Lateral access minimally invasive spine surgery in adult spinal deformity

Bashyal Santosh Kumar; Masato Tanaka; Shinya Arataki; Yoshihiro Fujiwara; Mohammad Mushtaq; Takuya Taoka; Konstantinos Zygogiannnis; Sameer Ruparel

doi:10.1016/j.jor.2023.09.007

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doi:

10.1016/j.jor.2023.09.007

Lateral access minimally invasive spine surgery in adult spinal deformity

Bashyal Santosh Kumar, Masato Tanaka , Shinya Arataki, Yoshihiro Fujiwara, Mohammad Mushtaq, Takuya Taoka, Konstantinos Zygogiannnis, Sameer Ruparel

Department of Orthopedic Surgery, Spine Center, Okayama Rosai Hospital, Japan

∗Corresponding author: Masato Tanaka. tanaka0896@gmail.com

Received: 2023-7-9, Accepted: 2023-9-13, Published: 2023-9-27

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Oblique lumbar interbody fusion (OLIF) and percutaneous posterior approach for screw fixation (PPS) is the latest minimal invasive treatment for spinal deformity in adult patients (ASD). This study aims to design and highlight key points for ASD correction.

We retrospectively analyzed 54 patients who had undergone OLIF with PPS for ASD from October 2019 to January 2022 (average 71.5 ± 6.2 years-old, male 4, female 50) with a mean follow-up period of 29.2 months. Clinical outcomes are expressed by values including the Oswestry disability index (ODI) and visual analogue scale (VAS) for back pain. The imagistic assessment was also performed preoperatively and at 12, and 24 months postoperatively. For OLIF51, CT- MRI fusion images were obtained before surgery.

Postoperative ODI and VAS were 30.5 ± 18.9% and 31.2 ± 6.9 mm, respectively. The average operating time and blood loss during the surgical exposure was 490.9 ± 85.4 min and 1195.2 ± 653.8 ml. Preoperative SVA, PI-LL, and PT were 96.5 ± 55.9 mm, 39.3 ± 22.1°, 34.5 ± 11.0°, respectively. Postoperatively, SVA and PT became normal (24.1 ± 39.0 mm, 17.1 ± 10.3°) and PI-LL was ideal (2.4 ± 12.6°). Postoperative ODI and VAS were 30.5 ± 18.9% and 31.2 ± 6.9 mm. For OLIF51, the results revealed gain in L5-S1 lordosis and intervertebral disc height 9.4° and 4.2 mm respectively. The complications consisted of PJK in 21 cases (38.9%), rod breakage in 5 cases (9.3%), deep or superficial wound infection in 2 cases (3.7%).

Clinical and imagistic results of OLIF and PPS for ASD were excellent. The radiographic measurements revealed that OLIF51 created good L5-S1 lordosis and significant L5-S1 disc height. CT-MRI fusion images were very useful for evaluating vascular anatomy for OLIF51.

Keywords

Adult spinal deformity

Lateral access spine surgery

Oblique lumbar interbody fusion

Minimally invasive spine surgery

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1 Introduction

Adult Spinal deformity (ASD) is a condition that causes sagittal and coronal imbalance, disabilitating pain, neurological impairment, and/or functional loss.¹ The approach to treat and manage ASD needs to concentrate on restoring age-specific harmonious alignment, comorbidities, and risk factors of everyone for the prevention of devastating complications and improvement of quality of life.² There is a great role in preoperative planning with a structured and systematic analytic approach for spine surgeons to decide on surgical correction for ASD.³ Due to a large number of complications like a high mortality rate of 2.4%, non-union, neurological impairment, deep surgical sites infection, dural tear, and excessive blood loss.⁴^,⁵ Open osteotomies like vertebral column resection (VCR) and pedicle subtraction osteotomy (PSO) have become quite unpopular.^4–7 The core concept of this minimally invasive spinal surgery technique (MISS) is to gain adequate strong fusion via the insertion of a cage. Although the surgical method is considered superior the risk of complications such as nerve root injury, vertebral endplate failure, collapse or misplacement of an interbody cage, and other hazardous complications still exists.⁸

Some of the important points to consider are 1) the placement of an accurate reference frame is necessary to avoid an otherwise risk for cage or PPS misplacement, 2) the exposure to radiation is significally decreased for the operating surgeons and its staff, 3) the navigating O arm guided PPS is accurate.⁹^,¹⁰ The latest novel techniques used for ASD correction include oblique lumbar interbody fusion at L5-S1 level (OLIF51) to consider success in creating lumbar lordosis and 360° fusion.¹¹^,¹² The application of CT-MRI combined fusion image is for clariﬁcation purposes of the lumbosacral vascular anatomy using 3D non-enhanced MRI and CT medical image fusion techniques.¹³ The objective of this retrospective study is to discuss key points that will help in strategic planning of lateral access in ASD surgery.

