Technique, Safety, and Accuracy Assessment of Percutaneous Pedicle Screw Placement Utilizing Computer-Assisted Navigation in Lateral Decubitus Single-Position Surgery.

BACKGROUND: Percutaneous pedicle screw (PPS) placement has become a pivotal technique in spinal surgery, increasing surgical efficiency and limiting the invasiveness of surgical procedures. The aim of this study was to analyze the accuracy of computer-assisted PPS placement with a standardized technique in the lateral decubitus position. METHODS: A retrospective review of prospectively collected data was performed on 44 consecutive patients treated between 2021 and 2023 with lateral decubitus single-position surgery. PPS placement was assessed by computed tomography scans, and breaches were graded based on the magnitude and direction of the breach. Facet joint violations were assessed. Variables collected included patient demographics, indication, intraoperative complications, operative time, fluoroscopy time, estimated blood loss, and length of stay. RESULTS: Forty-four patients, with 220 PPSs were identified. About 79.5% of all patients underwent anterior lumbar interbody fusion only, 13.6% underwent lateral lumbar interbody fusion only, and 6.8% received a combination of both anterior lumbar interbody fusion and lateral lumbar interbody fusion. Eleven screw breaches (5%) were identified: 10 were Grade II breaches (<2 mm), and 1 was a Grade IV breach (>4 mm). All breaches were lateral. About 63.6% involved down-side screws indicating a trend toward the laterality of breaches for down-side pedicles. When analyzing breaches by level, 1.2% of screws at L5, 13% at L4, and 11.1% at L3 demonstrated Grade II breaches. No facet joint violations were noted. CONCLUSION: PPS placement utilizing computer-assisted navigation in lateral decubitus single-position surgery is both safe and accurate. An overall breach rate of 5% was found; considering a safe zone of 2 mm, only 1 screw (0.5%) demonstrated a relevant breach. CLINICAL RELEVANCE: PPS placement is both safe and accurate. Breaches are rare, and when breaches do occur, they are lateral.

Clinical Outcomes of Prone Transpsoas Lumbar Interbody Fusion: A 1-Year Follow-Up.

BACKGROUND: Lateral lumbar interbody fusion (LLIF) is commonly used to address various lumbar pathologies. LLIF using the prone transpsoas (PTP) approach has several potential advantages, allowing simultaneous access to the anterior and posterior columns of the spine. The aim of this study was to report the 1-year outcomes of LLIF via PTP. METHODS: This is a retrospective review of 97 consecutive patients who underwent LLIF via PTP. Radiographic parameters, including lumbar-lordosis, segmental-lordosis, anterior disc height, and posterior disc height, were measured on preoperative, initial-postoperative, and 1-year postoperative imaging. Patient-reported outcomes measures, including Oswestry Disability Index, visual analog scale (VAS), pain EQ5D, and postoperative complications, were reviewed. RESULTS: Ninety-seven consecutive patients underwent 161 levels of LLIF. Fifty-seven percent underwent 1-level LLIF, 30% 2-level LLIF, 6% 3-level LLIF, and 7% 4-level LLIF. The most common level was L4 to L5 (35%), followed by L3 to L4 (33%), L2 to L3 (21%), and L1 to L2 (11%). Significant improvements were noted at initial and 1-year postoperative periods in lumbar-lordosis (2° ± 10°, P = 0.049; 3° ± 9°, P = 0.005), segmental-lordosis (6° ± 5°, P < 0.001; 5° ± 5°, P < 0.001), anterior disc height (8 mm ± 4 mm, P < 0.001; 7 mm ± 4 mm, P < 0.001), and posterior disc height (3 mm ± 2 mm, P < 0.001; 3 mm ± 2 mm, P < 0.001). Significant improvements were seen in Oswestry Disability Index at 6 weeks (P = 0.002), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively; pain EQ5D at 6 weeks (P < 0.001), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively; and leg and back visual analog scale at 2 weeks (P < 0.001), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively. The average length of stay was 2.5 days, and the most common complications were ipsilateral hip flexor pain (46%), weakness (59%), and contralateral hip flexor pain (29%). CONCLUSION: PTP is a novel way of performing LLIF. These 1-year data support that PTP is an effective, safe, and viable approach with similar patient-reported outcome measures and complications profiles as LLIF performed in the lateral decubitus position.

