An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion

Clinical article

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Object

The minimally invasive transpsoas interbody fusion technique requires dissection through the psoas muscle, which contains the nerves of the lumbosacral plexus posteriorly and genitofemoral nerve anteriorly. Retraction of the psoas is becoming recognized as a cause of transient postoperative thigh pain, numbness, paresthesias, and weakness. However, few reports have described the nature of thigh symptoms after this procedure.

Methods

The authors performed a review of patients who underwent the transpsoas technique for lumbar spondylotic disease, disc degeneration, and spondylolisthesis treated at a single academic medical center. A review of patient charts, including the use of detailed patient-driven pain diagrams performed at equal preoperative and follow-up intervals, investigated the survival of postoperative thigh pain, numbness, paresthesias, and weakness of the iliopsoas and quadriceps muscles in the follow-up period on the ipsilateral side of the surgical approach.

Results

Over a 3.2-year period, 59 patients underwent transpsoas interbody fusion surgery. Of these, 62.7% had thigh symptoms postoperatively. New thigh symptoms at first follow-up visit included the following: burning, aching, stabbing, or other pain (39.0%); numbness (42.4%); paresthesias (11.9%); and weakness (23.7%). At 3 months postoperatively, these percentages decreased to 15.5%, 24.1%, 5.6%, and 11.3%, respectively. Within the patient sample, 44% underwent a 1-level, 41% a 2-level, and 15% a 3-level transpsoas operation. While not statistically significant, thigh pain, numbness, and weakness were most prevalent after L4–5 transpsoas interbody fusion at the first postoperative follow-up. The number of lumbar levels that were surgically treated had no clear association with thigh symptoms but did correlate directly with surgical time, intraoperative blood loss, and length of hospital stay.

Conclusions

Transpsoas interbody fusion is associated with high rates of immediate postoperative thigh symptoms. While larger, prospective studies are necessary to validate these findings, the authors found that half of the patients had symptom resolution at approximately 3 months postoperatively and more than 90% by 1 year.

Abbreviations used in this paper: BMP = bone morphogenetic protein; DLIF = direct lateral interbody fusion; EMG = electromyography; LFCN = lateral femoral cutaneous nerve; PLIF = posterior lumbar interbody fusion; XLIF = extreme lateral interbody fusion.

Article Information

Address correspondence to: Matthew D. Cummock, B.A., Department of Neurological Surgery, University of Miami Miller School of Medicine, 1095 NW 14th Terrace, Lois Pope LIFE Center, D4-6, Miami, Florida 33136. email: mcummock@med.miami.edu.

Please include this information when citing this paper: published online April 8, 2011; DOI: 10.3171/2011.2.SPINE10374.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Example of a patient-driven pain diagram filled out at equal preoperative and follow-up intervals: burning (red), aching (blue), numbness (yellow), and paresthesias (pins/needles, purple). Although not shown in this example, green would indicate an area of stabbing pain, and brown would indicate an area of other pain.

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    Thigh symptoms experienced by patients at each lumbar site of transpsoas fusion at the first follow-up visit (median 16 days postoperatively). Pain, numbness, and weakness were most prevalent after L4–5 transpsoas interbody fusion.

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    Thigh symptoms experienced by patients at each lumbar site of transpsoas fusion at the second follow-up visit (median 64 days postoperatively).

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    Kaplan-Meier survival analysis of thigh pain (burning, aching, stabbing, or other): 39.0% of patients at Day 1 postoperatively, 15.5% at 3 months postoperatively. F/U = follow-up.

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    Kaplan-Meier survival analysis of thigh numbness: 42.4% of patients at Day 1 postoperatively, 24.1% at 3 months postoperatively.

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    Kaplan-Meier survival analysis of thigh paresthesias: 11.9% of patients at Day 1 postoperatively, 5.6% at 3 months postoperatively.

  • View in gallery

    Kaplan-Meier survival analysis of thigh weakness: 23.7% of patients at Day 1 postoperatively, 11.3% at 3 months postoperatively.

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