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This figure illustrates the occurrence of sensory deficits in each distribution zone at different time points
Source publication
Lateral lumbar interbody fusion (LLIF) is a minimally invasive technique that has gained growing interest in recent years. We performed a retrospective review of the medical records and operative reports of patients undergoing LLIF between March 2006 and December 2009. We seek to identify the incidence and nature of neurological deficits following...
Contexts in source publication
Context 1
... found sensory deficits at 6 weeks of 28.7% (n = 70), 13.1% at 12 weeks (n = 32), 5.7% at 6 months (n = 14), and 1.6% at 12 months (n = 4). The detailed analysis of the sensory deficits is depicted in Fig. 1. Not only did the total number of sensory deficits decrease over time, but a reduc- tion of deficit in each nerve zone was also observed. The rate of anterior groin/thigh pain per 100 patients was 41% (n = 101) at 6 weeks, 16% (n = 39) at 12 weeks, 3.7% (n = 9) at 6 months, and 0.8% (n = 2) at 12 months (Fig. ...
Context 2
... parameters for safe retraction of psoas/lumbar plexus have not been defined. In our multi- variate regression analysis, operative involvement of L4-5 did not increase the risk of either a lumbar plexus motor deficit or psoas muscle mechanical deficit (Tables 1, 2). However, increased odds-ratios and a trend towards sig- nificance were observed for both and could indicate that our analysis might be underpowered. ...
Citations
... It is associated with a low risk of vascular, visceral, and dural injuries (29). Due to the proximity of the lumbar plexus within or beneath the psoas muscle (30), the transpsoas approach has been associated with neurologically adverse complications (31)(32)(33). The risk of persistent motor deficits following LIF has shown to be increased with utilizing bone morphogenetic protein-2 as a bone graft substitute (32). ...
... Después de una selección inicial, la aplicación de los criterios de inclusión y exclusión, y la eliminación de los duplicados, se incluyeron y evaluaron integralmente 18 estudios. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] dIscusIón En su primera publicación sobre este procedimiento, en 2006, Ozgur y cols. 1 no comunicaron complicaciones en los primeros 13 pacientes tratados. Sin embargo, estas fueron apareciendo a medida que el procedimiento fue ganando popularidad. ...
... La mayoría de las lesiones se producen al atravesar el psoas con los dilatadores o con el distractor 26 y se ha comprobado que el tiempo de permanencia en posición abierta tiene una relación directa con la tasa de lesión neurológica posoperatoria. 3,[8][9][10]27 El nivel L4-L5 es el más propenso a sufrir esta lesión, ya que, aproximadamente en el 44% de los casos, las estructuras nerviosas cruzan a nivel del campo quirúrgico ideal teórico (Figura 1). 23 Pumberger y cols. ...
... Standard, nonendoscopic LLIF surgery carries the risk of lumbar plexus and psoas motor deficits as a result of prolonged muscle retraction. 13,14 Studies have reported incidences of >25% for immediate, transient postoperative neurologic, and motor deficits, with an incidence of 2.9% to 4.1% for persistent neurologic deficits and 5% for femoral nerve injury. [14][15][16][17][18] While the majority of these complications resolve in the 12 to 18 months following surgery, their presence and impact on the patient should not be overlooked. ...
... 13,14 Studies have reported incidences of >25% for immediate, transient postoperative neurologic, and motor deficits, with an incidence of 2.9% to 4.1% for persistent neurologic deficits and 5% for femoral nerve injury. [14][15][16][17][18] While the majority of these complications resolve in the 12 to 18 months following surgery, their presence and impact on the patient should not be overlooked. ...
Background:
Our objective is to describe a minimally invasive endoscopic surgical technique for performing lateral lumbar interbody fusion (LLIF). LLIF is a common approach to lumbar fusion in cases of degenerative lumbar disease; however, complications associated with psoas and lumbar plexus injury sometimes arise. The endoscopic modification presented here diminishes the requirement for sustained muscle retraction, minimizing complication risk while allowing for adequate decompression in select cases.
Methods:
Endoscopic LLIF (ELLIF) was performed in 3 patients from 2019 to 2021. Surgeries were performed in the lateral position under general anesthesia with neurophysiological monitoring. Discectomy, endplate preparation, and harvesting of iliac crest bone were performed through a working channel endoscope. The introduction of an interbody cage (Joimax EndoLIF) was performed over a nitinol blunt-tip wire (Joimax). No expandable blade retractors were required.