Analyzing the L4-5 Segmental Alignment Change of Two Minimally Invasive Prone-Based Interbody Fusions.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Restoration of lumbar lordosis (LL) is a principal objective during spinal fusion procedures, traditionally focusing on achieving an LL within 10° of the pelvic incidence (PI). Recent studies have demonstrated a relatively constant L4-S1 alignment of 35-40° at L4-S1 and at least 15° at L4-5, regardless of PI. Based on these results, this study was created to examine the success rate of achieving a minimum of 15° at L4-5 through two differing prone-based techniques: Prone Lateral (pLLIF) and Trans Foraminal Interbody Fusion (TLIF). METHODS: One hundred patients with a primary single-level L4-5 interbody fusion (50 pLLIF and 50 TLIF) were retrospectively analyzed. Pre and post-operative radiographs were measured to examine the segmental change at each level in the lumbar spine and calculate the success rate for achieving a minimum L4-5 segmental lordosis of 15° at the final follow-up. RESULTS: The overall success rate of achieving an L4-5 segmental alignment >15° at the final follow-up was 70%. Prone LLIF was significantly more likely than TLIF to achieve this goal, achieving L4-5 > 15° 84% of the time vs TLIFs 56% (P = 0.002). Prone LLIF demonstrated an average L4-5 increase of 5.6 ± 5.9° which was larger than the mean increase for TLIF 0.4 ± 3.8° (P < 0.001). In both techniques, there was an inverse correlation between pre-operative L4-5 angle and L4-5 angle change. CONCLUSION: Prone lateral lumbar interbody fusion demonstrates a high success rate for achieving a post-operative L4-5 angle >15° and achieves this at a higher rate than TLIF.

Single-Position Robotic-Assisted Prone Lateral Fusion: Technical Description and Feasibility.

Single-position lateral interbody fusion surgery has gained traction over the years because of reduced surgical time and improved operating theater workflow. With the introduction of robotics in spine surgery, surgeons can place pedicle screws with a high degree of accuracy and efficiency; moreover, the robot allows us to localize the disk space and perform endplate preparation accurately with minimal radiation. In this study, we discuss the potential synergistic benefits of integrating robotic-assisted spine surgery and singleposition prone lateral surgery. We share our technique and provide the operative nuances of using the Mazor X Stealth Edition system (Medtronic, Minneapolis, MN, USA). We highlighted the potential synergistic benefits of integrating both the prone lateral and robotic-assisted surgical techniques, including the challenges encountered. This approach is not meant to replace other techniques or be used in all patients. Instead, it adds to our arsenal for managing spine fusion.

Risk of Injury to Retroperitoneal Structures in Prone and Lateral Decubitus Transpsoas Approaches to Lumbar Interbody Fusion: A Pilot Cadaveric Anatomical Study.

Introduction The retroperitoneal approach for lateral lumbar interbody fusion (LLIF) originally described an initial posterolateral fascial incision enabling finger dissection from behind the peritoneum and guidance of instruments through a second direct-lateral fascial incision. It has since become common for single direct-lateral incisional access to the retroperitoneum. This study attempted to quantify the distance of the peritoneum from posterior landmarks in the space, assess the risk of peritoneal violation in each access trajectory (i.e., posterolateral versus direct lateral retroperitoneal dissection), and determine whether there are differences based on patient position (prone versus lateral decubitus). Methods In three prone cadaveric torsos, Steinman pins were percutaneously placed mid-disc at each level L2-5 bilaterally (for a total of 18 prone approaches). Open dissections exposed the retroperitoneum including the quadratus lumborum and psoas muscles, maintaining the natural reflection of the peritoneum. Visual assessment qualified whether any pin violated any retroperitoneal structure. Distance from the anterior border of the quadratus lumborum to the posterior-most reflection of the peritoneum was measured. For comparison, three additional torsos were positioned in lateral decubitus, and the above steps were repeated, only unilaterally (for a total of nine lateral decubitus approaches). Results In prone, no pin violated the peritoneum; three (3/18 total approaches) violated the kidney, all at L2-3 (3/6 approaches at L2-3). In lateral decubitus, all three L2-3 pins violated the kidney (3/3 approaches at L2-3); five of the six remaining pins from L3-5 violated the peritoneum (totaling eight violations in the nine total approaches). The incidence of any violation was significantly greater in lateral decubitus vs. prone (8/9 vs. 3/18, p=0.0006). The structure at risk (kidney vs. peritoneum) was significantly associated with disc level (p=0.0041): all kidney violations occurred at L2-3 and all peritoneal violations occurred at L3-4 or L4-5. Distance from the quadratus lumborum to the posterior-most reflection of the peritoneum averaged 8.7 cm (range: 6-10) in prone, and 2.9 cm (range: 2.5-3.2) in lateral decubitus (p=0.0129). Conclusion A cadaveric study of retroperitoneal anatomy demonstrates that there is an increased distance from the quadratus lumborum to the peritoneum in prone versus lateral decubitus and that the trajectory of approach to the lumbar discs risks violation of the peritoneum more frequently when accessing directly laterally versus posterolaterally. In either approach, care should be taken to identify and release the peritoneal reflection to create a safe passage to the lumbar discs.

