Anterolateral Psoas-Sparing Approach to the Lumbar Spine
Tony Tannoury
Akhil Tawari
Chadi Tannoury
REBUTTAL ▪ The Case against MIS Anterolateral Psoas-Sparing LIF
Douglas A. Hollern
Tristan B. Fried
Gregory D. Schroeder
Worawat Limgthongkul
Kris E. Radcliff
Alexander R. Vaccaro
Lumbar interbody fusion is indicated in various degenerative and deforming spinal conditions. Many surgical options have been described with satisfactory outcomes, and these include posterior (PLIF), transforaminal (TLIF), extreme lateral transpsoas (XLIF-DLIF), and direct anterior (ALIF) interbody fusions.
Traditional open anterior lumbar fusion (ALIF) offers a high union rate with ability to correct spinal deformity, and neural decompression under direct visualization.1, 2, 3, 4
However, alarming complications (vascular, visceral, retrograde ejaculation, etc.) have been well reported, and not to mention the typical need for an exposure surgeon.5, 6, 7
Alternatively, less invasive surgical techniques such as direct lateral transpsoas lumbar interbody fusion (MIS-LLIF) have been developed with encouraging early reports.8, 9, 10, 11 Transpsoas techniques, however, are notorious for lumbar plexus injuries (36%), femoral nerve injuries, bowel perforations, kidney laceration, vascular injuries, failure to adequately correct moderate and severe lumbar deformities, and inability to safely access the lumbosacral junction.9,12, 13, 14, 15, 16
In order to overcome the shortcomings of the transpsoas techniques and the traditional open ALIF, the senior author has developed a mini-open retroperitoneal anterior to the psoas (ATP) approach that will be further described and discussed in detail.
INDICATIONS
Lumbar fusion is indicated in patients with traumatic and degenerative spinal conditions who have failed lengthy conservative treatments. Patients with intractable back pain, radicular, or neurogenic claudicatory symptoms, and patients with global coronal or sagittal imbalance are great surgical candidates for such technique. Surgical risks and benefits should be clearly stated and discussed with the consenting patients.17, 18, 19, 20, 21, 22
POSITIONING
Appropriate positioning is essential for this minimally invasive retroperitoneal approach. The lumbar spine can be approached from either the left or the right side depending on the concavity of the deformity and the number of levels involved. The patient is typically placed in a decubitus lateral position with the pelvis and chest perpendicular to the operating table supported by hip positioners. One hip positioner is placed posterior to the pelvis (Fig. 27.1A) and another anterior to the chest at the sternum-xiphoid level (Fig. 27.1B). Simple taping assures proper and stable patient position.
 Figure 27.1 Patient positioned in the lateral decubitus. Hip pads (A), and chest pads (B) are used to secure the patient position. |
The authors recommend the following surgical steps:
Incision location is chosen according to the segment(s) being fused and to the pelvis depth and anatomy (Fig. 27.2).
With coronal deformities, the incision is placed on the concave side for ease of access (Fig. 27.3).
4 to 6 cm skin incision is made, followed by muscle splitting approach of the external oblique, internal oblique and transversus abdominis layers. Attention is made to split the transversus abdominis from posterior to anterior direction in order to reduce the risk of perforating the peritoneum.
Once in the retroperitoneal space, blunt dissection is pursued to expose the belly of the psoas muscle. Attention to not confuse the quadratus lumborum for the psoas. Inadvertent dissection anterior to the quadratus, and behind the psoas, leads to more bleeding, risk of nerve damage, and lack of safe identifiable plane.
The space between the psoas and the large vessels fat is then developed (Fig. 27.4).
In order to address L5-S1, it is often necessary to isolate and ligate the L5 segmental vessels or the iliolumbar vein depending whether the access is from the right or left side (Fig. 27.5).
Adjustable retractor blades with blunt tips are used to maintain the exposure.
In the majority of cases, there is no need to forcefully retract the psoas muscle. Exceptions include significant psoas muscle hypertrophy or severe axial rotation of the spine; however, in general, a gentle retraction of the muscle belly suffices.Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