2 Materials and methods

All necessary approval was taken from the ethical committee to conduct this study and informed consent was duly signed from all included patients. A retrospective study was performed for 54 patients from October 2019 to January 2022 for C-arm free OLIF L1-S1 (L5) (average 71.5 ± 6.2 years-old, male 4, female 50) (Table 1). The mean follow-up interval was 29.2 ± 7.2 months, varying from 24 to 48 months. Clinical results are assessed by values including the Oswestry disability index (ODI) and visual analogue scale (VAS) for back pain. Radiographic evaluation was also collected preoperatively and at 12, and 24 months postoperatively. For OLIF51, CT- MRI fusion images were obtained before surgery.

Table 1 Patient demographic.

Patients (54)	Female 50, Male 4
Age (year)	71.5 ± 6.2
BMI (kg/m2)	22.9 ± 4.1
BMD T-score	−0.72 ± 1.7
Disease	Parkinson disease, Cerebral palsy 1
Follow-up period (months)	29.2 ± 8.4

For this study, inclusion criteria were patients above 60 years with a sagittal vertical axis (SVA) 95 mm or greater, severe low back pain, daily activities disturbance, difficulty maintaining posture while walking, and failure of conservative treatment for 2 months. We excluded neoplastic causes and infection of the spine. We selected the patients for OLIF51 based on the lack of any paraspinal vessel anomalies and with a wider spine vascular window of more than 20 mm without any intervention done at peritoneal adhesions.

2.1

2.1 Clinical assessment

All the patients were examined thoroughly for severe low back pain, numbness, claudication and reflexes of the abdomen, and range of motion for both leg and spine motion.

For low back pain assessment, we used the visual Analogue scale (VAS) and Oswestry disability index (ODI). We analyzed all clinical findings and data from patients. All patients underwent OLIF L1 to L5 (S1) and neuromonitoring. The amount of blood loss and duration of surgery is noted. Intraoperative and postsurgical complications such as unintentional durotomy, end plate fragmentation, surgical infection, epidural hematoma, focal sensory-motor deficits, reoperation, implant failure, mal-positioned implants, nerve roots, and the need for revision surgery will also be documented for further management.

2.2

2.2 Patient demographics

Patients’ demographics were summarized in Table 1.

2.3

2.3 Radiological assessments

Lateral dynamic radiographs were assessed to check for instability, sagittal alignment, pelvic tilt (PT), sagittal vertical axis (SVA), and pelvic incidence (PI) at preoperatively and one year follow-up. A Preoperative MRI was performed to evaluate degenerative disc condition, psoas muscle location, and spinal canal stenosis. CT was done for checking facet osteoarthritis, and disc height. CT-MRI fusion image combining 3D vascular image with bony structure was obtained using Synapse Vincent version 3.3 software (Fujifilm, Tokyo, Japan).¹³ This helps to find the accuracy of the operative procedure and found out any anomaly or anatomical variation. Bone mineral density (BMD) to assess the bone condition and osteoporosis. Postoperatively, lateral radiograms and computer tomography (CT) to evaluate for spinal bony union, disc height and L5-S1 angle, and sagittal alignment (Fig. 1).

Spinopelvic parameters and L5-S1 parameters. The Sagittal vertical axis (SVA), pelvic incidence (PI)-lumbar lordosis (LL), pelvic tilt (PT), L5-S1 angle; angle AGC, L5-S1 height; EF.

2.4

2.4 Statistical calculation

The data that were analyzed, has been documented as mean ± standard deviation. For correlation between cohorts, Mann-Whitney U test analysis was utilized to determine continuous variables for the appraisal of the p values. A p-value <0.05 was defined as statistically prominent and notable.