Retrospective single-surgeon study of prone versus lateral robotic pedicle screw placement: a CT-based assessment of accuracy.

OBJECTIVE: Lateral lumbar interbody fusion including anterior-to-psoas oblique lumbar interbody fusion has conventionally relied on pedicle screw placement (PSP) for construct stabilization. Single-position surgery with lumbar interbody fusion in the lateral decubitus position with concomitant PSP has been associated with increased operative efficiency. What remains unclear is the accuracy of PSP with robotic guidance when compared with the more familiar prone patient positioning. The present study aimed to compare robot-assisted screw placement accuracy between patients with instrumentation placed in the prone and lateral positions. METHODS: The authors identified all consecutive patients treated with interbody fusion and PSP in the prone or lateral position by a single surgeon between January 2019 and October 2022. All pedicle screws placed were analyzed using CT scans to determine appropriate positioning according to the Gertzbein-Robbins classification grading system (grade C or worse was considered as a radiographically significant breach). Multivariate logistic regression models were constructed to identify risk factors for the occurrence of a radiographically significant breach. RESULTS: Eighty-nine consecutive patients (690 screws) were included, of whom 46 (477 screws) were treated in the prone position and 43 (213 screws) in the lateral decubitus position. There were fewer breaches in the prone (n = 13, 2.7%) than the lateral decubitus (n = 15, 7.0%) group (p = 0.012). Nine (1.9%) radiographically significant breaches occurred in the prone group compared with 10 (4.7%) in the lateral decubitus group (p = 0.019), for a prone versus lateral decubitus PSP accuracy rate of 98.1% versus 95.3%. There were no significant differences in BMI between prone versus lateral decubitus cohorts (30.1 vs 29.6) or patients with screw breach versus those without (31.2 vs 29.5). In multivariate models, the prone position was the only significant protective factor for screw accuracy; no other significant risk factors for screw breach were identified. CONCLUSIONS: The present data suggest that pedicle screws placed with robotic assistance have higher placement accuracy in the prone position. Further studies will be needed to validate the accuracy of PSP in the lateral position as single-position surgery becomes more commonplace in the treatment of spinal disorders.

Single position L5-S1 lateral ALIF with simultaneous robotic posterior fixation is safe and improves regional alignment and lordosis distribution index.

PURPOSE: Minimally invasive single position lateral ALIF at L5-S1 with simultaneous robot-assisted posterior fixation has technical and anatomic considerations that need further description. METHODS: This is a retrospective case series of single position lateral ALIF at L5-S1 with robotic assisted fixation. End points included radiographic parameters, lordosis distribution index (LDI), complications, pedicle screw accuracy, and inpatient metrics. RESULTS: There were 17 patients with mean age of 60.5 years. Eight patients underwent interbody fusion at L5-S1, five patients at L4-S1, two patients at L3-S1, and one patient at L2-S1 in single lateral position. Operative times for 1-level and 2-level cases were 193 min and 278 min, respectively. Mean EBL was 71 cc. Mean improvements in L5-S1 segmental lordosis were 11.7 ± 4.0°, L1-S1 lordosis of 4.8 ± 6.4°, sagittal vertical axis of - 0.1 ± 1.7 cm°, pelvic tilt of - 3.1 ± 5.9°, and pelvic incidence lumbar-lordosis mismatch of - 4.6 ± 6.4°. Six patients corrected into a normal LDI (50-80%) and no patients became imbalanced over a mean follow-up period of 14.4 months. Of 100 screws placed in lateral position with robotic assistance, there were three total breaches (two lateral grade 3, one medial grade 2) for a screw accuracy of 97.0%. There were no neurologic, vascular, bowel, or ureteral injuries, and no implant failure or reoperation. CONCLUSION: Single position lateral ALIF at L5-S1 with simultaneous robotic placement of pedicle screws by a second surgeon is a safe and effective technique that improves global alignment and lordosis distribution index.

Complications associated with single-position prone lateral lumbar interbody fusion: a systematic review and pooled analysis.

