Lateral interbody fusion combined with open posterior surgery for adult spinal deformity

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OBJECTIVE

Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD.

METHODS

All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients.

RESULTS

LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045).

CONCLUSIONS

LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

ABBREVIATIONSALIF = anterior lumbar interbody fusion; ASD = adult spinal deformity; CVA = coronal vertical axis; HRQOL = health-related quality of life; ICU = intensive care unit; LIF = lateral interbody fusion; LL = lumbar lordosis; MIS = minimally invasive surgery; ODI = Oswestry Disability Index; OP = open posterior; PI = pelvic incidence; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; SVA = sagittal vertical axis; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale.

OBJECTIVE

Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD.

METHODS

All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients.

RESULTS

LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045).

CONCLUSIONS

LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

Loss of sagittal balance is associated with pain and disability, and its restoration is the primary goal of adult spinal deformity (ASD) surgery.13,16 Facet osteotomies often provide limited sagittal correction because stiff, collapsed disc spaces impair posterior shortening. Moderate to severe ASD generally requires anterior disc space augmentation and/or posterior 3-column osteotomy.6 Anterior lumbar interbody fusion (ALIF) and pedicle subtraction osteotomy (PSO) each carry significant risks.5,11,17,29,33,34

Lateral lumbar interbody fusion (LIF) through a minimally invasive transpsoas approach22 has recently been used for ASD.1,4,7,24,28 LIF with percutaneous screw fixation is effective for coronal-plane deformities,24 but only small improvements in lumbar lordosis (LL) have been reported (3°–8°).1,4,7,23,24,28 As a result, LIF has only been recommended for mild sagittal correction goals.10 A key shortcoming of these studies was limited use of traditional open posterior (OP) techniques for deformity correction.

LIF is one of many tools we have adopted for the treatment of ASD. In patients with primary ASD of moderate severity, we often combine LIF with a traditional OP approach (Fig. 1). Sagittal correction is enhanced using facet osteotomies and a rod-cantilever technique. It is unclear how this hybrid strategy compares to OP-only surgery for ASD. In this study we assess the deformity correction, complications, and outcomes when LIF is added to an OP approach.

FIG. 1.
FIG. 1.

Preoperative and postoperative standing radiographs showing coronal and sagittal correction using the LIF+OP approach for ASD.

Methods

Patient Population

Following institutional review board approval, departmental databases were searched for all adult thoracolumbar deformity operations ≥ 5 levels performed by a single neurosurgical/orthopedic spine team (the 2 senior authors [C.P.A. and V.D.]) from 2009 to 2014. Deformities in the sagittal and/or coronal plane were included. Deformity cases by other surgeons at our institution were not included. Patients with less than 6 months follow-up, prior lumbar fusion, severe sagittal imbalance (defined as sagittal vertical axis [SVA] > 200 mm or pelvic incidence [PI]–LL > 40°), and those undergoing ALIF were excluded.

The remaining patients were categorized according to their surgical strategy: LIF+OP (LIF followed by OP surgery with facet osteotomies) or OP-only (open posterior surgery with facet or pedicle subtraction osteotomies). There were no specific criteria for selecting one approach over another. Both approaches were used throughout the study period. All LIF cases were performed by the senior author alone (V.D.), and all posterior cases (second stage LIF+OP and OP-only) were performed by the 2 senior authors as a team.

Surgical Technique

The LIF+OP operations were performed under separate anesthesia sessions. In the first stage, multilevel LIF was performed using the Nuvasive extreme lateral interbody fusion system.22 For coronal deformities, the concave side was approached to avoid the iliac crest and maximize the number of interbody grafts. After docking over the lateral annulus through a transpsoas approach, the tubular retractor was translated posteriorly and expanded anteriorly. This maneuver retracted the lumbosacral plexus and maximized anteroposterior exposure. Following discectomy and trial placement, a 10° lordotic implant of maximum safe size was chosen. The polyetheretherketone cage was filled with cellular allograft and inserted into the disc space. Scoliosis radiographs were obtained between stages to gauge the remaining correction needed.

For posterior surgery, the patient was positioned prone on a Jackson table with his or her thighs extended to promote LL. Interspinous ligament resection and Schwab27 Grade 1 facet osteotomies were performed from L-1 to S-1. Additional bone resection (Grade 2 Ponte osteotomy or Grade 3–4 PSO) was performed as necessary. We routinely performed L5–S1 transforaminal lumbar interbody fusion (TLIF) and iliac bolt fixation. Lumbar lordosis was enhanced using a rod-cantilever technique and compression. Local autograft, iliac crest autograft, and corticocancellous chips were applied for fusion, together with bone morphogenetic protein (24 mg for fusions to the lower thoracic spine, 36 mg for fusions to the upper thoracic spine). Patients were brought to the regular surgical floor or intensive care unit (ICU) based on anesthesiologist and surgeon assessment of hemodynamic stability, pain management needs, sedation level, age, and medical comorbidities.

Clinical Assessment

Patients were evaluated in the clinic before surgery and postoperatively at 6 weeks, 3 months, 6 months, 12 months, and yearly thereafter. They were asked to complete health-related quality of life (HRQOL) questionnaires (visual analog scale [VAS] back pain, VAS leg pain, Oswestry Disability Index [ODI], SRS-22, and SF-36). The HRQOL metrics were recorded by research assistants blinded to the study. Standing anteroposterior and lateral 36-inch spinal radiographs were obtained at each visit and reviewed by the attending surgeon.

Data Collection

The medical record was searched for baseline clinical features, operative data, health care resource usage, and immediate and delayed complications. The surgical outcomes database was searched for HRQOL metrics before surgery and at last follow-up.