2.5

2.5 Operative procedure¹⁴

For every patient, positing is important where the patient is placed in the right lateral decubitus position on an adjustable hinged operating carbon table as the left side is a natural corridor between aorta and psoas muscle while permitting an easier approach (OSI Axis Jackson table, Mizuho, union city, CA, USA), followed by a 3D image with navigation by O arm (Medtronic Sofamor, Minneapolis, MN, USA)(Fig. 2). For protecting neurovascular structures in the axilla, Axillary rolls are placed while use positioning the patient. The patient was positioned in the center with the left slightly flexed to loosen the psoas muscles and lumbar nerve plexus. There are 15° convex in a table to open intervertebral disc space. We routinely use neuromonitoring to prevent injury to lumbar plexus and properly evaluate the condition's neurological complications during OLIF. The reference frame is attached percutaneously through SI joints.3D reconstruction images are obtained and transmitted to the navigation system (Stealth 7, Medtronic).

Skin incision One is for both L1-2 and L2-3, another one is for L3-4 and L4-5 and the other is for L5-S1.

2.5.1

2.5.1 Skin incision

All navigated spinal instruments are verified for the best available entry point for each separate disc, marked by a navigated pinpoint probe. We make three oblique skin incisions around 5 cm for this surgical method. A separate incision for L1-2 and L2-3 segments exists, another one is for L3-4 and L4-5 and finally a different one for L5-S1 (Fig. 3). Subcutaneous fat layers are dissected till down the abdominal musculature is identified. In sequence external and internal oblique, transverse abdominal muscles are divided along with muscle fibers. Bipolar cauterization is utilized to prevent injury at the area of iliohypogastric and ilioinguinal nerve. Using both Index fingers inside the retroperitoneal space it is easy to visualize posteriorly down to the psoas muscle. Then, a first direct lateral dilator is resting on the anterior border of the psoas muscle at disc level then use of a hand-held retractor to properly visualized peritoneal structures and a probe will lessen the risk of injury to ureter and vascular structure which are situated anteriorly. After the first probe safely passes in front of the anterior portion of the psoas sequential dilator of 22 mm is used. The depth of the skin was measured and the retractor is placed in the correct position and assembly to the flexible arm to fix the retractor.

2.5.2

2.5.2 Disc preparation and cage placements

MAST quadrant illumination system is attracted for proper visualization with a retractor blade then Annulotomy is done with pituitaries, Kerrison rongeurs, navigated ring curettes, and navigated shaver (Fig. 4). Navigated Cobb is used to pass along both ends of the plate's contralateral annulus with a mallet. With the navigation monitor, the correct height and length of the cage are measured and the proper height of the trail is inserted during impaction of trail and preoperative measurement of the disc are the key points to choose correct cage height.

Navigated shaver and curate. A: Navigated shaver, B: Navigated curate.

For bone graft, Iliac bone was obtained from posterior iliac crest. The mixture of the iliac bone autograft and demineralized allograft is placed into the cage hole and a mallet is used for gentle insertion of the OLIF cage (Clydesdale PTC, Medtronic Sofamor Danek, Minneapolis, MN) with navigated guidance (Fig. 5). After it is confirmed the position at the center of the disc space, the inserter is removed. Similarly, L2-5 OLIF with disc preparation with a similar approach. For OLIF51, after the cage insertion, minimum one supplemental screw should be placed to prevent cage displacement.

Navigated trial and cage. A: Navigated trial, B: Navigated cage.

2.5.3

2.5.3 Second-stage PPS fixation

One week later, the second stage of surgery is planned. The patient is prone position on the table and a reference frame attached with T11 spinous process. After taking the 3D image from T10-L3, every navigated instrument is calibrated with PPS inserted with navigation guidance (Fig. 4). For proximal T10 and T11 screw fixation, triangular fixation is done to prevent screw back out (A). Dual S2-sacral alar iliac screws are inserted for pelvic anchors¹⁵ (Fig. 6).

79 years old female, ASD OLIF L1-5 and Ponte Preoperative spinopelvic parameters were SVA 150 mm, PI 60°, PT 55°, LL -40°, PI-LL 100°, Cobb angle 50° (T6-L1), 72° (L1-4). Postoperative spinopelvic parameters were improved dramatically. (SVA -15mm, PI 60°, PT 20°, LL 50°, PI-LL 10°, Cobb 11° T6-L1, 12° L1-4).

3 Case presentation

3.1

3.1 Case 1 79 years old female, ASD, L1-5 OLIF, T10-pelvis posterior fusion and Ponte osteotomy (Fig. 7)

Case 2 77 years old female, ASD, L1-S1 OLIF, T10-pelvis PPS (Fig. 8).