OBJECTIVE: Lateral lumbar interbody fusion (LLIF) is a workhorse surgical approach for lumbar arthrodesis. There is growing interest in techniques for performing single-position surgery in which LLIF and pedicle screw fixation are performed with the patient in the prone position. Most studies of prone LLIF are of poor quality and without long-term follow-up; therefore, the complication profile related to this novel approach is not well known. The objective of this study was to perform a systematic review and pooled analysis to understand the safety profile of prone LLIF. METHODS: A systematic review of the literature and a pooled analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting prone LLIF were assessed for inclusion. Studies not reporting complication rates were excluded. RESULTS: Ten studies meeting the inclusion criteria were analyzed. Overall, 286 patients were treated with prone LLIF across these studies, and a mean (SD) of 1.3 (0.2) levels per patient were treated. The 18 intraoperative complications reported included cage subsidence (3.8% [3/78]), anterior longitudinal ligament rupture (2.3% [5/215]), cage repositioning (2.1% [2/95]), segmental artery injury (2.0% [5/244]), aborted prone interbody placement (0.8% [2/244]), and durotomy (0.6% [1/156]). No major vascular or peritoneal injuries were reported. Sixty-eight postoperative complications occurred, including hip flexor weakness (17.8% [21/118]), thigh and groin sensory symptoms (13.3% [31/233]), revision surgery (3.8% [3/78]), wound infection (1.9% [3/156]), psoas hematoma (1.3% [2/156]), and motor neural injury (1.2% [2/166]). CONCLUSIONS: Single-position LLIF in the prone position appears to be a safe surgical approach with a low complication profile. Longer-term follow-up and prospective studies are needed to better characterize the long-term complication rates related to this approach.

Robot-assisted percutaneous pedicle screw placement accuracy compared with alternative guidance in lateral single-position surgery: a systematic review and meta-analysis.

OBJECTIVE: While single-position surgery (SPS) eliminates the need for patient repositioning, the placement of screws in the unconventional lateral position poses unique challenges related to asymmetry relative to the surgical table. Use of robotic guidance or intraoperative navigation can help to overcome this. The aim of this study was to compare the relative accuracies offered by these various navigation modalities for pedicle screws placed in lateral SPS. METHODS: According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the PubMed/Medline, Embase, and Cochrane Library databases were queried for studies reporting pedicle screw placement accuracy using fluoroscopic, CT-navigated, O-arm, or robotic guidance in lateral SPS, and a systematic review and meta-analysis was performed. Included studies all compared evaluated screw placement accuracy in lateral SPS using a single navigation method. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system; risk of bias was assessed using the Newcastle-Ottawa Scale and the Joanna Briggs Institute checklist. The primary outcome, rate of pedicle screw breach, was analyzed using random-effects meta-analysis. RESULTS: Eleven studies were included comprising 548 patients who underwent the placement of instrumentation with 2488 screws. For the fluoroscopic, CT-navigated, O-arm, and robotic guidance cohorts, there were 3, 2, 3, and 3 studies, respectively. Breach rates by modality were as follows: fluoroscopic guidance (6.6%), CT navigation (4.7%), O-arm (3.9%), and robotic guidance (3.9%). Random-effects meta-analysis showed a significant difference between studies, with an overall breach rate of 4.9% (95% CI 3.1%-7.5%; p < 0.001); however, testing for subgroup differences failed to show a significant difference between guidance modalities (QM = 0.69, df = 3; p = 0.88). Heterogeneity between studies was significant (I2 = 79.0%, τ2 = 0.41, χ2 = 47.65, df = 10; p < 0.001). CONCLUSIONS: Robotic guidance of screws is noninferior to alternative guidance modalities in lateral SPS; however, additional prospective studies directly comparing different guidance types are merited.

A retrospective review of single-position prone lateral lumbar interbody fusion cases: early learning curve and perioperative outcomes.

PURPOSE: The objective of this study was to discuss our experience performing LLIF in the prone position and report our complications. METHODS: A retrospective chart review was conducted that included all patients who underwent single- or multi-level single-position pLLIF alone or as part of a concomitant procedure by the same surgeon from May 2019 to November 2022. RESULTS: A total of 155 patients and 250 levels were included in this study. Surgery was most commonly performed at the L4-L5 level (n = 100, 40%). The most common preoperative diagnosis was spondylolisthesis (n = 74, 47.7%). In the first 30 cases, 3 surgeries were aborted to an MIS TLIF. Complications included 3 unintentional ALL ruptures (n = 3/250, 1.2%), and 1 malpositioned implant impinging on the contralateral foramen requiring revision (n = 1/250, 0.4%), which all occurred within the first 30 cases. Out of 147 patients with more than 6-week follow-ups, there were 3 cases of femoral nerve palsy (n = 3/147, 2.0%). Two cases of femoral nerve palsy improved to preoperative strength by the 6th week postoperatively, while one improved to 4/5 preoperative strength by 1 year. There were no cases of bowel perforation or vascular injury. CONCLUSION: Our single-surgeon experience demonstrates the initial learning curve when adopting pLLIF. Thereafter, we experienced reproducibility in our technique and large improvements in our operative times, and complication profile. We experienced no technical complications after the 30th case. Further studies will include long-term clinical and radiographic outcomes to understand the complete utility of this approach.