Radiographic parameters before surgery and at last follow-up were measured by the study authors using Surgimap software. Sagittal parameters were defined as follows. The SVA was defined as the anteroposterior distance between the C-7 centroid and posterosuperior aspect of the S-1 superior endplate. Pelvic tilt (PT) was the angle between a vertical line and a line connecting the midpoint of the S-1 superior endplate to the bicoxofemoral axis. PI was defined as the angle between a line perpendicular to the S-1 superior endplate and a line connecting the midpoint of the S-1 superior endplate to the bicoxofemoral axis. LL was the angle between the L-1 superior endplate and the S-1 superior endplate. PI–LL mismatch was defined as PI minus LL. The coronal vertical axis (CVA) was defined as the lateral distance between the C-7 centroid and central sacral vertical line. All CVA values were recorded as positive to facilitate group-wide comparison. Cobb angles for lumbar and thoracic curves were measured between the most coronally angulated vertebral bodies.

Data Analysis

Changes in HRQOL and radiographic parameters from before surgery to last follow-up were calculated. LIF+OP and OP-only groups were compared with regard to clinical, operative, resource use, complication, HRQOL, and radiographic variables. For numerical variables, means and standard deviations were calculated, and comparisons were made using a 2-tailed Student t-test. Categorical variables were compared using a 2-tailed Fisher's exact test. The OP-only group was subdivided into those undergoing PSO (+PSO) vs facet osteotomy only (−PSO), and the same comparisons were made between LIF+OP and these subgroups.

Results

Clinical and Operative Data

The patients had a mean age of 68 years. Their primary diagnoses were adult degenerative scoliosis and flat back syndrome. Thirty-two LIF+OP and 60 OP-only cases were identified. All patients in the LIF+OP group had Grade 1 facet osteotomies only; none underwent PSO. On average, 3.8 LIFs were performed. Forty-three OP-only patients had Grade 1 or 2 facet osteotomies only, while 17 had PSO. On average, the LIF+OP and OP-only groups had similar baseline features and number of levels fused (Table 1). Patients in the LIF+OP group had significantly greater VAS back pain before surgery (7.2 vs 4.8, p = 0.024). Disability levels were similar (ODI score 50 [LIF+OP] vs 51 [OP-only], p = 0.894).

TABLE 1

Clinical and operative variables*

VariableLIF+OPOP-Only
+PSOp Value−PSOp Value+/− PSOp Value
No. of patients32174360
Clinical variables
  Mean age ± SD66 ± 870 ± 110.17568 ± 80.16469 ± 90.097
  Male (%)6 (19)6 (35)0.29610 (23)0.77816 (27)0.452
  Tobacco (%)1 (3)0 (0)11 (2)11 (2)1
  Mean BMI ± SD28 ± 631 ± 70.23929 ± 60.37130 ± 60.240
  Diabetes (%)1 (3)2 (12)0.2738 (19)0.06910 (17)0.089
  Mean ASA score ± SD2.3 ± 0.52.6 ± 0.50.0682.5 ± 0.50.1372.6 ± 0.50.066
Op variables
  Mean no. of interspaces fused ± SD
    LIF3.8 ± 0.7
    OP10 ± 411 ± 40.21211 ± 40.28611 ± 40.193
  Mean blood loss ± SD (ml)
    LIF130 ± 141
    OP999 ± 8632639 ± 17660.0051457 ± 8630.0841833 ± 13250.005
    Total1129 ± 8502639 ± 17660.0091457 ± 8630.2071833 ± 13250.016
  Mean intraop transfusion volume ± SD (ml)
    LIF0 ± 0
    OP504 ± 5631104 ± 10200.063563 ± 5840.730735 ± 7810.199
    Total504 ± 5631104 ± 10200.063563 ± 5840.730735 ± 7810.199
  Mean surgery time ± SD (min)
    LIF141 ± 31
    OP263 ± 64333 ± 770.011290 ± 550.146304 ± 650.031
    Total404 ± 60333 ± 77<0.001290 ± 55<0.001304 ± 65<0.001

ASA score = American Society of Anesthesiologists physical status classification; BMI = body mass index.

Boldface type indicates statistical significance.

Despite undergoing 2 operations, the LIF+OP group had significantly lower total blood loss (1129 vs 1833 ml, p = 0.016). Total surgery time was longer (404 vs 304 minutes, p < 0.001), but posterior surgery time was significantly shorter (263 vs 304 minutes, p = 0.031; Table 1).

Resource Use, Complications, and Reoperations

The LIF+OP stages were on average 2 days apart, but hospital stays were not significantly increased (9.0 vs 9.3 days, p = 0.691). LIF+OP patients required significantly less ICU care (0.7 vs 2.8 days, p < 0.001) and were less likely to require inpatient rehabilitation after discharge (63% vs 87%, p = 0.015). These findings remained true when +PSO and −PSO OP-only subgroups were separately compared with LIF+OP (Table 2).

