Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Summary

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Abstract

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large implant size and optimal implant position. However, current methods for lateral interbody cage placement require either a two-staged procedure or a single lateral decubitus position that precludes surgeons from having either full access to the posterior spine for direct decompression or comfortable pedicle screw placement.

Herein is one institution's experience with 10 cases of a prone single-position approach for simultaneous access to the anterior and posterior lumbar spine. This allows both lateral lumbar interbody cage placement, direct posterior decompression, and pedicle screw placement, all in one position. Three-dimensional (3D) navigation is utilized for increased precision in both approaching the lateral spine and interbody cage placement. The traditional blind psoas muscle tubular dilation was also modified. Tubular retractors and lateral vertebral body retractor pins were used to minimize the risks to the lumbar plexus.

Introduction

First described as extreme lateral interbody fusion (XLIF) in 2006, the lateral lumbar interbody fusion approach (LLIF) utilizes a transpsoas approach to the vertebral body¹. The LLIF presents several operative advantages over other traditional approaches. First, the LLIF is one of the least invasive interbody fusion approaches, minimizing perioperative tissue damage and blood loss, as well as postoperative pain and length of hospital stay^2,3. The LLIF allows for the placement of larger interbody spacers, which confers a greater likelihood of fusion and greater disc height distraction

Protocol

NOTE: The protocol follows the guidelines of and was approved by the Brigham human research ethics committee.

1. Equipment and positioning

1. Use an open Jackson table for the procedure. Ensure the availability of both frameless stereotactic navigation and intraoperative neuromonitoring with lower extremity electromyography (EMGs), which are critical to the success of the case.
   ​NOTE: An open Jackson table allows the abdominal viscera to fall away from the spine during the lateral approach.
2. Place the patient in the prone position with legs extended. Pay special attention to the hip and/or thigh pads on the si....

Results

Cohort demographics
Ten consecutive patients underwent the Pro-LLIF procedure from August 2020 to February 2021. The eligibility criteria for this procedure were ages 18 and older and symptomatic degenerative spondylosis with spinal instability (spondylolisthesis or degenerative scoliosis) from L2 to L5, requiring interbody fusion. Per the institution's standard of care, all patients had trialed and failed a course of conservative management. The exclusion criteria were patients excluded from operati.......

Discussion

This study provides a detailed protocol for a prone, single-position, 3D-navigation-guided lateral lumbar interbody fusion (Pro-LLIF). Pro-LLIF permits concurrent access to the anterior and posterior spine and does not require patient repositioning, unlike the two-stage OLIF or XLIF approach⁹. This single-position approach has been associated with decreased operative time, anesthesia time, and surgical staffing requirements, presenting physical and financial benefits^8,.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
CONDUIT Lateral Lumbar Implants	DePuy Synthes		EIT Cellular Titanium Interbody
COUGAR LS Lateral Spreaders	DePuy Synthes		Lateral Spreaders: 6, 8, 10, 12, 16 mm
COUGAR LS Lateral Trials	DePuy Synthes		Parallel Trial, 18 x 6 mm
COUGAR LS Lateral Trials	DePuy Synthes		Lordotic Trials, 18 x 8 mm 18 x 10 mm 18 x 12 mm 18 x 14 mm
DePuy Synthes ATP/Lateral Discetomy Instruments	Avalign Technologies LLC
Dual Lead Awl Tip Taps 4.35 mm – 10 mm	DePuy Synthes		Navigation Enabled Instruments used with Medtronic StealthStation Navigation System
EXPEDIUM 5.5 System	DePuy Synthes		with VIPER Cortical Fix Screws
EXPEDIUM Driver Shaft T20 5.5	DePuy Synthes		Navigation Enabled Instruments used with Medtronic StealthStation Navigation System
EXPEDIUM Drive Sleeve 5.5	DePuy Synthes		Navigation Enabled Instruments used with Medtronic StealthStation Navigation System
Phantom XL3 Lateral Access System	TeDan Surgical Innovations, LLC	Lateral Access retractor (includes dilators and LED Lightsource)
PIPELINE LS LATERAL Fixation Pins	DePuy Synthes
The R Project, R package version 4.0, MatchIt package			propensity-score matching
SENTIO MMG Lateral Probe	DePuy Synthes		Lateral Access Probe
SENTIO MMG Stim Clip	DePuy Synthes		attaches to insilated dilators, conducting triggered EMG while rotating 360 degrees
VIPER 2 1.45 mm Guidewire, Sharp	DePuy Synthes