Minimally invasive lateral single-position surgery for multilevel degenerative lumbar spine disease: feasibility and perioperative results in a single Latin-American spine center.

INTRODUCTION: Within advances in minimally invasive spine surgery, the implementation of lateral single position (LSP) increases efficiency while limiting complications, avoiding intraoperative repositioning and diminishing surgical time. Most literature describes one-level instrumentation of the lumbar spine; this study includes the use of LSP for multilevel degenerative disease. OBJECTIVE: The objective of the article is to analyze initial clinical results and complications in the use of LSP for multiple level instrumentation in adults with lumbar degenerative disease. METHODS: A retrospective early clinical series was performed for patients who had multiple level instrumentation in LSP between August 2019 and September 2022 at the Hospital Universitario San Ignacio in Bogota, Colombia. Inclusion criteria were patients older than 18 years with symptomatic lumbar degenerative disease, undergoing any combination of multilevel anterior lumbar interbody fusion, lateral lumbar interbody fusion (LLIF) and pedicle screw fixation. RESULTS: Forty patients with an average age of 61.3 years were included, with diagnosis of multilevel degenerative spondylotic changes. Four-, three- and two-level interventions were performed in 52.5, 35 and 12.5%, respectively. Average time per level was 68.9 min, and length of hospital stay had an average of 2.4 days, with all patients starting ambulation within the first postoperative day. CONCLUSION: Procedural time and blood loss were similar to those reported in literature. No severe lesions, postoperative infections or reinterventions took place. Although it was a small number of patients and further clinical trials are needed, LSP for multiple levels is apparently safe with adequate outcomes which may improve efficiency in the operating room.

Single-Position Anterior and Lateral Lumbar Fusion in the Supine Position: A Novel Technique for Multilevel Arthrodesis.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion are common techniques that typically require staged procedures when performed in combination. Interest is emerging in single-position surgery to increase operative efficiency. We report a novel surgical technique, supine extended reach lateral fusion, to perform ALIF and lateral lumbar interbody fusion with the patient in a single supine position. METHODS: A man in his fifties presented with degenerative levoscoliosis, spondylolisthesis, sagittal plane deformity, and progressive low back pain. He was offered L3-S1 anterolateral fusion. RESULTS: With the patient supine, a left abdominal paramedian incision was performed to gain anterior retroperitoneal access, and standard L5-S1 and L4-5 ALIFs were performed. The anterior incision was used for direct visualization, retraction, and bimanual dissection. A left lateral incision was then made to perform an L3-4 lateral lumbar interbody fusion. He subsequently underwent a second-stage L3-S1 posterior percutaneous fixation. The patient tolerated the procedures well, without complications. His postoperative radiograph findings confirmed acceptable implant positioning. He was discharged home in stable condition and was doing well at follow-up. CONCLUSIONS: This case description is the first report of the supine extended reach technique, which allows incorporation of anterior and lateral fusion constructs at adjacent levels without changing patient positioning. Many surgeons believe the ALIF to be the most powerful technique for achieving lordosis, and this technique enables concomitant lateral access in a supine position. It can also be used as an alternative strategy when anterior access to the disc space is unobtainable. Further clinical investigation of this technique is warranted.

Setting for single position surgery: survey from expert spinal surgeons.

PURPOSE: To describe a comprehensive setting of the different alternatives for performing a single position fusion surgery based on the opinion of leading surgeons in the field. METHODS: Between April and May of 2021, a specifically designed two round survey was distributed by mail to a group of leaders in the field of Single Position Surgery (SPS). The questionnaire included a variety of domains which were focused on highlighting tips and recommendations regarding improving the efficiency of the performance of SPS. This includes operation room setting, positioning, use of technology, approach, retractors specific details, intraoperative neuromonitoring and tips for inserting percutaneous pedicle screws in the lateral position. It asked questions focused on Lateral Single Position Surgery (LSPS), Lateral ALIF (LA) and Prone Lateral Surgery (PLS). Strong agreement was defined as an agreement of more than 80% of surgeons for each specific question. The number of surgeries performed in SPS by each surgeon was used as an indirect element to aid in exhibiting the expertise of the surgeons being surveyed. RESULTS: Twenty-four surgeons completed both rounds of the questionnaire. Moderate or strong agreement was found for more than 50% of the items. A definition for Single Position Surgery and a step-by-step recommendation workflow was built to create a better understanding of surgeons who are starting the learning curve in this technique. CONCLUSION: A recommendation of the setting for performing single position fusion surgery procedure (LSPS, LA and PLS) was developed based on a survey of leaders in the field.