Results:
At 2-year follow-up of these 3 patients, the mean visual analog scale (VAS) score for leg pain improved from 9.3 to 1.7, and the mean Oswestry Disability Index (ODI) score improved from 40 to 8.3. There were no complications, readmissions, or recurrence of symptoms during the 2-year follow-up period. Patients spent an average of 36 hours in the hospital postoperatively and returned to normal daily activities after an average of 48 days.
Conclusions:
A minimally invasive modification to the LLIF procedure is presented that offers several potential advantages due to the application of endoscopic techniques: reduced muscle retraction, smaller incision, and the opportunity to perform both indirect decompression and endoscopically visualized discectomy in the same fusion procedure.
Clinical relevance:
The proposed endoscopic lateral lumbar interbody fusion and decompression is a minimally invasive technique that may provide patients with minimal complications, quick recovery, and good functional recovery.
... potentially cause posterior compression when significant lordosis is created. [9][10][11][12][13][14] Intraoperative neuromonitoring (IONM) is a multimodal electrophysiological technique that measures somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), and electromyography (EMG) activity to evaluate neurophysiological integrity during surgery. [15][16][17][18] IONM has become popular because of its ability to aid surgeons in identifying intraoperative nerve injury in a timely manner and provide them with the opportunity to reverse or correct a potentially precipitating event. ...
... This phenomenon has been described in an array of studies on deficits following lateral access surgery, where etiologies included not only direct transection/injury to the nerves during dissection, but also stretch from the retractor itself. 10 For example, Houten et al. reported 2 cases of patients experiencing a motor deficit following LLIF. 24 Despite this, however, no IONM changes were detected during the operations. ...
OBJECTIVE
Intraoperative neuromonitoring (IONM) has become commonplace in assessing neurological integrity during lateral approaches to lumbar interbody fusion surgeries. Neuromonitoring is designed to aid surgeons in identifying the potential for intraoperative nerve injury and reducing associated postoperative complications. However, standardized protocols for neuromonitoring have not been provided, and outcomes are not well described. The purpose of this study was to provide a standardized protocol for IONM, and to describe clinical outcomes in a cohort of individuals who underwent lateral lumbar interbody fusion (LLIF) surgery.
METHODS
A retrospective review of 169 consecutive patients who underwent LLIF surgery at a single institution from October 2014 to October 2016 was performed. Patient characteristics, intraoperative details, clinical outcomes, and postoperative deficits (PODs) were compared between patients who did and did not trigger IONM alerts, and between patients who did and did not demonstrate a POD. A protocol for IONM decision-making was generated based on these observations.
RESULTS
Most patients (91.7%) underwent surgery for a degenerative spine condition. Twenty-three patients (13.6%) triggered neuromonitoring alerts, and 16 patients (9.5%) demonstrated a POD. Leg pain, back pain, and disability improved significantly (p < 0.045), and 2 patients had both motor and sensory deficits at the 12-week postoperative time point. Patients with a POD demonstrated greater operating room time (p = 0.034) and a greater number of interbody fusion levels (p = 0.015) but were less likely to have triggered a neuromonitoring alert (p = 0.04). There was no association between retractor time and POD (p = 0.98). When an IONM protocol was followed, individuals who experienced a POD were less likely to trigger an alert than those who did not experience a POD (p = 0.04).
CONCLUSIONS
This study provides a protocol algorithm for IONM alert responses in patients undergoing LLIF surgery. PODs are most associated with multilevel fusion, and patients with alerts had a low rate of persistent deficit. Future research is needed to validate these findings using a more rigorous comparative study design.
... GBS has been associated through multiple reports following elective spine surgery. [4] Interventions involving lumbar spinal levels L2-L3 and L4-L5 in particular have been associated with development of GBS. [2,3] In most cases, GBS develops 1-3 weeks after surgery, then resolves over weeks to months. ...
... [2,3] In most cases, GBS develops 1-3 weeks after surgery, then resolves over weeks to months. [4] While cases of GBS following minimally invasive surgical transforaminal lumbar interbody fusion (MIS TLIF) as well as other lumbar fusion techniques have been reported, there is no reported case of GBS following lateral retroperitoneal transpsoas approach (LLIF). Furthermore, the classic neural stretch injury/apraxia that can be observed after LLIF can be indistinguishable from early GBS. ...
... Patients who developed GBS following spinal surgery as reported in the literature tend to generally have favorable outcomes, with symptoms resolving in weeks to months, either on their own or with the administration of IVIG. [4] At the most recent follow-up, the recovery for the patient presented here seems to have also been favorable. ...