TABLE 2

Resource use, complications, and reoperations*

VariableLIF+OPOP-Only
+PSOp Value−PSOp Value+/− PSOp Value
No. of patients32174360
Resource use (%)
  Mean hospital stay ± SD (days)9.0 ± 2.410.4 ± 4.60.2838.9 ± 4.30.8759.3 ± 4.40.691
  Mean ICU stay ± SD (days)0.7 ± 1.23.1 ± 1.9<0.0012.6 ± 1.5<0.0012.8 ± 1.6<0.001
  Discharge to inpatient rehabilitation facility20 (63)16 (94)0.02036 (84)0.05952 (87)0.015
  90-day readmission3 (9)2 (12)13 (7)15 (8)1
Complications (%)
  Any new leg symptom9 (28)7 (41)0.5236 (14)0.15313 (22)0.609
  Pain2 (6)1 (6)10 (0)0.1791 (2)0.276
  Numbness5 (16)6 (35)0.1563 (7)0.2759 (15)1
  Weakness5 (16)4 (24)0.7004 (9)0.4848 (13)0.762
  Leg symptom lasting >6 mos0 (0)1/7 (14)0.4700 (0)11/13 (8)1
  Durotomy0 (0)3 (18)0.03711 (26)0.00214 (23)0.002
  Vascular injury0 (0)0 (0)10 (0)10 (0)1
  Bowel injury0 (0)0 (0)10 (0)10 (0)1
  Blindness0 (0)0 (0)10 (0)10 (0)1
  Death0 (0)0 (0)10 (0)10 (0)1
  Any medical complication5 (16)4 (24)0.70011 (26)0.39615 (25)0.427
  Transfusion reaction0 (0)1 (6)0.3471 (2)12 (3)0.541
  Urinary tract infection2 (6)3 (18)0.3263 (7)16 (10)0.709
  Pneumonia0 (0)1 (6)0.3471 (2)12 (3)0.541
  Ileus3 (9)1 (6)14 (9)15 (8)1
  Thromboembolism0 (0)1 (6)0.3473 (7)0.2564 (7)0.294
  Myocardial infarction0 (0)0 (0)11 (2)11 (2)1
  Stroke0 (0)0 (0)13 (7)0.2563 (5)0.549
  Any surgical complication requiring reoperation8 (25)5 (29)0.74618 (42)0.14923 (38)0.250
  Hematoma0 (0)1 (6)0.3500 (0)11 (2)1
  Infection4 (13)0 (0)0.2843 (7)0.4513 (5)0.232
  Pseudarthrosis2 (6)4 (24)0.16412 (28)0.01916 (27)0.026
  Proximal junctional kyphosis2 (6)1 (6)16 (14)0.4547 (12)0.488
Mean follow-up ± SD (mos)28 ± 1821 ± 130.10027 ± 170.81525 ± 160.462

Boldface type indicates statistical significance.

The incidence of new postoperative leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All new leg symptoms resolved within 6 months, except for persistent weakness and numbness from an epidural hematoma in 1 OP-only patient. LIF+OP patients had significantly lower durotomy rates overall (0% vs 23%, p = 0.002) and when compared with the +PSO and −PSO subgroups (Table 2). LIF+OP patients also had fewer medical complications, but this difference was not significant (16% vs 25%, p = 0.427).

Average follow-up duration was similar between the groups (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis requiring reoperation (6% vs 27%, p = 0.026). Both the +PSO and −PSO subgroups had greater pseudarthrosis than the LIF+OP group. The 2 pseudarthrosis cases with LIF+OP occurred at L5–S1 (where a TLIF had been performed). No interspaces treated with LIF developed pseudarthrosis. Rates of wound infection and proximal junctional kyphosis requiring reoperation were similar between groups (Table 2).

Clinical Outcome Metrics

Table 3 illustrates HRQOL metrics before surgery and at last follow-up. Patients in the LIF+OP group had superior improvement in VAS back pain (mean decrease 4.0 vs 1.9, p = 0.046). They also experienced a greater reduction of disability (mean ODI decrease 21 vs 12, p = 0.035).

TABLE 3

HRQOL metrics*

MetricLIF+OPOP-Only
+PSOp Value−PSOp Value+/− PSOp Value
VAS Back
  Before surgery7.2 ± 1.93.7 ± 4.00.2715.0 ± 3.50.0634.8 ± 3.50.024
  At last follow-up3.2 ± 3.14.3 ± 2.30.4882.5 ± 3.00.5952.9 ± 2.90.803
  Change−4.0 ± 3.10.7 ± 2.10.034−2.5 ± 2.90.161−1.9 ± 3.00.046
VAS Leg
  Before surgery5.6 ± 3.34.7 ± 4.70.7627.0 ± 2.60.1996.6 ± 3.10.390
  At last follow-up2.8 ± 3.35.7 ± 5.10.4434.4 ± 3.70.2284.7 ± 3.90.148
  Change−2.8 ± 3.11.0 ± 4.60.287−2.6 ± 2.90.855−1.9 ± 3.40.444
ODI
  Before surgery50 ± 1852 ± 50.62650 ± 180.98951 ± 150.894
  At last follow-up29 ± 1636 ± 170.26140 ± 220.06939 ± 200.055
  Change−21 ± 13−15 ± 170.404−10 ± 180.029−12 ± 170.035
SRS-22
  Before surgery2.7 ± 0.72.5 ± 0.70.5702.6 ± 0.70.8762.6 ± 0.70.715
  At last follow-up3.6 ± 0.93.4 ± 0.80.4333.4 ± 0.80.4543.4 ± 0.70.380
  Change1.0 ± 1.11.1 ± 1.30.7460.8 ± 0.80.5770.9 ± 1.00.864
SF-36 PCS
  Before surgery32 ± 1126 ± 90.20828 ± 90.28527 ± 90.203
  At last follow-up38 ± 1036 ± 100.63833 ± 100.11933 ± 100.162
  Change6 ± 610 ± 100.4155 ± 90.5426 ± 90.920
SF-36 MCS
  Before surgery43 ± 1843 ± 140.96647 ± 140.44846 ± 140.577
  At last follow-up52 ± 1544 ± 170.33151 ± 140.79649 ± 150.526
  Change9 ± 102 ± 80.0923 ± 150.2163 ± 140.117

MCS = mental component summary; PCS = physical component summary.

All data given as mean ± SD, unless otherwise indicated. Boldface type indicates statistical significance.

Radiographic Parameters

In the coronal plane, LIF+OP provided greater lumbar Cobb angle correction than OP-only surgery (mean decrease 22° ± 13° vs 14° ± 13°, p = 0.010, Table 4). LIF+OP patients had 22° ± 13° restoration of LL, more than OP-only patients as a group (16° ± 11°, p = 0.031). When the OP-only group was subdivided on the basis of osteotomy type, LIF+OP provided an LL gain intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and PSO (29° ± 10°, p = 0.045).

