.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Acosta FL, Liu J, Slimack N, Moller D, Fessler R, Koski T. Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. J Neurosurg Spine. 2011;15(1):9296.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Pawar AY, Hughes AP, Sama AA, Girardi FP, Lebl DR, Cammisa FP. A comparative study of lateral lumbar interbody fusion and posterior lumbar interbody fusion in degenerative lumbar spondylolisthesis. Asian Spine J. 2015;9(5):668674.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    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
  • 10

    Kepler CK, Bogner EA, Herzog RJ, Huang RC. Anatomy of the psoas muscle and lumbar plexus with respect to the surgical approach for lateral transpsoas interbody fusion. Eur Spine J. 2011;20(4):550556.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Houten JK, Alexandre LC, Nasser R, Wollowick AL. Nerve injury during the transpsoas approach for lumbar fusion. J Neurosurg Spine. 2011;15(3):280284.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Knight RQ, Schwaegler P, Hanscom D, Roh J. Direct lateral lumbar interbody fusion for degenerative conditions: early complication profile. J Spinal Disord Tech. 2009;22(1):3437.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Tohmeh AG, Rodgers WB, Peterson MD. Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine. 2011;14(1):3137.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Guérin P, Obeid I, Gille O, et al. Safe working zones using the minimally invasive lateral retroperitoneal transpsoas approach: a morphometric study. Surg Radiol Anat. 2011;33(8):665671.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Guérin P, Obeid I, Bourghli A, et al. The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach. Surg Radiol Anat. 2012;34(2):151157.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Regev GJ, Chen L, Dhawan M, Lee YP, Garfin SR, Kim CW. Morphometric analysis of the ventral nerve roots and retroperitoneal vessels with respect to the minimally invasive lateral approach in normal and deformed spines. Spine (Phila Pa 1976). 2009;34(12):13301335.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Ahmadian A, Deukmedjian AR, Abel N, Dakwar E, Uribe JS. Analysis of lumbar plexopathies and nerve injury after lateral retroperitoneal transpsoas approach: diagnostic standardization. J Neurosurg Spine. 2013;18(3):289297.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Pumberger M, Hughes AP, Huang RR, Sama AA, Cammisa FP, Girardi FP. Neurologic deficit following lateral lumbar interbody fusion. Eur Spine J. 2012;21(6):11921199.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19

    Voyadzis JM, Felbaum D, Rhee J. The rising psoas sign: an analysis of preoperative imaging characteristics of aborted minimally invasive lateral interbody fusions at L4-5. J Neurosurg Spine. 2014;20(5):531537.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Tanida S, Fujibayashi S, Otsuki B, Matsuda S. The spontaneous restoration of the course of psoas muscles after corrective surgery for adult spinal deformity. J Orthop Sci. 2020;25(1):7381.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Tanida S, Fujibayashi S, Otsuki B, Masamoto K, Matsuda S. Influence of spinopelvic alignment and morphology on deviation in the course of the psoas major muscle. J Orthop Sci. 2017;22(6):10011008.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Chung NS, Jeon CH, Lee HD, Won SH. Measurement of spinopelvic parameters on standing lateral lumbar radiographs: validity and reliability. Clin Spine Surg. 2017;30(2):E119E123.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Iguchi T, Wakami T, Kurihara A, Kasahara K, Yoshiya S, Nishida K. Lumbar multilevel degenerative spondylolisthesis: radiological evaluation and factors related to anterolisthesis and retrolisthesis. J Spinal Disord Tech. 2002;15(2):9399.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24

    Koslosky E, Gendelberg D. Classification in brief: the Meyerding classification system of spondylolisthesis. Clin Orthop Relat Res. 2020;478(5):11251130.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Park DK, Lee MJ, Lin EL, Singh K, An HS, Phillips FM. The relationship of intrapsoas nerves during a transpsoas approach to the lumbar spine: anatomic study. J Spinal Disord Tech. 2010;23(4):223228.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Benglis DM, Vanni S, Levi AD. An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 2009;10(2):139144.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27

    Syed HR, Yaeger K, Sandhu FA. Resolution of the more anteriorly positioned psoas muscle following correction of spinal sagittal alignment from spondylolisthesis: case report. J Neurosurg Spine. 2017;26(4):441447.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28

    Gandhoke GS, Kasliwal MK, Smith JS, et al. A multicenter evaluation of clinical and radiographic outcomes following high-grade spondylolisthesis reduction and fusion. Clin Spine Surg. 2017;30(4):E363E369.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29

    Mummaneni PV, Dhall SS, Eck JC, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 11: Interbody techniques for lumbar fusion. J Neurosurg Spine. 2014;21(1):6774.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Park P, Wang MY, Lafage V, et al. Comparison of two minimally invasive surgery strategies to treat adult spinal deformity. J Neurosurg Spine. 2015;22(4):374380.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31

    Dahdaleh NS, Smith ZA, Snyder LA, Graham RB, Fessler RG, Koski TR. Lateral transpsoas lumbar interbody fusion: outcomes and deformity correction. Neurosurg Clin N Am. 2014;25(2):353360.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32

