39 Translumbar Surgery Comparison: Four Surgeons and Regions
39.1 How I Do It
Summary
This chapter will provide the reader with the “step sequence” from four different surgeons around the world, performing translumbar surgery (LLIF). The format presented here includes “classic” case example images, patient positioning tips, and surgical details (approach, incision, tricks, closure) displayed in columns and simultaneously presented in a side-by-side format to facilitate their comparison. After going through this chapter, the readers should be able to reinforce, adopt, or change their practice based on the sequence and/or tricks presented by the authors.
| Region: Latin America Dr. Luiz Pimenta | Region: Europe/UK Dr. Khai Lam |
| Step 1: Preoperative planning | Step 1: Preoperative planning |
•Anteroposterior (AP) and lateral X-ray with measurement of spinopelvic parameters and global spinal alignment. •Flexion/extension X-ray to determine need for posterior fixation. •Computed tomography (CT). •Magnetic resonance imaging (MRI)—evaluate psoas anatomy and location of the lumbar plexus. •Neuromonitoring (IOM) is mandatory.
| •Standing AP and lateral X-ray with measurement of spinopelvic parameters and global spinal alignment. •CT •MRI—evaluate psoas anatomy and location of the lumbar plexus. •IOM.
|
| Step 2: Patient positioning | Step 2: Patient positioning |
•Radiolucent table, can be bent to increase space between iliac crest and ribs. •Lateral decubitus with padding between the knees. •Securely tape patient: Below iliac crest, thoracic region, from greater trochanter over knee to table, from knee over ankle to table. •True 90-degree lateral position: AP image at 0 degree shows spinous processes in midline and lateral image at 90 degrees shows pedicles and end plates are aligned. •Notice the 1,2,3 of the picture, highlighting the “single vertebral body image” pattern of a “true” lateral (left) view and the perfect round circles observed on a “true” AP view (right).
| •Breakable Allen table, can be flexed to open space between iliac crest and ribs; avoid over-flexion (typically 20–30 degrees) to prevent excess traction on psoas and neural plexus. •Lateral decubitus with hips and knees flexed to 30 degrees, ipsilateral leg placed atop a rectangular bolster. •Securely tape patient: Upper torso, “figure of 8” tape to secure pelvis and legs. •Obtain a true lateral fluoroscopic image: Pedicles and end plates are perfectly aligned (Refer to the Step 2 of Dr. Luiz Pimenta).
|
| Region: Europe Dr. Massimo Balsano | Region: Asia Dr. Masato Tanaka |
| Step 1: Preoperative planning | Step 1: Preoperative planning |
•AP and lateral X-ray. •Flexion/extension X-ray. •MRI—evaluate psoas anatomy and location of the lumbar plexus. •IOM.
| •Evaluate location of iliac crest relative to L4–L5 disc space on lateral X-ray. •High rising psoas is a contraindication. •Evaluate vascular anatomy on MRI. •IOM
|
| Step 2: Patient positioning | Step 2: Patient positioning |
•Radiolucent table; can break table at the level of iliac crest to open the space between crest and ribs. •If necessary break table to access L4–L5; increase the degree of knee flexion to relieve stretch on the lumbar plexus. •Lateral decubitus with secure patient taping.
| •Radiolucent table; can break table by 15 degrees to access L4–L5; high rising psoas is a contraindication. •Lateral decubitus, true lateral position which also enables percutaneous pedicle screw insertion. •Legs slightly flexed to loosen psoas and lumbar plexus and secured with tape.
|
| Region: America Dr. Luiz Pimenta | Region: Europe/UK Dr. Khai Lam |
| Step 3: Incision | Step 3: Incision |
•Two K-wires identify the center of the target disc space using lateral fluoroscopy. •One line drawn in the AP direction in line with the disc space. •One line drawn in the superior-inferior direction crossing center of the vertebral bodies adjacent to the disc space. •A single skin incision made at the intersection of these two lines.
| •A radio-opaque cross is placed over the target disc space and a 4 cm oblique skin mark is made in line with the disc 0.5 cm anterior to center of the disc.
|
| Step 4: Approach | Step 4: Approach |
•Lateral abdominal layers identified and opened (external and internal obliques, transversus abdominis, transversalis fascia) until retroperitoneal fat is encountered. •Index finger dissects through the retroperitoneal fat, sweeping finger deep and up toward skin to open the space above the psoas muscle. •A second incision is made in the fascia through which index finger guides first dilator onto the psoas (single skin incision, two fascial incisions).
| •External and internal obliques and transversus abdominis are identified and sharply dissected with scissors. •Langenbeck retractors used to retract in the direction of the muscle fibers until the transversalis fascia is identified and sharply punctured using scissors to access the retroperitoneal space. •Peanut swabs on a 22-cm Roberts artery forceps used to gently sweep the retroperitoneal sac anteriorly to reveal psoas. •The retroperitoneal space is further enlarged by index finger sweeping. •Index finger palpates psoas and the first dilator is passed posterior to the finger atop the psoas.
|
| Region: Europe Dr. Massimo Balsano | Region: Asia Dr. Masato Tanaka |
| Step 3: Incision | Step 3: Incision |
•A metal cross is used to localize the middle third of the disc space. •A transverse incision of 4 cm is sufficient for one level.
| •Lateral X-ray used to mark location, orientation, and anterior and posterior margins of L4–L5. •Target site for docking indicated by line perpendicular to disc space at the posterior third. •4 cm oblique skin incision.
|
| Step 4: Approach | Step 4: Approach |
•Blunt scissors are used to dissect through subcutaneous tissue until external oblique muscle is identified. •The muscles are then gently divided along their natural course using a Langenbeck retractor in sequence. •Index finger touches the “spaghetti bag” psoas muscle and sweeps the peritoneum anteriorly. •Blunt scissors are used to split the lateral fibers of the psoas and the first dilator is inserted with electromyography (EMG) monitoring. |
