Complications for minimally invasive lateral interbody arthrodesis: a systematic review and meta-analysis comparing prepsoas and transpsoas approaches

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OBJECTIVE

Minimally invasive anterolateral retroperitoneal approaches for lumbar interbody arthrodesis have distinct advantages attractive to spine surgeons. Prepsoas or transpsoas trajectories can be employed with differing complication profiles because of the inherent anatomical differences encountered in each approach. The evidence comparing them remains limited because of poor quality data. Here, the authors sought to systematically review the available literature and perform a meta-analysis comparing the two techniques.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A database search was used to identify eligible studies. Prepsoas and transpsoas studies were compiled, and each study was assessed for inclusion criteria. Complication rates were recorded and compared between approach groups. Studies incorporating an analysis of postoperative subsidence and pseudarthrosis rates were also assessed and compared.

RESULTS

For the prepsoas studies, 20 studies for the complications analysis and 8 studies for the pseudarthrosis outcomes analysis were included. For the transpsoas studies, 39 studies for the complications analysis and 19 studies for the pseudarthrosis outcomes analysis were included. For the complications analysis, 1874 patients treated via the prepsoas approach and 4607 treated with the transpsoas approach were included. In the transpsoas group, there was a higher rate of transient sensory symptoms (21.7% vs 8.7%, p = 0.002), transient hip flexor weakness (19.7% vs 5.7%, p < 0.001), and permanent neurological weakness (2.8% vs 1.0%, p = 0.005). A higher rate of sympathetic nerve injury was seen in the prepsoas group (5.4% vs 0.0%, p = 0.03). Of the nonneurological complications, major vascular injury was significantly higher in the prepsoas approach (1.8% vs 0.4%, p = 0.01). There was no difference in urological or peritoneal/bowel injury, postoperative ileus, or hematomas (all p > 0.05). A higher infection rate was noted for the transpsoas group (3.1% vs 1.1%, p = 0.01). With regard to postoperative fusion outcomes, similar rates of subsidence (12.2% prepsoas vs 13.8% transpsoas, p = 0.78) and pseudarthrosis (9.9% vs 7.5%, respectively, p = 0.57) were seen between the groups at the last follow-up.

CONCLUSIONS

Complication rates vary for the prepsoas and transpsoas approaches owing to the variable retroperitoneal anatomy encountered during surgical dissection. While the risks of a lasting motor deficit and transient sensory disturbances are higher for the transpsoas approach, there is a reciprocal reduction in the risks of major vascular injury and sympathetic nerve injury. These results can facilitate informed decision-making and tailored surgical planning regarding the choice of minimally invasive anterolateral access to the spine.

ABBREVIATIONS DLIF = direct lateral interbody fusion; LLIF = lateral lumbar interbody fusion; OLIF = oblique lateral interbody fusion; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; XLIF = extreme lateral interbody fusion.

Article Information

Correspondence Corey T. Walker: Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ. corey.walker@barrowbrainandspine.com.

INCLUDE WHEN CITING Published online January 25, 2019; DOI: 10.3171/2018.9.SPINE18800.

C.T.W. and S.H.F. contributed equally to this work.

Disclosures Dr. Uribe receives consulting fees and royalties from NuVasive Medical Inc. and is a consultant for Masonix Inc. and SI Bone Inc. Dr. Turner receives consulting fees from NuVasive Medical Inc. and SeaSpine Inc. Dr. Porter is the owner and founder of Medical Memory Inc. The other authors have no competing interests to disclose related to this study.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Anatomical illustration depicting the critical visceral, vascular, muscular, and neural structures at risk during the approach of minimally invasive retroperitoneal interbody arthrodesis procedures. Copyright Barrow Neurological Institute. Published with permission.

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    Flowchart demonstrating systematic review of the literature, study selection, and inclusion for analysis for the prepsoas approach. Data added to the PRISMA template (from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097) under the terms of the Creative Commons Attribution License. Figure is available in color online only.

  • View in gallery

    Flowchart demonstrating systematic review of the literature, study selection, and inclusion for analysis for the transpsoas approach. Data added to the PRISMA template (from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097) under the terms of the Creative Commons Attribution License. Figure is available in color online only.

  • View in gallery

    Forest plot of complication rates for both the prepsoas and transpsoas approaches. Data are represented as the proportion of patients with that complication and the 95% confidence interval. Figure is available in color online only.

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