Fluoroscopy-based percutaneous posterior screw placement in the lateral position using the tunnel view technique: technical note.

PURPOSE: Lumbar fusion using lateral single position surgery (LSPS) gained popularity during the last few years. While prone percutaneous pedicle screw placement is well described, placing percutaneous pedicle screws with the patient in the lateral position is considered the most complicated part of LSPS. In this article we describe the fluoroscopy navigated technique for lateral percutaneous screw placement using the tunnel view technique. METHODS: The radiologic background and principles of the tunnel view technique are described. In addition, the special positioning of the patient, the C-arm and the surgical technique is discussed in detail. RESULTS: This technique is used as the standard for percutaneous screw placement in the prone or lateral positions in our department since 2017. Since the introduction of this technique we have had 0% reoperation rate for symptomatic malpositioned pedicle screws. CONCLUSION: The tunnel view technique simplifies pedicle screw placement while allowing for permanent observation of pedicle walls and the superior joint surface during placement of the Jamshidi needle. It also allows for confirmation of intrapedicular position of the screw after its implantation. This technique is safe and feasible in our clinical experience.

Surgical fixation of pathologic and traumatic spinal fractures using single position surgery technique in lateral decubitus position.

STUDY DESIGN: Retrospective Case Series. OBJECTIVES: This study aims to determine complications, readmission, and revision surgery rates in patients undergoing single position surgery (SPS) for surgical treatment of traumatic and pathologic thoracolumbar fractures. METHODS: A multi-center review of patients who underwent SPS in the lateral decubitus position (LSPS) for surgical management of traumatic or pathologic thoracolumbar fractures between January 2016 and May 2020 was conducted. Operative time, estimated blood loss (EBL), intraoperative complications, postoperative complications, readmissions, and revision surgeries were collected. RESULTS: A total of 12 patients with a mean age of 45 years (66.67% male) were included. The majority of patients underwent operative treatment for acute thoracolumbar trauma (66.67%) with a mean injury severity score (ISS) of 16.71. Mean operative time was 175.5 min, mean EBL of 816.67 cc. Five patients experienced a complication, two of which required revision surgery for additional decompression during the initial admission. All ambulatory patients were mobilized on postoperative day 1. The mean hospital length of stay (LOS) was 9.67 days. CONCLUSION: The results of this case series supports LSPS as a feasible alternative to the traditional combined anterior-posterior approach for surgical treatment of pathologic and thoracolumbar fractures. These results are similar to reductions in operative time, EBL, and LOS seen in the elective spine literature with LSPS. LEVEL OF EVIDENCE: IV.