TABLE 4

Sagittal and coronal radiographic parameters*

Radiographic ParameterLIF+OPOP-Only
+PSOp Value−PSOp Value+/− PSOp Value
Sagittal Parameters
  SVA
    Before surgery65 ± 48116 ± 500.00359 ± 450.57074 ± 530.422
    At last follow-up37 ± 3433 ± 410.74339 ± 440.84237 ± 430.976
    Change−28 ± 38−83 ± 500.001−20 ± 470.419−37 ± 550.387
  PT
    Before surgery22 ± 1025 ± 100.29420 ± 90.45421 ± 90.878
    At last follow-up20 ± 819 ± 100.82618 ± 100.55618 ± 100.577
    Change−2 ± 8−6 ± 60.051−2 ± 90.994−3 ± 90.544
  PI
    Before surgery53 ± 1257 ± 110.26050 ± 70.26352 ± 90.7 09
    At last follow-up53 ± 1357 ± 110.23050 ± 80.34152 ± 90.815
    Change0 ± 20 ± 20.4420 ± 20.0980 ± 20.109
  LL
    Before surgery36 ± 1627 ± 140.06837 ± 140.71334 ± 140.695
    At last follow-up57 ± 1156 ± 90.64948 ± 140.00250 ± 130.006
    Change22 ± 1329 ± 100.04511 ± 7<0.00116 ± 110.031
  PI-LL
    Before surgery17 ± 1530 ± 110.00113 ± 120.19718 ± 140.859
    At last follow-up−5 ± 131 ± 100.1063 ± 130.0222 ± 120.019
    Change−22 ± 14−29 ± 100.047−11 ± 8<0.001−15 ± 120.045
Coronal parameters
  CVA
    Before surgery27 ± 2228 ± 270.98625 ± 270.63825 ± 260.715
    At last follow-up16 ± 1522 ± 290.44219 ± 150.47720 ± 190.348
    Change−11 ± 25−5 ± 370.563−6 ± 250.382−6 ± 280.354
  Thoracic Cobb angle
    Before surgery20 ± 1411 ± 100.01519 ± 140.87717 ± 140.378
    At last follow-up8 ± 95 ± 50.1159 ± 80.7878 ± 70.815
    Change−12 ± 11−6 ± 80.038−11 ± 110.684−9 ± 110.329
  Lumbar Cobb angle
    Before surgery35 ± 1821 ± 190.03430 ± 140.25228 ± 160.085
    At last follow-up13 ± 813 ± 120.91214 ± 90.55714 ± 100.690
    Change−22 ± 13−9 ± 110.001−16 ± 130.066−14 ± 130.010

All data given as mean ± SD, unless otherwise indicated. Boldface type indicates statistical significance.

Discussion

ASD is associated with lumbar disc degeneration,25 leading to malalignment in the sagittal plane (flat back syndrome), coronal plane (adult degenerative scoliosis), or frequently a combination of the two. Positive sagittal balance is a strong predictor of pain and disability, both without surgery and after fusion.16 Restoration of sagittal balance is the primary goal of ASD surgery.13,16 Coronal realignment has less effect on overall outcome13 but is important for relief of neurological symptoms related to foraminal collapse.

Lumbar disc degeneration is a major barrier to sagittal correction in ASD. Mild, flexible ASD can be treated with facet osteotomies (Schwab27 Grade 1 or 2) and compression across posterior instrumentation. However, facet osteotomies are often inadequate because stiff, collapsed disc spaces limit posterior shortening. Moderate or severe ASD typically requires anterior disc space augmentation and/or posterior 3-column osteotomy.6

ALIF restores disc height and serves as a reliable foundation for circumferential spinal fusion. The spinal portion of the operation is not technically demanding. However, ALIF carries many access-related risks including arterial thrombosis, venous laceration, deep vein thrombosis, bowel obstruction, hernia, ureter injury, lymphedema, lymphocele, and retrograde ejaculation.29,34,35 Effective deformity correction can often be achieved without ALIF and the associated risks, leading many authors to question its routine use in ASD.11,20

PSO (Schwab27 Grade 3 of 4) provides excellent sagittal correction for severe ASD, with up to 35° LL restoration and 10-cm posterior trunk translation.32 Even in experienced hands, PSO carries significant surgical risks, both immediate (neurological deficit, durotomy) and delayed (infection, pseudarthrosis).5,15,17,33 PSO is resource intense, because high blood loss mandates aggressive resuscitation and postoperative intensive care. Medical complications are not uncommon and add to treatment costs. Complications after spinal fusion increase with age.8 Many patients who undergo ASD are in their 7th or 8th decades, driving a search for less invasive treatment strategies.

Lateral LIF through a transpsoas approach has been used for degenerative disease over the past decade.22 Like ALIF, it restores disc height and indirectly decompresses the neural foramina, but it is less invasive and requires no bowel or great vessel retraction.3 Direct muscle trauma can cause isolated psoas weakness, and lumbosacral plexus irritation can cause leg pain, weakness, or numbness.18,19,21 The majority of leg symptoms resolve within 6–12 months.9,21,26 There are rare reports of great vessel injury and pseudohernia from abdominal wall denervation.2,7,12 Overall, LIF is believed to have a lower complication profile compared with open anterior or posterior spinal fusion.3,19,24

More recently, LIF has been adopted in the treatment of ASD.1,4,7,24,28 LIF is effective for coronal plane deformities,24 but only mild improvement in sagittal alignment has been reported. Acosta et al. reported a mean 11.7° lumbar coronal Cobb angle correction in patients with degenerative scoliosis.1 Mean LL restoration was only 4.1°, and there was no significant improvement in SVA.1 Park et al. reported more LL restoration when LIF was coupled with open instead of percutaneous screw fixation (8° vs 3°, respectively).23 Other studies have reported modest improvements in LL (5°–8°) and SVA (0–2.5 cm), with coronal correction more substantial.4,7,24,28 Consequently, LIF has been recommended for only small sagittal correction goals (10° in LL and 5 cm in SVA).10 A key shortcoming of these studies was limited use of traditional open posterior techniques for deformity correction.