    Dakwar E, Cardona RF, Smith DA, Uribe JS. Early outcomes and safety of the minimally invasive, lateral retroperitoneal transpsoas approach for adult degenerative scoliosis. Neurosurg Focus. 2010;28(3):E8.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33

    Isaacs RE, Hyde J, Goodrich JA, Rodgers WB, Phillips FM. A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine (Phila Pa 1976). 2010;35(26 suppl):S322S330.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34

    Graham RB, Wong AP, Liu JC. Minimally invasive lateral transpsoas approach to the lumbar spine: pitfalls and complication avoidance. Neurosurg Clin N Am. 2014;25(2):219231.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35

    Moller DJ, Slimack NP, Acosta FL Jr, Koski TR, Fessler RG, Liu JC. Minimally invasive lateral lumbar interbody fusion and transpsoas approach-related morbidity. Neurosurg Focus. 2011;31(4):E4.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976). 2013;38(1):E13E20.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37

    Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 2011;36(1):2632.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38

    Buckland AJ, Beaubrun BM, Isaacs E, et al. Psoas morphology differs between supine and sitting magnetic resonance imaging lumbar spine: implications for lateral lumbar interbody fusion. Asian Spine J. 2018;12(1):2936.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39

    Winder MJ, Gambhir S. Comparison of ALIF vs. XLIF for L4/5 interbody fusion: pros, cons, and literature review. J Spine Surg. 2016;2(1):28.

  • 40

    Barnes B, Rodts GE Jr, Haid RW Jr, Subach BR, McLaughlin MR. Allograft implants for posterior lumbar interbody fusion: results comparing cylindrical dowels and impacted wedges. Neurosurgery. 2002;51(5):11911198.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 41

    Villavicencio AT, Burneikiene S, Bulsara KR, Thramann JJ. Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability. J Spinal Disord Tech. 2006;19(2):9297.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42

    Rao PJ, Loganathan A, Yeung V, Mobbs RJ. Outcomes of anterior lumbar interbody fusion surgery based on indication: a prospective study. Neurosurgery. 2015;76(1):724.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 43

    Burke PJ. Anterior lumbar interbody fusion. Radiol Technol. 2001;72(5):423430.

  • 44

    Mummaneni PV, Haid RW, Rodts GE. Lumbar interbody fusion: state-of-the-art technical advances. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine. 2004;1(1):2430.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45

    Rao PJ, Ghent F, Phan K, Lee K, Reddy R, Mobbs RJ. Stand-alone anterior lumbar interbody fusion for treatment of degenerative spondylolisthesis. J Clin Neurosci. 2015;22(10):16191624.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 46

    Inamasu J, Guiot BH. Vascular injury and complication in neurosurgical spine surgery. Acta Neurochir (Wien). 2006;148(4):375387.

  • 47

    Wood KB, Devine J, Fischer D, Dettori JR, Janssen M. Vascular injury in elective anterior lumbosacral surgery. Spine (Phila Pa 1976)s. 2010;35(9 suppl):S66S75.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 48

    Wuertz-Kozak K, Bleisch D, Nadi N, et al. Sexual and urinary function following anterior lumbar surgery in females. Neurourol Urodyn. 2019;38(2):632636.

  • 49

    Malham GM, Parker RM, Ellis NJ, Blecher CM, Chow FY, Claydon MH. Anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2: a prospective study of complications. J Neurosurg Spine. 2014;21(6):851860.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 50

    Phan K, Thayaparan GK, Mobbs RJ. Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion—systematic review and meta-analysis. Br J Neurosurg. 2015;29(5):705711.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 51

    Glassman S, Gornet MF, Branch C, et al. MOS Short Form 36 and Oswestry Disability Index outcomes in lumbar fusion: a multicenter experience. Spine J. 2006;6(1):2126.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 52

    Sembrano JN, Tohmeh A, Isaacs R. Two-year comparative outcomes of MIS lateral and MIS transforaminal interbody fusion in the treatment of degenerative spondylolisthesis: Part I: Clinical findings. Spine (Phila Pa 1976). 2016;41(suppl 8):S123-S132.

    • Search Google Scholar
    • Export Citation
  • 53

    Barrey C, Jund J, Noseda O, Roussouly P. Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases. Eur Spine J. 2007;16(9):14591467.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 54

    Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine (Phila Pa 1976). 2005;30(3):346353.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 55

    Labelle H, Roussouly P, Berthonnaud E, et al. Spondylolisthesis, pelvic incidence, and spinopelvic balance: a correlation study. Spine (Phila Pa 1976). 2004;29(18):20492054.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 56

    Berlemann U, Jeszenszky DJ, Bühler DW, Harms J. Facet joint remodeling in degenerative spondylolisthesis: an investigation of joint orientation and tropism. Eur Spine J. 1998;7(5):376380.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 57

    Matsunaga S, Sakou T, Morizono Y, Masuda A, Demirtas AM. Natural history of degenerative spondylolisthesis. Pathogenesis and natural course of the slippage. Spine (Phila Pa 1976). 1990;15(11):12041210.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 58

    Le Huec JC, Aunoble S, Philippe L, Nicolas P. Pelvic parameters: origin and significance. Eur Spine J. 2011;20(suppl 5):564-571.

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 508 508 270
PDF Downloads 490 490 268
EPUB Downloads 0 0 0