Single position lumbar fusion: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Recently, a single position lumbar fusion has been described in which both the anterior or lateral interbody fusion as well as posterior percutaneous pedicle screw fixation are performed in a single position. PURPOSE: The purpose of this study was to present and analyze the current evidence for single position lumbar fusion. STUDY DESIGN/SETTING: This is a systematic review and meta-analysis. PATIENT SAMPLE: Prospective or retrospective studies published in English that assessed outcomes of single position lumbar fusion surgery for patients with lumbar degenerative disease, spondylolisthesis, or radiculopathy were included. OUTCOME MEASURES: Outcome measures included operative time, estimated blood loss, hospital length of stay, X-Ray exposure time, and postoperative outcomes including leg numbness or pain, leg weakness, lumbar lordosis, and segmental lordosis. METHODS: This systematic review was performed in accordance with PRISMA guidelines. Two separate meta-analyses were performed. The first compared single position (SP) surgery, both lateral and prone, to dual position or flipped (F) surgery. The second meta-analysis compared lateral single position (LSP) surgery to prone single position (PSP) surgery. Variables were included if (1) they were a mean with a reported standard deviation or (2) if they were a categorical variable. For calculating standard error of the mean, we used sample size, mean, and standard deviation. A random effects model was used. The heterogeneity among studies was assessed with a significance level of <0.05. RESULTS: Twenty-one articles were included for analysis. Three studies were prospective nonrandomized studies, while 18 were retrospective. Seven articles studied lateral single position only, 10 articles compared lateral single position to traditional repositioning surgery, three articles studied prone single position surgery, and one article compared prone single position surgery to traditional repositioning surgery. A detailed review is provided for all 21 articles. Seventeen studies were included for meta-analysis comparing the SP versus F groups, for a total of 942 patients in the SP group and 254 in the F group. Mean operative time was significantly less for the SP group compared with the F group (SP: 127.5±7.9, F: 188.7±15.5, p<.001). Average hospital length of stay was 2.87±0.3 days in the SP group and 6.63±0.6 days in the F group (p<.001). Complication rates did not significantly differ between groups. Pedicle screws placed in the lateral position had a higher rate of complication as compared with those placed in a prone position (L: 10.2±2%, P: 1.6±1%, p=.015). Seventeen studies were included in the LSP versus PSP analysis, including 13 in the LSP group and four in the PSP group, with a total of 785 patients in the LSP group and 85 patients in the PSP group. Operative time and X-Ray exposure was significantly less in the LSP compared with the PSP group (117.1±5.5 minutes vs. 166.9±21.9 minutes, p<.001; 43.7±15.5 minutes vs. 171.0±25.8 minutes, p<.001). Postoperative segmental lordosis was greater in the prone single position group (p<.001). CONCLUSIONS: Single position surgery decreases operative times and hospital length of stay, while maintaining similar complication rates and radiographic outcomes. PSP surgery was found to be longer in duration and have increased radiation exposure time compared with LSP, while increasing postoperative segmental lordosis.

Single-position prone lateral transpsoas approach: early experience and outcomes.

OBJECTIVE: Lateral lumbar interbody fusion (LLIF) via a transpsoas approach is a workhorse minimally invasive approach for lumbar arthrodesis that is often combined with posterior pedicle screw fixation. There has been increasing interest in performing single-position surgery, allowing access to the anterolateral and posterior spine without requiring patient repositioning. The feasibility of the transpsoas approach in patients in the prone position has been reported. Herein, the authors present a consecutive case series of all patients who underwent single-position prone transpsoas LLIF performed by an individual surgeon since adopting this approach. METHODS: A retrospective review was performed of a consecutive case series of adult patients (≥ 18 years old) who underwent single-position prone LLIF for any indication between October 2019 and November 2020. Pertinent operative details (levels, cage use, surgery duration, estimated blood loss, complications) and 3-month clinical outcomes were recorded. Intraoperative and 3-month postoperative radiographs were reviewed to assess for interbody subsidence. RESULTS: Twenty-eight of 29 patients (97%) underwent successful treatment with the prone lateral approach over the study interval; the approach was aborted in 1 patient, whose data were excluded. The mean (SD) age of patients was 67.9 (9.3) years; 75% (21) were women. Thirty-nine levels were treated: 18 patients (64%) had single-level fusion, 9 (32%) had 2-level fusion, and 1 (4%) had 3-level fusion. The most commonly treated levels were L3-4 (n = 15), L2-3 (n = 12), and L4-5 (n = 11). L1-2 was fused in 1 patient. The mean operative time was 286.5 (100.6) minutes, and the mean retractor time was 29.2 (13.5) minutes per level. The mean fluoroscopy duration was 215.5 (99.6) seconds, and the mean intraoperative radiation dose was 170.1 (94.8) mGy. Intraoperative subsidence was noted in 1 patient (4% of patients, 3% of levels). Intraoperative lateral access complications occurred in 11% of patients (1 cage repositioning, 2 inadvertent ruptures of anterior longitudinal ligament). Subsidence occurred in 5 of 22 patients (23%) with radiographic follow-up, affecting 6 of 33 levels (18%). Postoperative functional testing (Oswestry Disability Index, SF-36, visual analog scale-back and leg pain) identified significant improvement. CONCLUSIONS: This single-surgeon consecutive case series demonstrates that this novel technique is well tolerated and has acceptable clinical and radiographic outcomes. Larger patient series with longer follow-up are needed to further elucidate the safety profile and long-term outcomes of single-position prone LLIF.

Utility of Power Tool and Intraoperative Neuromonitoring for Percutaneous Pedicle Screw Placement in Single Position Surgery: A Technical Note.