In contrast to other reports of LIF with posterior fixation, our LIF+OP approach provided substantial LL restoration (22° ± 13°).”1,4,7,23,24,28 Several factors may have played a role in these results. In the lateral stage, we maximized LIF graft size in all 3 dimensions and treated as many levels as safely possible. In the posterior stage, we maximized thigh extension during positioning to promote LL. We resected the interspinous ligaments and performed Grade 1 osteotomies from L-1 to S-1 to loosen the spine. We employed a rod-cantilever technique and compression to enhance sagittal correction. Many reports of LIF for ASD have used percutaneous screw fixation,1,7 which is less conducive to facet/ligament resection and rod reduction techniques. The few studies using open fixation did not specify the frequency or number of facet osteotomies.4,23,28,30

The LIF+OP approach also provided more LL restoration than our OP-only operations without PSO (11° ± 7°). Most of our patients were in their 7th or 8th decades with stiff, collapsed discs. In this population, it is intuitive that anterior release and disc height restoration would augment correction achievable with facet resection and rod compression. LIF+OP surgery provided effective coronal plane realignment, with a 22° ± 13° reduction in lumbar Cobb angle. The hybrid technique corrected moderately severe deformities that would have otherwise required multilevel ALIF or PSO. A minimally invasive lateral approach helped us avoid complications and resource use associated with these procedures.

The hybrid technique was associated with less morbidity, faster recovery, and superior outcomes compared with OP-only surgery. Patients who underwent LIF+OP had less blood loss, shorter posterior surgery duration, and lower durotomy rates. We attribute these findings to the need for only Grade 1 facet osteotomies (no entry into the epidural space). The LIF+OP group had fewer medical complications, although the difference was not statistically significant. New leg symptoms from psoas or plexus irritation did occur in 28% of patients (versus 22% with OP-only), but all cases in the LIF+OP group resolved within 6 months. The LIF+OP group had shorter ICU stays and was less likely to require inpatient rehabilitation after discharge. These patients had dramatically less pseudarthrosis requiring reoperation (6% vs 27%). This finding is likely related to the circumferential fusion provided by the combined approach. Patients who underwent LIF+OP had superior improvement in back pain and disability at last follow-up. Most of these findings remained true when +PSO and −PSO subgroups were separately compared with the LIF+OP group, although some statistical significance was lost due to limited patient numbers (Tables 14).

Uddin et al. reviewed 71 patients undergoing either an open or minimally invasive surgery (MIS) approach for ASD.31 MIS patients had lower hospitalization cost, less blood loss, and shorter length of stay, while patients undergoing an open approach had superior long-term pain relief and deformity correction.31 From a health care resource standpoint, our hybrid technique appears to combine the benefits of open surgery (effectiveness, durability) and MIS (treatment risk, recovery). LIF+OP surgery does involve higher upfront implant costs, and further analysis of total treatment expense is needed.

LIF+OP surgery is only appropriate for a subset of patients with ASD. For severe sagittal imbalance, LIF+OP would typically provide inadequate correction, and we pursue 3-column osteotomy in this population. Our data confirmed greater SVA and LL correction with PSO. In patients with iatrogenic flat-back deformity, the prior fusion mass and instrumentation typically impair anterior reconstruction with LIF. Patients with prior retroperitoneal surgery or radiation are not ideal candidates for a transpsoas approach. In most patients with ASD of moderate severity and no prior surgery, we have found LIF+OP to be a safe and effective option. Advances in LIF techniques may broaden their applicability for use in severe deformity. Anterior longitudinal ligament release with hyperlordotic cage placement has been shown to increase segmental lordosis by 17°.14 At the moment, this technique has a steep learning curve, with potential for catastrophic vascular injury unless performed in experienced hands.14

This study has several limitations. It is a retrospective review of patients who underwent different treatments without specific selection criteria. Our results may have been confounded by variables other than the operations themselves. On average, the 2 groups had similar clinical and radiographic features before surgery. However, the OP-only group was composed of a heterogeneous population with varying parameters (+PSO and −PSO patients). Therefore, we separately compared LIF+OP against +PSO and −PSO subgroups of the OP-only population. We found that LIF+OP remained superior in many comparisons against the +PSO and −PSO subgroups (Tables 14); yet, the study is prone to selection bias because the groups were not randomized or matched. We used several exclusion criteria to promote similar study populations. We excluded revision spinal fusions because iatrogenic flat-back syndrome is typically not conducive to an LIF+OP approach. We excluded severe sagittal deformities (SVA > 200 mm or PI–LL > 40°) for the same reason. We excluded deformity operations performed by other surgeons at our institution to eliminate surgeon differences in indications, technique, and management. Despite relatively small treatment groups, we observed significant differences in deformity correction, resource use, complication profile, and clinical outcomes. We cannot credit the lower pseudarthrosis rate to LIF per se, but rather to the high number of interbody fusions we achieved with this technique (mean 3.8 LIFs + 1 TLIF with LIF+OP, vs 1 TLIF with OP-only). Nevertheless, our data suggest that LIF is a safe and effective method of achieving anterior release, disc height restoration, and solid interbody fusion over many levels of the lumbar spine. Multilevel LIF avoided the epidural bleeding, durotomies, nerve retraction, and limited correction associated with TLIF, as well as the approach-related risks of ALIF. Our mean follow-up duration was 28 months in the LIF+OP group versus 25 months in the OP-only group. This was adequate to capture most delayed complications, but it is possible that some cases of late infection or pseudarthrosis were missed. Larger, prospective studies with matched cohorts and longer follow-up durations are needed to corroborate our results.

Conclusions

LIF+OP surgery is an effective strategy for ASD of moderate severity. Except for severe rigid deformities requiring 3-column osteotomy, LIF+OP provided more sagittal and coronal correction than our OP-only operations. Patients treated with the hybrid approach had faster recovery, fewer immediate and delayed complications, and greater relief of back pain and disability.

