Spine surgery for degenerative scoliosis is challenging due to the technical difficulties and commonly associated complications. Surgical morbidities are primarily related to the extensive nature of the surgery and the patients’ associated medical and age-related comorbidities. Many authors reported an overall 35% rate of major and minor complications. Similarly, the Scoliosis Research Society data of 5,980 patients found a 10.5% rate of major complications.¹, ², ³, ⁴, ⁵, ⁶

Alternative less invasive surgical treatment options such as direct lateral transpsoas lumbar interbody fusion (MIS LLIF) is gaining popularity. Early reports were encouraging with a quick learning curve.⁷, ⁸, ⁹, ¹⁰ Transpsoas techniques, however, proved to have their own set of complications. These include lumbar plexus injuries (36%), femoral nerve injuries, bowel perforations, kidney laceration, vascular injuries, etc.⁸,¹¹,¹² Additionally with MIS LLIF there is a ceiling effect for deformity correction, and inability to safely reach the L5-S1, and at times L4-L5 levels.¹³,¹⁴ Although accessing the lumbosacral junction is a well-known limitation of transpsoas surgery, appropriately addressing the frequently overlooked L4-S1 pathologies is crucial for successful deformity correction, arthrodesis, and with less risk of hardware failure.¹⁵,¹⁶ As the transpsoas approach is becoming frequently adopted, it is worrisome to see that L5-S1 (and at times L4-L5) anterior fusions being omitted simply because of the technique’s surgical limitation. From the open literature, the L5-S1 is reportedly involved in about 70% of degenerative conditions; however, it is well underreported in the MIS transpsoas (20%) literature.⁸ Furthermore, the limited capability of the MIS LLIF to successfully correct moderate to severe adult lumbar deformities has been well reported.¹³,¹⁷