77 years old female, ASD, L1-S1 OLIF, T10-pelvis PPS Preoperative spinopelvic parameters were SVA 60.7 mm, PI 60°, PT 27°, LL 35°, PI-LL 21°. The Preoperative Cobb angle was 53° (T12-L4). The Vascular window of L5-S1 was 34 mm, for corrective surgery OLIF51 and dual SAI were performed. Postoperative spinopelvic parameters were improved dramatically (SVA 6.5 mm, PI 60°, PT 21°, LL 48°, PI-LL 8°, Cobb 9° T12-L4).

4 Results

Postoperative and one year follow-up ODI were 45.9 ± 12.5% and 30.5 ± 18.9%, respectively (P < 0.01). Postoperative and one year follow-up VAS were 52.9 ± 7.3 mm and 31.2 ± 6.9 mm, respectively (P < 0.01). Surgical time was 490.9 ± 85.4 min, intraoperative blood loss was 1195.2 ± 653.8 ml (Table 2). Postoperatively, SVA and PT became normal (24.1 ± 39 mm, 17.1 ± 10.3°) and PI-LL was ideal (2.4 vs 12.6°) (Table 3). For OLIF51, postoperative L5-S1 angle was 12.0 ± 5.4°, L5-S1 angle gain was 9.4 ± 4.7 mm, Complications were PJK in 21 cases (38.9%), rod breakage in 5 cases (9.3%), surgical site infection in 2 cases (3.7%) and revision surgery 10 cases (18.5%). Revision surgeries were done for rod breakage. Solid bony fusions were found in all final follow-up cases.

Table 2 Clinical results.

	Preoperative value	Postoperative value	P value
ODI (%)	46.0 ± 10.4	30.5 ± 18.9	P < 0.01
VAS (mm)	52.9 ± 7.3	31.2 ± 6.9	P < 0.01
Surgical time (min)		490.9 ± 85.4
Intraoperative blood loss (ml)		1195.2 ± 653.8

Table 3 Radiological results.

	PREOPERATIVE VALUE	POSTOPERATIVE VALUE (1 YEAR FOLLOW-UP)	P VALUE
SVA (mm)	96.5 ± 55.9	24.1 ± 39.0	P < 0.01
PI (degree)	49.0 ± 11.3	49.1 ± 11.5
PT (degree)	34.5 ± 11.0	17.1 ± 10.3	P < 0.01
LL (degree)	13.3 ± 18.6	49.1 ± 9.7	P < 0.01
PI - LL (degree)	39.3 ± 22.1	2.4 ± 12.6	P < 0.01

5 Discussion

Literature review regarding corrective surgery for adult spine deformity (ASD) suggests that major complication rates are up to 26% and mortality rate is up to 2.4%, though these numbers may vary due to factors such as surgeon's experience, number of fused levels and patient's comorbidities.⁴^,⁵ Additionally, those rates are statistically even greater in cases was one stage correction with multiple level osteotomies is performed.⁶^,⁷ Research data revealed that mechanical complications such as implant-related failures, PJF, and PJK have an incidence rate of revision surgery varying from 20%–40%.^16–23 One fundamental concept is that while alignment is a static entity, balance is a dynamic one. As a result of soft tissue and muscle quality is crucial for maintaining the surgical correction. Considering all these factors, the main goals of the ASD are solid bony fusion, alignment-balance correction, reduce of the pain and indirect decompression toward neural structures following strict rehabilitation protocol. Extreme Lumbar Interbody Fusion (XLIF) was first introduced by Ozgur, who used the concept of MIS lateral interbody fusion to address ASD.²⁴ However, due to severe complications like psoas muscle weakness, lumbar nerve plexus paralysis, this procedure couldn't become regular advanced method of surgical techniques.^25–27

Our PJK incidence was 38.9% at two years follow-up. Among the reported complications for ASD surgery, incidence of PJK is very high (20–40%).²⁸ There have been reported methods to prevent PJK such as hook,²⁹ taping,³⁰ augmented screw,³¹ and proximal bone cement injection.³² The authors reported triangular fixation to prevent proximal screw pullout³³ As the strength of a triangular design is dependent on the amount of bone between the hardware rather than only screw purchase, it provides a stronger fixation.³⁴