References

  • 1

    Acosta FLLiu JSlimack NMoller DFessler RKoski 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 15:92962011

    • Search Google Scholar
    • Export Citation
  • 2

    Aichmair AFantini GAGarvin SBeckman JGirardi FP: Aortic perforation during lateral lumbar interbody fusion. J Spinal Disord Tech 28:71752015

    • Search Google Scholar
    • Export Citation
  • 3

    Alimi MHofstetter CPCong GTTsiouris AJJames ARPaulo D: Radiological and clinical outcomes following extreme lateral interbody fusion. J Neurosurg Spine 20:6236352014

    • Search Google Scholar
    • Export Citation
  • 4

    Baghdadi YMLarson ANDekutoski MBCui QSebastian ASArmitage BM: Sagittal balance and spinopelvic parameters after lateral lumbar interbody fusion for degenerative scoliosis: a case-control study. Spine (Phila Pa 1976) 39:E166E1732014

    • Search Google Scholar
    • Export Citation
  • 5

    Baron EMAlbert TJ: Medical complications of surgical treatment of adult spinal deformity and how to avoid them. Spine (Phila Pa 1976) 31:19 SupplS106S1182006

    • Search Google Scholar
    • Export Citation
  • 6

    Bradford DSTay BKHu SS: Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine (Phila Pa 1976) 24:261726291999

    • Search Google Scholar
    • Export Citation
  • 7

    Caputo AMMichael KWChapman TMJennings JMHubbard EWIsaacs RE: Extreme lateral interbody fusion for the treatment of adult degenerative scoliosis. J Clin Neurosci 20:155815632013

    • Search Google Scholar
    • Export Citation
  • 8

    Carreon LYPuno RMDimar JR IIGlassman SDJohnson JR: Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am 85-A:208920922003

    • Search Google Scholar
    • Export Citation
  • 9

    Castro COliveira LAmaral RMarchi LPimenta L: Is the lateral transpsoas approach feasible for the treatment of adult degenerative scoliosis?. Clin Orthop Relat Res 472:177617832014

    • Search Google Scholar
    • Export Citation
  • 10

    Costanzo GZoccali CMaykowski PWalter CMSkoch JBaaj AA: The role of minimally invasive lateral lumbar interbody fusion in sagittal balance correction and spinal deformity. Eur Spine J 23:Suppl 66997042014

    • Search Google Scholar
    • Export Citation
  • 11

    Crandall DGRevella J: Transforaminal lumbar interbody fusion versus anterior lumbar interbody fusion as an adjunct to posterior instrumented correction of degenerative lumbar scoliosis: three year clinical and radiographic outcomes. Spine (Phila Pa 1976) 34:212621332009

    • Search Google Scholar
    • Export Citation
  • 12

    Dakwar ELe TVBaaj AALe AXSmith WDAkbarnia BA: Abdominal wall paresis as a complication of minimally invasive lateral transpsoas interbody fusion. Neurosurg Focus 31:4E182011

    • Search Google Scholar
    • Export Citation
  • 13

    Daubs MDLenke LGBridwell KHKim YJHung MCheh G: Does correction of preoperative coronal imbalance make a difference in outcomes of adult patients with deformity?. Spine (Phila Pa 1976) 38:4764832013

    • Search Google Scholar
    • Export Citation
  • 14

    Deukmedjian ARDakwar EAhmadian ASmith DAUribe JS: Early outcomes of minimally invasive anterior longitudinal ligament release for correction of sagittal imbalance in patients with adult spinal deformity. ScientificWorldJournal 2012:7896982012

    • Search Google Scholar
    • Export Citation
  • 15

    Dickson DDLenke LGBridwell KHKoester LA: Risk factors for and assessment of symptomatic pseudarthrosis after lumbar pedicle subtraction osteotomy in adult spinal deformity. Spine (Phila Pa 1976) 39:119011952014

    • Search Google Scholar
    • Export Citation
  • 16

    Glassman SDBerven SBridwell KHorton WDimar JR: Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976) 30:6826882005

    • Search Google Scholar
    • Export Citation
  • 17

    Hassanzadeh HJain AEl Dafrawy MHAin MCMesfin ASkolasky RL: Three-column osteotomies in the treatment of spinal deformity in adult patients 60 years old and older: outcome and complications. Spine (Phila Pa 1976) 38:7267312013

    • Search Google Scholar
    • Export Citation
  • 18

    Isaacs REHyde JGoodrich JARodgers WBPhillips 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) 35:26 SupplS322S3302010

    • Search Google Scholar
    • Export Citation
  • 19

    Khajavi KShen AY: Two-year radiographic and clinical outcomes of a minimally invasive, lateral, transpsoas approach for anterior lumbar interbody fusion in the treatment of adult degenerative scoliosis. Eur Spine J 23:121512232014

    • Search Google Scholar
    • Export Citation
  • 20

    Lippman CRSpence CAYoussef ASCahill DW: Correction of adult scoliosis via a posterior-only approach. Neurosurg Focus 14:1e52003

  • 21

    Lykissas MGAichmair AHughes APSama AALebl DRTaher F: Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J 14:7497582014

    • Search Google Scholar
    • Export Citation
  • 22

    Ozgur BMAryan HEPimenta LTaylor WR: Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:4354432006

    • Search Google Scholar
    • Export Citation
  • 23

    Park PWang MYLafage VNguyen SZiewacz JOkonkwo DO: Comparison of two minimally invasive surgery strategies to treat adult spinal deformity. J Neurosurg Spine 22:3743802015

    • Search Google Scholar
    • Export Citation
  • 24

    Phillips FMIsaacs RERodgers WBKhajavi KTohmeh AGDeviren V: Adult degenerative scoliosis treated with XLIF: clinical and radiographical results of a prospective multicenter study with 24-month follow-up. Spine (Phila Pa 1976) 38:185318612013

    • Search Google Scholar
    • Export Citation
  • 25

    Pritchett JWBortel DT: Degenerative symptomatic lumbar scoliosis. Spine (Phila Pa 1976) 18:7007031993