Complications following lateral retroperitoneal transpsoas lumbar fusion (LLIF) surgery include femoral nerve apraxia, bowel/bladder injury, ureteral injury, and potentially, as illustrated in this case report, Guillain-Barré syndrome. Guillain-Barré syndrome (GBS) is an autoimmune inflammatory condition that typically presents after infection, or, less frequently, post-operatively. We report a case of GBS following elective lumbar fusion through the lateral retroperitoneal transpsoas approach (LLIF). A 56-year-old patient presented with left lower extremity (LLE) weakness on post-operative day 12. EMG showed bilateral upper extremity muscle recruitment, worse distally. Following a treatment with intravenous immunoglobulin (IVIG), the patient gradually improved, and her condition was favorable at 6-month post-operative follow-up. CSF analysis and EMG should be part of the workup for patients presenting with lower extremity neuropathy following LLIF.
... In our first series, we reported the prevalence of neurological compromise after LLIF in 235 patients (444 levels fused). At 12 months follow-up, we reported 1.6% of patients had sensory deficits, 1.6% with mechanical psoas weakness, and 2.9% of patients with lumbar plexus related deficits (30). This relative low rate of neurological deficits was confirmed in further studies (23,29,31). ...
Lateral lumbar interbody fusion (LLIF) is a minimally invasive surgical approach used to treat
a variety of degenerative and deformity conditions of the lumbar spine such as advanced degenerative
disease, degenerative scoliosis, foraminal and central stenosis. It has emerged as an alternative to the
traditional posterior and anterior lumbar approaches with some potential benefits such as lower blood loss
and shorter hospital stay. In this article, we provide our single institutional surgical experience including
main indications and contraindications, a step-by-step surgical technique description, a detailed preoperative
imaging assessment with a focus on magnetic resonance imaging (MRI) psoas anatomy, operative room
(OR) setup and patient positioning. A descriptive surgical technical note of the following steps is provided:
positioning and fluoroscopic confirmation, incision and intraoperative level confirmation, discectomy and
endplate preparation, implant size selection and insertion and final fluoroscopic control, hemostasis check
and wound closure along with an instructional surgical video with tips and pearls, postoperative patient care
recommendations, common approach-related complications, along with our historical clinical institutional
group experience. Finally, we summarize our research experience in this surgical approach with a focus on
LLIF as a standalone procedure. Based on our experience, LLIF can be considered an effective surgical
technique to treat degenerative lumbar spine conditions. Proper patient selection is mandatory to achieve
good outcomes. Our institutional experience shows higher fusion rates with good clinical outcomes and a
relatively low rate of complications
... Therefore, lumbar plexus injury in patients undergoing lumbar surgery with the lateral approach may be due to direct or indirect nerve injury caused by strong pressure on the psoas muscle. Several studies have also reported that nerve damage is associated with the time for which the psoas muscle is under traction and the duration of surgery [17,18]. The more anteriorly the psoas muscles are situated, the higher the risk of direct injury, and the harder and longer the psoas muscles are pressed, the higher the risk of indirect injury. ...
Background and Objectives: The lateral approach is commonly used for anterior column reconstruction, indirect decompression, and fusion in patients with lumbar degenerative diseases and spinal deformities. However, intraoperative lumbar plexus injury may occur. This is a retrospective comparative study to investigate and compare neurological complications between the conventional lateral approach and a modified lateral approach at L4/5. Materials and Methods: Patients with a lumbar degenerative disease requiring single-level intervertebral fusion at L4/5 were included and categorized into group X and group A. Patients in group X underwent conventional extreme lateral interbody fusion, while those in group A underwent a modified surgical procedure that included splitting of the anterior third of the psoas muscle, which was dilated by the retractor on the anterior third of the intervertebral disc. The incidence of lumbar plexus injury, defined as a decrease of ≥1 grade on manual muscle testing of hip flexors and knee extensors and sensory impairment of the thigh for ≥3 weeks, on the approach side, was investigated. Results: Each group comprised 50 patients. No significant between-group differences in age, sex, body mass index, and approach side were observed. There was a significant between-group difference in intraoperative neuromonitoring stimulation value (13.1 ± 5.4 mA in group X vs. 18.5 ± 2.3 mA in group A, p < 0.001). The incidence of neurological complications was significantly higher in group X than in group A (10.0% vs. 0.0%, respectively, p < 0.05). Conclusions: In our modified procedure, the anterior third of the psoas muscle was entered and split, and the intervertebral disc could be reached without damaging the lumbar plexus. When performing lumbar surgery using the lateral approach, lumbar plexus injury can be avoided by following surgical indication criteria based on the location of the lumbar plexus with respect to the psoas muscle and changing the transpsoas approach to the intervertebral disc.
... [14][15][16][17] 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. ...
... 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 ...
