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Hasan R. Syed, Kurt Yaeger and Faheem A. Sandhu

, procedures in which a lateral exposure is used lead to reduced operation time, less postoperative pain, and shorter hospital stay. 6 , 10 , 20 , 24 One potential complication of the transpsoas lateral interbody approach results from the surgical proximity to the psoas muscle and lumbar plexus, specifically at L4–5. 3 , 10 , 12 , 21 , 23 It has been reported that injury due to intraoperative traction, mechanical disruption, or thermal injury may contribute to postoperative iliopsoas and quadriceps muscle weakness or groin and thigh paresthesias in 2%–30% of cases, a

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Jean-Marc Voyadzis, Daniel Felbaum and Jay Rhee

disruption of osteoligamentous structures, to avoid retraction of the neural elements within the spinal canal, and to eliminate the need for an access surgeon and associated complications with the anterior approach. 12 , 14 , 22 This procedure can be performed with minimal tissue disruption and blood loss, leading to less postoperative pain and shorter hospital stays. 1 , 6 , 9 , 12 , 14 , 16 , 18 , 20 , 22 Disadvantages of the lateral approach are the result of involvement of the psoas muscle and the proximity of the lumbar plexus particularly at L4–5. 2 , 5 , 7 , 10

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William W. Orrison, Enrique L. Labadie and Vadakepat Ramgopal

T hree cases of fatal meningitis caused by the extension of undiagnosed psoas abscesses have been seen at this institution in the past 11 years. This complication of a psoas muscle infection was not encountered in our literature review. An analysis of these three patients is presented. Case Reports Case 1 This 55-year-old man was readmitted in July, 1974, with a traumatic fracture of the left hip. His past medical history included diabetes mellitus, chronic alcoholism, chronic obstructive pulmonary disease, seizure disorder, and malabsorption

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Ganesh Rao, Robert Bohinski, Iman Feiz-Erfan and Laurence D. Rhines

T he retroperitoneal approach to the lumbar spine has gained popularity in procedures undertaken for stabilizing traumatic fractures and resecting VB tumors. 1–3 This approach may be used to gain access to the ventral aspects of L1–5. 4 One of the drawbacks to the technique, however, is that the large psoas muscle may obscure the spine, particularly along its posterolateral aspect. Exposure of this part of the spine is especially important in cases of neoplastic infiltration because the neural elements may be distorted by the tumor mass. Retraction of

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Timothy T. Davis, Richard A. Hynes, Daniel A. Fung, Scott W. Spann, Michael MacMillan, Brian Kwon, John Liu, Frank Acosta and Thomas E. Drochner

approach is preferred by many surgeons due to ease of access, shorter operation time, larger cage placement, decreased tissue trauma, less vascular injury, minimal blood loss, and faster patient recovery. 14 , 21 , 33 The transpsoas approach does, however, pose risk to neural structures of the lumbar plexus as they course through the psoas. 2 , 12 , 13 , 15 , 21 The large muscle belly of the psoas and overlap of the iliac crest make access to the L4–5 disc difficult and eliminate access to the L5–S1 disc. 2 , 3 , 8 , 10 , 15 Access to the L4–5 disc in a lateral

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Joshua M. Beckman, Berney Vincent, Michael S. Park, James B. Billys, Robert E. Isaacs, Luiz Pimenta and Juan S. Uribe

outcomes and minimize these risks, we must remain transparent about our complications and learn from our own experiences and those of our colleagues. Complications from LLIF have been well documented in the literature. 1–6 , 10 , 12–14 An uncommon or potentially underreported complication is the psoas hematoma on the contralateral side of lateral access. In this multicenter retrospective series, we report the incidence of the contralateral psoas hematoma and its neurological sequelae following retroperitoneal transpsoas LLIF. There have previously been reports of

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Elias Dakwar, Fernando L. Vale and Juan S. Uribe

pathway and the resultant risk of injury to nerves. The addition of intraoperative real-time nerve monitoring to this procedure allows the surgeon to safely traverse the psoas muscle while avoiding the major motor branches of the lumbar plexus. However, this neural monitoring does not help prevent injury to nerves living outside the psoas. A thorough understanding of the anatomical complexity of the lumbar plexus may reduce the risk of injury to the nerves. The anatomy of the lumbar plexus has been well described. 23 In our previous study, we analyzed the nerves of

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Cristian Gragnaniello and Kevin A. Seex

Lateral interbody cages have proven useful in lumbar fusion surgery. Spanning both lateral cortical rims while sparing the anterior longitudinal ligament, they restore disc height, improve coronal balance and add stability. The standard approach to their insertion is 90 degrees lateral transpsoas which is bloodless compared to other techniques of interbody cage insertion but requires neuro-monitoring and at L4/5 can be difficult because of iliac crest obstruction or an anterior plexus position. The oblique muscle-splitting approach with the patient in a lateral position, remains retroperitoneal, and on the left side enters the disc space through a window between psoas and the common iliac vein. Reports of this approach are few and none previously have described how to use the large lateral-type cages so effective at restoring spinal alignment. In this video we demonstrate our technique of anterior to psoas fusion of the lumbar spine with a retroperitoneal approach and gentle retraction of the psoas muscle.

The video can be found here: http://youtu.be/OS2vNcX9JMA.

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Christopher Wilkerson, Vance Mortimer, Andrew T. Dailey and Marcus D. Mazur

access to the L4–5 disc space challenging from a direct lateral transpsoas approach. The patient’s anatomy was favorable for an oblique anterior to psoas approach with an appropriate corridor between the aorta and iliac vessels and the psoas muscle. The distance between the major arteries and the psoas should be greater than 1 cm on MRI. This distance is typically greater at the upper lumbar levels, L2–3 and L3–4. 1:20 Advantages to the anterior oblique approach Advantages to the anterior oblique approach are: it avoids disruption of the psoas muscle, the working

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Hesham Mostafa Zakaria, Azam Basheer, David Boyce-Fappiano, Erinma Elibe, Lonni Schultz, Ian Lee, Farzan Siddiqui, Brent Griffith and Victor Chang

treatment, be it chemotherapy, radiation, surgery, or palliation. In this study, we applied morphometric analysis of psoas muscle size to predict oncological outcomes in patients who have had lung cancer metastases to the spine. In our previous work, we identified patients who were at higher risk of postoperative morbidity after lumbar spine surgery by using the psoas area as a marker for sarcopenia. 57 Our hypothesis is that patients with lung cancer metastasis to the spine will have shorter survival if they have less lean muscle mass as measured by the psoas area