The lateral transpsoas approach for interbody fusion is a minimally invasive technique that has been gaining increasing popularity in the management of a variety of spinal degenerative disorders. Recently, there has been increasing utilization of this technique in the management of adult deformity. The authors present a review of the current evidence of using the lateral lumbar transpsoas approach in the correction of adult degenerative scoliosis.
Key points
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The lateral transpsoas approach for interbody fusion is a minimally invasive technique that has been successfully used in the treatment of a variety of spinal degenerative disorders.
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There is growing evidence that this technique can be used in the management of adult deformity with good results and acceptable risks.
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It is more powerful in correcting coronal deformity than sagittal deformity if used as the sole approach or technique.
Introduction
The lateral transpsoas approach for interbody fusion was first described by McAffee and colleagues and later on further advanced by Ozgur and colleagues. Through a small incision, a lateral window through the psoas muscle is created; through a table-mounted working channel, lumbar interbody fusion can be completed using large cages with footprints that span the vertebral body from side to side.
This minimally invasive technique, which lacks an open counterpart, has been increasingly used to accomplish interbody fusions for a wide variety of spinal degenerative disorders that include spondylolisthesis and degenerative disk disease with reportedly excellent outcomes and an acceptable risk profile ( Fig. 1 ). Following the interbody fusion, most surgeons supplement the construct with percutaneous pedicle screws placed though a posterior or dorsal approach because this has been proven to be biomechanically superior to stand-alone lateral interbody fusions. Moreover, pedicle screw supplementation improves correction and decreases the risk of graft subsidence.
The degree of segmental correction in the coronal plane ranges from 3.0° to 5.9°. The average segmental correction in the sagittal plane varied between 2.2° and 3.3°. Following the increasing successful use of this interbody fusion technique in the degenerative arena, reports of its application to adult deformity and mainly adult degenerative scoliosis started to emerge as an alternative way to open traditional corrections, where blood loss and muscle dissection are not insignificant. This article presents a review of the literature analyzing clinical and radiographic studies using the lateral lumbar transpsoas approach in the correction of adult degenerative scoliosis.
Introduction
The lateral transpsoas approach for interbody fusion was first described by McAffee and colleagues and later on further advanced by Ozgur and colleagues. Through a small incision, a lateral window through the psoas muscle is created; through a table-mounted working channel, lumbar interbody fusion can be completed using large cages with footprints that span the vertebral body from side to side.
This minimally invasive technique, which lacks an open counterpart, has been increasingly used to accomplish interbody fusions for a wide variety of spinal degenerative disorders that include spondylolisthesis and degenerative disk disease with reportedly excellent outcomes and an acceptable risk profile ( Fig. 1 ). Following the interbody fusion, most surgeons supplement the construct with percutaneous pedicle screws placed though a posterior or dorsal approach because this has been proven to be biomechanically superior to stand-alone lateral interbody fusions. Moreover, pedicle screw supplementation improves correction and decreases the risk of graft subsidence.
The degree of segmental correction in the coronal plane ranges from 3.0° to 5.9°. The average segmental correction in the sagittal plane varied between 2.2° and 3.3°. Following the increasing successful use of this interbody fusion technique in the degenerative arena, reports of its application to adult deformity and mainly adult degenerative scoliosis started to emerge as an alternative way to open traditional corrections, where blood loss and muscle dissection are not insignificant. This article presents a review of the literature analyzing clinical and radiographic studies using the lateral lumbar transpsoas approach in the correction of adult degenerative scoliosis.
Materials and methods
A computerized literature search of the National Library of Medicine’s database, Cochrane database, and Google Scholar was performed for published material between January 1966 and August 2013 using keywords and medical subject headings. The keywords included the following: lateral lumbar interbody fusion, direct lateral interbody fusion, extreme lateral interbody fusion, lateral transpsoas interbody fusion, DLIF (direct lateral interbody fusion), and XLIF (extreme lateral interbody fusion). The search yielded 546 citations. The authors then selected for English citations and reviewed all abstracts generated in the search.
Among the citations reviewed, the authors identified 10 articles that primarily focused on radiographic and clinical outcomes following lateral transpsoas interbody fusion for the correction of spinal deformity. All 10 citations were retrospective studies ( Table 1 ). The articles are summarized in the results section.
| Author, Year | Number of Patients | Follow-up (mo) | Average Lateral Interbody Fusion Segments | Coronal Cobb Angle Preoperative | Coronal Cobb Angle Postoperative | Sagittal Cobb Angle Preoperative | Sagittal Cobb Angle Postoperative | Outcomes Improved | Blood Loss (mL) | Hospital Stay (d) |
|---|---|---|---|---|---|---|---|---|---|---|
| Anand et al, 2008 | 12 | 2.5 | 3.6 | 18.9 | 6.1 | N/A | N/A | VAS, TIS | 257 | 8.6 |
| Tormenti et al, 2010 | 8 | 10.5 | 2.8 | 38.5 | 10.0 | 47.3 | 40.4 | VAS | N/A | N/A |
| Wang & Mummaneni, 2010 | 23 | 13.4 | 3.7 | 31.4 | 11.5 | 37.4 | 45.5 | VAS | 447 | 6.2 |
| Dakwar et al, 2010 | 25 | 11.0 | 3.0 | 21.1 | 6.4 | N/A | N/A | VAS, ODI | 53/level | 6.2 |
| Karikari et al, 2011 | 11 | 16.4 | N/A | 22.0 | 14.0 | 39.0 | 44.0 | VAS, ODI | 228 | 4.8 |
| Sharma et al, 2011 | 25 | 12.0 | N/A | 24.0 | 13.6 | 47.8 | 48.3 | VAS,ODI, SF-12 P | N/A | N/A |
| Acosta et al, 2011 | 8 | 21.0 | N/A | 21.4 | 9.7 | 42.1 | 46.2 | VAS, ODI | N/A | N/A |
| Kotwal et al, 2012 | 31 | 24.0 minimum | N/A | 24.8 | 13.6 | N/A | N/A | VAS, ODI, SF-12 P | 537 | 7.7 |
| Johnson et al, 2013 | 15 | 6.0 minimum | N/A | 13.0 | 7.1 | 42.8 | 44.4 | VAS, ODI, SF-36 | N/A | N/A |
| Anand et al, 2013 | 66 | 39.0 | 4.0 | 24.7 | 9.5 | N/A | N/A | VAS, TIS, ODI, SF-36 | 314 for lateral interbody fusion | 7.6 |
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