  • 26

    Pumberger MHughes APHuang RRSama AACammisa FPGirardi FP: Neurologic deficit following lateral lumbar interbody fusion. Eur Spine J 21:119211992012

    • Search Google Scholar
    • Export Citation
  • 27

    Schwab FBlondel BChay EDemakakos JLenke LTropiano P: The comprehensive anatomical spinal osteotomy classification. Neurosurgery 76:Suppl 1S33S412015

    • Search Google Scholar
    • Export Citation
  • 28

    Tempel ZJGandhoke GSBonfield CMOkonkwo DOKanter AS: Radiographic and clinical outcomes following combined lateral lumbar interbody fusion and posterior segmental stabilization in patients with adult degenerative scoliosis. Neurosurg Focus 36:5E112014

    • Search Google Scholar
    • Export Citation
  • 29

    Than KDWang ACRahman SUWilson TJValdivia JMPark P: Complication avoidance and management in anterior lumbar interbody fusion. Neurosurg Focus 31:4E62011

    • Search Google Scholar
    • Export Citation
  • 30

    Tormenti MJMaserati MBBonfield CMOkonkwo DOKanter AS: Complications and radiographic correction in adult scoliosis following combined transpsoas extreme lateral interbody fusion and posterior pedicle screw instrumentation. Neurosurg Focus 28:3E72010

    • Search Google Scholar
    • Export Citation
  • 31

    Uddin OMHaque RSugrue PAAhmed YMEl Ahmadieh TYPress JM: Cost minimization in treatment of adult degenerative scoliosis. J Neurosurg Spine 23:7988062015

    • Search Google Scholar
    • Export Citation
  • 32

    Wang MYBerven SH: Lumbar pedicle subtraction osteotomy. Neurosurgery 60:ONS140ONS1462007

  • 33

    Williams EL: Postoperative blindness. Anesthesiol Clin North America 20:605622viii2002

  • 34

    Wood KBDevine JFischer DDettori JRJanssen M: Vascular injury in elective anterior lumbosacral surgery. Spine (Phila Pa 1976) 35:9 SupplS66S752010

    • Search Google Scholar
    • Export Citation
  • 35

    Zdeblick TADavid SM: A prospective comparison of surgical approach for anterior L4–L5 fusion: laparoscopic versus mini anterior lumbar interbody fusion. Spine (Phila Pa 1976) 25:268226872000

    • Search Google Scholar
    • Export Citation

Disclosures

Christopher Ames, MD, is a consultant for DePuy, Stryker, and Medtronic; receives royalties from Biomet Spine and Stryker; has stock/stock options with Doctors Research Group; and has a patent with Fish & Richardson, P.C. Vedat Deviren, MD, is a consultant for NuVasive and Guidepoint.

Author Contributions

Conception and design: all authors. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Strom. Statistical analysis: Strom. Study supervision: Deviren.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Correspondence Russell G. Strom, Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Ave., MU320W, San Francisco, CA 94143-0728. email: russell.strom@ucsf.edu.

INCLUDE WHEN CITING Published online June 24, 2016; DOI: 10.3171/2016.4.SPINE16157.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Preoperative and postoperative standing radiographs showing coronal and sagittal correction using the LIF+OP approach for ASD.

References

  • 1

    Acosta FLLiu JSlimack NMoller DFessler RKoski 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 15:92962011

    • Search Google Scholar
    • Export Citation
  • 2

    Aichmair AFantini GAGarvin SBeckman JGirardi FP: Aortic perforation during lateral lumbar interbody fusion. J Spinal Disord Tech 28:71752015

    • Search Google Scholar
    • Export Citation
  • 3

    Alimi MHofstetter CPCong GTTsiouris AJJames ARPaulo D: Radiological and clinical outcomes following extreme lateral interbody fusion. J Neurosurg Spine 20:6236352014

    • Search Google Scholar
    • Export Citation
  • 4

    Baghdadi YMLarson ANDekutoski MBCui QSebastian ASArmitage BM: Sagittal balance and spinopelvic parameters after lateral lumbar interbody fusion for degenerative scoliosis: a case-control study. Spine (Phila Pa 1976) 39:E166E1732014

    • Search Google Scholar
    • Export Citation
  • 5

    Baron EMAlbert TJ: Medical complications of surgical treatment of adult spinal deformity and how to avoid them. Spine (Phila Pa 1976) 31:19 SupplS106S1182006

    • Search Google Scholar
    • Export Citation
  • 6

    Bradford DSTay BKHu SS: Adult scoliosis: surgical indications, operative management, complications, and outcomes. Spine (Phila Pa 1976) 24:261726291999

    • Search Google Scholar
    • Export Citation
  • 7

    Caputo AMMichael KWChapman TMJennings JMHubbard EWIsaacs RE: Extreme lateral interbody fusion for the treatment of adult degenerative scoliosis. J Clin Neurosci 20:155815632013

    • Search Google Scholar
    • Export Citation
  • 8

    Carreon LYPuno RMDimar JR IIGlassman SDJohnson JR: Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am 85-A:208920922003

    • Search Google Scholar
    • Export Citation
  • 9

    Castro COliveira LAmaral RMarchi LPimenta L: Is the lateral transpsoas approach feasible for the treatment of adult degenerative scoliosis?. Clin Orthop Relat Res 472:177617832014

    • Search Google Scholar
    • Export Citation
  • 10

    Costanzo GZoccali CMaykowski PWalter CMSkoch JBaaj AA: The role of minimally invasive lateral lumbar interbody fusion in sagittal balance correction and spinal deformity. Eur Spine J 23:Suppl 66997042014

    • Search Google Scholar
    • Export Citation
  • 11

    Crandall DGRevella J: Transforaminal lumbar interbody fusion versus anterior lumbar interbody fusion as an adjunct to posterior instrumented correction of degenerative lumbar scoliosis: three year clinical and radiographic outcomes. Spine (Phila Pa 1976) 34:212621332009