With this technique, the spinal surgeon when adapting this skill helps to indirectly decompress nerve roots and other neural bodies and easily access anatomy for placement of large-sized cage disc with bone graft.¹⁴ The key point of this method is the plan for large placement of the cage with a bone graft that give an advantage of segmental stability and preserves lumbar lordosis with minimizing iatrogenic injury. Many studies regarding OLIF51 for ASD shows some typical benefit for the spinal surgeon.⁵^,¹² Due to its unique position of the patient in a lateral position and due to gravity, it pushes down the abdominal structures and allows the minimal structure to deal to reach its target point. In surgical procedures due to unilateral blunt dissection and careful retraction of the hypogastric sympathetic plexus, we can prevent hypogastric plexus injury and risk of postoperative retrograde ejaculation.^35–41

The important point for operative strategy of OLIF51, Liu et al. emphsized the importance of CT angiography with 3D reconstruction image for variation and anatomical vascular study with dye injection.³⁶ With the advancement and addressing the dye-related allergic case, the use of CT-MRI fusion came into existence for a new treatment option to allow spinal pathologies to view with navigation guidance techniques.³⁸^,³⁹ The recent cadaveric study states that the technology of 3D non-enhanced MRI-CT medical image fusion helps clarity of the lumbosacral vascular anatomy for evaluating the feasibility of OLIF51 operation for adult spinal deformity when contrast media is contraindicated.¹³ There is another important point in this technique for spine surgeons that OLIF operation needs to avoid the ureter/major vascular injury.⁴²

Many studies have been published on the use of C arm radiation risk hazard to operation surgeons and staff involved in this surgery.¹²^,³³ This procedure has the advantage that radiation dose of O arm scan can be reduced by 60% of ordinary CT scan.⁴³ In the case of a severe osteoporotic spine, there is a chance of fracture and risk with guidewire-related problems in handling vertebrae and structure so with technique carefulness it is better in fixation and cage placements.⁴⁴

There are a few limitations of our study. First is technique related: inadvertent movement of the reference frame may cause misplacement of the cage, and real-time cage expansion is not monitored on the computer screen. This is a small sample size of a retrospective study. The follow-up period was a little shorter. For future studies with longer follow-ups, larger cohorts are required to support this study at a larger level.

6 Conclusion

Clinical and radiological results of OLIF and PPS for ASD correction were excellent. The radiographic outcomes showed that OLIF51 created good L5-S1 lordosis and L5-S1 disc height. CT-MRI fusion images were very useful for evaluating vascular anatomy for OLIF51. The C-arm-free technique is a safe and effective technique that reduces radiation exposure.

Informed consent

All the participants were agreed to participate in the study by signing the informed consent form.

Institutional ethical committee approval

Ethical approval was obtained from Okayama Rosai Hospital, the Institutional Review Board (in accordance with Declaration of Helsinki).

Author contribution statement

Masato Tanaka MD, PhD, Corresponding author. Bashyal Santosh Kumar, MD, Writing original article. Shinya Arataki MD, PhD,Data Curation. Yoshihiro Fujiwara MD, Data Curation. Takuya Taoka MD, Data Curation. Mohammad Mushtaq MD, Data Curation. Konstantinos Zygogiannnis MD, Writing Review & Editing. Sameer Ruparel MD, Writing Review & Editing.

Declaration of Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

Ethical approval was obtained from Okayama Rosai Hospital, the Institutional Review Board (in accordance with Declaration of Helsinki).

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Chang M.C., Kim G.-U., Choo Y.J., Lee G.W., . Transforaminal lumbar interbody fusion (TLIF) versus oblique lumbar interbody fusion (OLIF) in interbody fusion technique for degenerative spondylolisthesis: a systematic review and Meta-analysis. Life. 2021;11:696.
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Kim T.T., Drazin D., Shweikeh F., Pashman R., Johnson J.P., . Clinical and radiographic outcomes of minimally invasive percutaneous pedicle screw placement with intraoperative CT (O-arm) image guidance navigation. Neurosurg Focus. 2014;36(3):E1.
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Kakarla U.K., Little A.S., Chang S.W., Sonntag V.K., Theodore N., . Placement of percutaneous thoracic pedicle screws using neuronavigation. World Neurosurg. 2010;74(6):606-610.
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Lateral access minimally invasive spine surgery in adult spinal deformity

Abstract