... 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. [42][43][44][45] The major drawback of the ALIF approach is the morbidity and risk associated with transperitoneal dissection. ...
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.
... LLIFs are a popular lumbar fusion technique due to its ability to optimize sagittal alignment, while avoiding manipulation of the great vessels anteriorly. [14][15][16][17] The minimally invasive nature of the surgery allows for shorter overall hospital length of stay when compared to open surgeries. [18] When compared to similar minimally invasive fusions such as oblique lateral interbody fusion, LLIF has been shown to be safer for new surgeons due to a lower learning curve. ...
Context: Abdominal pain after surgery can occur for numerous reasons. Postoperative radiographs may be indicated to evaluate for ileus or other reasons for the pain. Whether outcomes are significantly different based on whether patients get radiographs following lateral lumbar interbody fusion (LLIF) are unclear.
Aims: To investigate the postoperative outcomes of patients experiencing abdominal pain after LLIF.
Settings and Design: This retrospective cohort study included patients at a tertiary academic medical center and surrounding affiliated hospitals.
Materials and Methods: Patients >18 years of age who underwent elective LLIF at a single institution were retrospectively identified. Patients were stratified into two groups depending on whether they received a postoperative abdominal radiograph or computed tomography (CT) scan for postoperative abdominal pain.
Statistical Analysis: Patient demographics, surgical characteristics, and surgical outcomes were compared between groups utilizing independent t-tests or Mann–Whitney U-tests for continuous variables or Pearson's Chi-square tests for categorical variables.
Results: A total of 153 patients (18 with abdominal scans, 135 without) were included. Patients who received a postoperative abdominal radiograph or CT scan were more likely to undergo exploratory laparotomy (11.1% vs. 0.00%, P = 0.013). Ultimately, patients with abdominal scans had a longer hospital length of stay (6.67 vs. 3.79 days, P = 0.002) and were discharged home less frequently (71.4% vs. 83.7%, P = 0.002).
Conclusions: Patients who received abdominal imaging after LLIF were more likely to undergo exploratory laparotomy, experience longer hospital length of stay, and were discharged home less frequently. Intra-abdominal air on postoperative imaging without corresponding physical exam findings consistent with bowel injury is not an appropriate indication for surgical intervention.
... Health care providers, especially surgeons, should be aware of these variations to avoid nerve injuries. Iatrogenic injury of the lumbar plexus during lateral approaches to spinal fusion surgery represents a primary concern during the procedure (Pumberger et al. 2012). Excessive retraction and intraoperative nerve damage can lead to chronic groin and inguinal dysesthesia and/or motor de cits of the thigh (Pawar et al. 2015). ...
... Femoral nerve (FN) and obturator nerve (ON) palsies represent the gravest of lateral approach injuries and must be the highest priority during the procedure. Abdominal wall paresis is frequently reported following lateral approaches (Pumberger et al. 2012). This is likely due to initial incision/dissection errors, damaged L1, ventral ramus, anterior cutaneous branches of the iliohypogastric nerve (IHN), and/or ilioinguinal nerve (IIN). ...
The lumbar plexus originates from the lumbar spinal cord providing sensation to the anterolateral abdominal wall and lower limbs. Primary motor components of the plexus include the femoral and obturator nerves, which innervate the anterior and medial compartments of the thigh, respectively. The plexus typically consists of four ventral segments (L1-L4) (73%); however, it can also consist of five segments (L1-L5) (21%), or even six segments (T12-L5) (6%). The furcal nerve of L4 typically ramifies to both the lumbar and sacral plexuses. An increase in laparoscopic surgeries, especially retroperitoneal approaches, made the areas around the psoas major muscle of major concern. Surgeons operating around the area should be aware of the natural variations in the lumbar plexus to avoid injuries. In this systematic review, we reviewed up to 1248 lumbar plexus variations in the literature. A comprehensive search was carried out using PRISMA guidelines to access the literature published about spinal levels. The femoral nerve was found to originate from L2-L4 in 83% of the cases. The obturator nerve was found to originate from L2-L4 in 83% of the cases. The accessory obturator nerve was found 14% of the time. The ilioinguinal nerve was found to originate from L1 in 81% of the cases. The iliohypogastric nerve was found to originate from L1 in 83% of the cases. The lateral femoral cutaneous nerve was found to originate from L2 and L3 in 72% of the cases. Finally, the genitofemoral nerve was found to originate from L1 and L2 in 81% of the cases.
Mini-abstract
Knowledge about the natural variations of nerves of the lumbar plexus is of major importance for operating surgeons in the abdomen or pelvis to avoid injuries to the nerves.