    • Search Google Scholar
    • Export Citation
  • 12

    Dakwar ELe TVBaaj AALe AXSmith WDAkbarnia BA: Abdominal wall paresis as a complication of minimally invasive lateral transpsoas interbody fusion. Neurosurg Focus 31:4E182011

    • Search Google Scholar
    • Export Citation
  • 13

    Daubs MDLenke LGBridwell KHKim YJHung MCheh G: Does correction of preoperative coronal imbalance make a difference in outcomes of adult patients with deformity?. Spine (Phila Pa 1976) 38:4764832013

    • Search Google Scholar
    • Export Citation
  • 14

    Deukmedjian ARDakwar EAhmadian ASmith DAUribe JS: Early outcomes of minimally invasive anterior longitudinal ligament release for correction of sagittal imbalance in patients with adult spinal deformity. ScientificWorldJournal 2012:7896982012

    • Search Google Scholar
    • Export Citation
  • 15

    Dickson DDLenke LGBridwell KHKoester LA: Risk factors for and assessment of symptomatic pseudarthrosis after lumbar pedicle subtraction osteotomy in adult spinal deformity. Spine (Phila Pa 1976) 39:119011952014

    • Search Google Scholar
    • Export Citation
  • 16

    Glassman SDBerven SBridwell KHorton WDimar JR: Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine (Phila Pa 1976) 30:6826882005

    • Search Google Scholar
    • Export Citation
  • 17

    Hassanzadeh HJain AEl Dafrawy MHAin MCMesfin ASkolasky RL: Three-column osteotomies in the treatment of spinal deformity in adult patients 60 years old and older: outcome and complications. Spine (Phila Pa 1976) 38:7267312013

    • Search Google Scholar
    • Export Citation
  • 18

    Isaacs REHyde JGoodrich JARodgers WBPhillips 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) 35:26 SupplS322S3302010

    • Search Google Scholar
    • Export Citation
  • 19

    Khajavi KShen AY: Two-year radiographic and clinical outcomes of a minimally invasive, lateral, transpsoas approach for anterior lumbar interbody fusion in the treatment of adult degenerative scoliosis. Eur Spine J 23:121512232014

    • Search Google Scholar
    • Export Citation
  • 20

    Lippman CRSpence CAYoussef ASCahill DW: Correction of adult scoliosis via a posterior-only approach. Neurosurg Focus 14:1e52003

  • 21

    Lykissas MGAichmair AHughes APSama AALebl DRTaher F: Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J 14:7497582014

    • Search Google Scholar
    • Export Citation
  • 22

    Ozgur BMAryan HEPimenta LTaylor WR: Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:4354432006

    • Search Google Scholar
    • Export Citation
  • 23

    Park PWang MYLafage VNguyen SZiewacz JOkonkwo DO: Comparison of two minimally invasive surgery strategies to treat adult spinal deformity. J Neurosurg Spine 22:3743802015

    • Search Google Scholar
    • Export Citation
  • 24

    Phillips FMIsaacs RERodgers WBKhajavi KTohmeh AGDeviren V: Adult degenerative scoliosis treated with XLIF: clinical and radiographical results of a prospective multicenter study with 24-month follow-up. Spine (Phila Pa 1976) 38:185318612013

    • Search Google Scholar
    • Export Citation
  • 25

    Pritchett JWBortel DT: Degenerative symptomatic lumbar scoliosis. Spine (Phila Pa 1976) 18:7007031993

  • 26

    Pumberger MHughes APHuang RRSama AACammisa FPGirardi FP: Neurologic deficit following lateral lumbar interbody fusion. Eur Spine J 21:119211992012

    • Search Google Scholar
    • Export Citation
  • 27

    Schwab FBlondel BChay EDemakakos JLenke LTropiano P: The comprehensive anatomical spinal osteotomy classification. Neurosurgery 76:Suppl 1S33S412015

    • Search Google Scholar
    • Export Citation
  • 28

    Tempel ZJGandhoke GSBonfield CMOkonkwo DOKanter AS: Radiographic and clinical outcomes following combined lateral lumbar interbody fusion and posterior segmental stabilization in patients with adult degenerative scoliosis. Neurosurg Focus 36:5E112014

    • Search Google Scholar
    • Export Citation
  • 29

    Than KDWang ACRahman SUWilson TJValdivia JMPark P: Complication avoidance and management in anterior lumbar interbody fusion. Neurosurg Focus 31:4E62011

    • Search Google Scholar
    • Export Citation
  • 30

    Tormenti MJMaserati MBBonfield CMOkonkwo DOKanter AS: Complications and radiographic correction in adult scoliosis following combined transpsoas extreme lateral interbody fusion and posterior pedicle screw instrumentation. Neurosurg Focus 28:3E72010

    • Search Google Scholar
    • Export Citation
  • 31

    Uddin OMHaque RSugrue PAAhmed YMEl Ahmadieh TYPress JM: Cost minimization in treatment of adult degenerative scoliosis. J Neurosurg Spine 23:7988062015

    • Search Google Scholar
    • Export Citation
  • 32

    Wang MYBerven SH: Lumbar pedicle subtraction osteotomy. Neurosurgery 60:ONS140ONS1462007

  • 33

    Williams EL: Postoperative blindness. Anesthesiol Clin North America 20:605622viii2002

  • 34

    Wood KBDevine JFischer DDettori JRJanssen M: Vascular injury in elective anterior lumbosacral surgery. Spine (Phila Pa 1976) 35:9 SupplS66S752010

    • Search Google Scholar
    • Export Citation
  • 35

    Zdeblick TADavid SM: A prospective comparison of surgical approach for anterior L4–L5 fusion: laparoscopic versus mini anterior lumbar interbody fusion. Spine (Phila Pa 1976) 25:268226872000

    • Search Google Scholar
    • Export Citation

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