OBJECTIVE: This study aimed to demonstrate the utility of power tools and intraoperative neuromonitoring of percutaneous pedicle screw (PPS) insertion (so-called PPS monitoring) by SINGLE-position surgery (SPS) after lateral lumbar interbody fusion. METHODS: A retrospective analysis of medical records from a single center was performed to identify patients who underwent SPS for lateral lumbar interbody fusion and posterior fixation using PPS during intraoperative computed tomography navigation from 2020 to 2021. We investigated the PPS insertion time and screw positional accuracy of patients who underwent SPS involving power tools and PPS monitoring during this period. In this technical note, we report on this surgical technique. RESULTS: Twenty-four patients (mean age 72.0 ± 8.5 years, range 53-81 years) were included in this study. There were no intraoperative complications in all cases. Posterior fixation using PPS was added in all cases, and a total of 106 PPSs were inserted. It took an average of 6.2 ± 2.4 seconds to insert the PPS from the PPS insertion point to the end using a power tool and PPS monitoring. Moreover, there were no cases of pedicle breaches. CONCLUSIONS: Similar to previous reports related to power tools in the prone position, the lateral decubitus SPS technique can also use power tools to save PPS insertion time. Furthermore, we suggest that the use of PPS monitoring may prevent erroneous PPS insertions by using intraoperative computed tomography navigation in advance.

Accuracy of Percutaneous Pedicle Screw Placement after Single-Position versus Dual-Position Insertion for Lateral Interbody Fusion and Pedicle Screw Fixation Using Fluoroscopy.

STUDY DESIGN: Retrospective study. PURPOSE: The purpose of this study was to compare the accuracy of percutaneous pedicle screw (PPS) placement between prone and lateral decubitus positions during lateral lumbar interbody fusion (LLIF) and to evaluate the tendency of PPS positioning based on simple computed tomography measurements with patients in the lateral decubitus position. OVERVIEW OF LITERATURE: There is insufficient information in the literature regarding the accuracy of inserting a PPS using fluoroscopy in patients in the lateral decubitus position. METHODS: We included 62 patients who underwent combined LLIF surgery and PPS fixation for degenerative lumbar spondylolisthesis with spinal canal stenosis. We compared the patient demographics and the accuracy of fluoroscopy-guided PPS placement between two groups: patients who remained in the lateral decubitus position for the pedicle screw fixation (single-position surgery [SPS] group) and those who were turned to the prone position (dual-position surgery [DPS] group). RESULTS: There were 40 patients in the DPS group and 22 in the SPS group. Of the 292 PPSs, only 12 were misplaced. In other words, 280/292 screws (95.9%) were placed correctly in the pedicle's cortical shell (grade 0). PPS insertion did not cause neurological, vascular, or visceral injuries in either group. The breach rates for the DPS and SPS groups were 4.1% (grade 1, 5 screws; grade 2, 3 screws; grade 3, 0 screw) and 4.1% (grade 1, 2 screws; grade 2, 2 screws; grade 3, 0 screw), respectively. Although there were no statistically significant differences, the downside PPS had more screw malpositioning than the upside PPS. CONCLUSIONS: We found that PPS insertion with the patient in the decubitus position under fluoroscopic guidance might be as safe and reliable a technique as PPS insertion in the prone position, with a misplacement rate similar to that previously published.

Simultaneous Anterior and Posterior Release in Lateral Decubitus Position for Rigid Adult Spinal Deformity: A Technical Note and 2 Case Reports.

BACKGROUND: Correction surgery for rigid adult spinal deformity usually involves a complex 360° osteotomy, multiple intraoperative position changes, and staged surgery. Moreover, there is a lack of consensus regarding the surgical strategy for this pathology. We report the technical advantages of a simultaneous anterior and posterior release only in the lateral decubitus position to reduce surgical invasiveness in two case reports. CASE DESCRIPTION: A 76-year-old woman and an 80-year-old woman presented with significant spinal imbalance and segmental fusion in the anterior and posterior columns around the apex of the lumbar spinal curvature. We conducted this procedure for these patients at the first stage of spinal corrective surgery to achieve 360° osteotomy. A long posterior fusion surgery was performed after 1 week. The mean values of the central sacral vertical line, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt improved substantially postoperatively: central sacral vertical line, from 51.0 to 7.5 mm; pelvic incidence minus lumbar lordosis, from 27.5° to 0.5°, sagittal vertical axis, from 107.6 to 14 mm; pelvic tilt, from 34.0° to 13.0°. The mean surgical time and blood loss in the first- and second-stage operations were 242.1 minutes and 702 mL and 315.5 minutes and 549 mL, respectively, and no perioperative complications occurred. CONCLUSIONS: Simultaneous 360° segmental release in the lateral decubitus position without repositioning can make it possible to acquire satisfactory correction and reduce surgical invasiveness compared with the conventional procedure for adult spinal deformity.