- Department of Neurosurgery, Centre of Excellence: Brain and Spine, Aster CMI, Bengaluru, Karnataka, India.
DOI:10.25259/SNI_292_2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Umesh Srikantha, Yadhu Kasetti Lokanath, Akshay Hari, S. Nirmala, Ravi Gopal Varma. Minimally invasive lateral transpsoas approach for lumbar corpectomy and stabilization. 02-Aug-2019;10:153
How to cite this URL: Umesh Srikantha, Yadhu Kasetti Lokanath, Akshay Hari, S. Nirmala, Ravi Gopal Varma. Minimally invasive lateral transpsoas approach for lumbar corpectomy and stabilization. 02-Aug-2019;10:153. Available from: http://surgicalneurologyint.com/surgicalint-articles/9555/
Background: Here, we present our experience with the minimally invasive (MI) transpsoas approach for lumbar corpectomy and stabilization. Transpsoas approach accesses the lumbar spine and includes both the direct lateral interbody fusion and extreme lateral interbody fusion techniques. Both procedures utilize a tubular retractor system which facilitates adequate retraction and direct visualization of the target, while supposedly reducing soft tissue trauma.
Case Description: We evaluated two patients, one with a traumatic L2 wedge compression fracture and the other with an L3 pathological compression fracture due to multiple myeloma. Both patients underwent MI transpsoas lumbar corpectomy, anterior column reconstruction with an expandable cage, and posterior pedicle screw instrumentation to correct a kyphotic deformity. Both patients were mobilized on the 1st postoperative day and experienced significant postoperative pain relief.
Conclusion: In two cases involving L2 and L3 compression fractures, MI transpsoas lumbar corpectomy was safely performed, with reduced perioperative and postoperative morbidity. Here, the transpsoas approach also allowed for early mobilization, adequate postoperative biomechanical stability, and resulted in immediate good outcomes.
Keywords: Lateral approach, Lumbar corpectomy, Minimally invasive surgery, Transpsoas approach
Conventional posterior open approaches for lumbar corpectomy have many drawbacks; complete facetectomy, extensive paraspinal muscle dissection, prolonged retraction resulting in ischemia, and muscle injury. These contribute to significant postoperative pain, infection risk, and disability.[
Minimally invasive (MI) techniques have lower approach-related complication rates in some studies, while others demonstrate greater risks attributed to inadequate visualization, which can be reduced by moving the expandable tubular retractor in cranial or caudal and medial or lateral direction allowing for adequate visualization. Understanding detailed anatomy and keeping precise surgical orientation are essential for this technique.
Potential benefits of MI include reduced soft tissue trauma, intraoperative blood loss, postoperative pain, along with faster mobilization, shorter hospital length of stay, and health-care costs.[
Here, we describe the MI lateral transpsoas approach to the lumbar spine to perform corpectomy and fusion. Two patients with L2 and L3 vertebral fractures underwent this surgery to the lumbar spine, accompanied by anterior column reconstruction with an expandable cage, and posterior pedicle screw instrumentation to correct kyphotic deformities.
Utilizing somatosensory evoked and motor evoked potential monitoring, the patient is positioned in the right lateral decubitus position. The desired vertebral body level is localized under fluoroscopy; this is marked on the left flank. A 5–6 cm incision then allows for routine exposure of the retroperitoneal space.
The first dilator is passed over a Kirschner wire and docked at the desired level. Retractors blades then expose the desired vertebrae. Discectomies caudal and cranial to the involved vertebra are then performed, and the corpectomy is completed in a piecemeal fashion. The end plates are decorticated and the interbody cage is inserted under fluoroscopy, followed by routine closure. The patient is then repositioned prone for the placement of posterior percutaneous pedicle screws.
A 55-year-old male with an L2 wedge compression fracture first underwent an L1–L3 pedicle screw fusion elsewhere. For persistent increasing back pain, progressive pseudoarthrosis, vertebral body collapse, and focal kyphotic angulation, he required an MI lateral corpectomy [
Case 1 – (a) Immediate postoperative fluoroscopic image of lumbosacral spine showing L2 wedge compression with pedicle screw at L1–L3 after primary surgery. (b and c) Anteroposterior/ lateral fluoroscopic image of lumbosacral spine at 1 year post instrumentation showing progressive L2 vertebral body collapse with pedicle screw loosening at L1 and L3.
This included partial resection of the 12th rib, placement of an interbody expandable cage, and revision of the posterior fusion using T12 to L4 percutaneous pedicle screw fixation [
Case 1 – (a) Patient positioned in the right lateral decubitus position with the kidney bridge raised and table bent to provide access to the lumbar spine. (b and c) Localizing the target vertebrae on fluoroscopy and marking the safe zone to access the vertebrae. (d) Planned incision. (e) Lateral lumbar fluoroscopic image showing placement of the corpectomy cage and posterior pedicle screw fixation from D12 to L4.
A 63-year-old female with multiple myeloma on chemotherapy presented with a pathological L3 vertebral body compression fracture presenting with worsening low back pain limiting her daily routine activities. The lumbar magnetic resonance imaging revealed 50% reduction in the L3 vertebral body height with dual-energy X-ray absorptiometry revealing osteopenia [
She underwent an L3 MI lateral corpectomy using an interbody expandable cage, supplemented with polymethyl methacrylate followed by percutaneous posterior pedicle screw fixation from L2 to L4 [
Case 2 – (a and b) Lateral and anteroposterior fluoroscopic image showing expandable cage with pedicle screw at L2 and L4. (c) Postoperative radiograph of lumbosacral spine at 4 months (anteroposterior) showing placement of the corpectomy cage and posterior pedicle screw fixation from L2 to L4.
The recent innovations in spine surgery have prompted the utilization of MI techniques to decrease operative morbidity.
Ozgur et al. first described MI lateral approach for interbody fusion in 2016.[
MI lateral lumbar corpectomy is a promising technique for carefully selected patients but still carries significant risks.
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
There are no conflicts of interest.
1. Assaker R. Minimal access spinal technologies: State-of-the-art, indications, and techniques. Joint Bone Spine. 2004. 71: 459-69
2. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine. 2003. 28: S26-35
3. Harris EB, Massey P, Lawrence J, Rihn J, Vaccaro A, Anderson DG. Percutaneous techniques for minimally invasive posterior lumbar fusion. Neurosurg Focus. 2008. 25: E12-
4. Hsieh PC, Koski TR, Sciubba DM, Moller DJ, O’Shaughnessy BA, Li KW. Maximizing the potential of minimally invasive spine surgery in complex spinal disorders. Neurosurg Focus. 2008. 25: E19-
5. Moller DJ, Slimack NP, Acosta FL, Koski TR, Fessler RG, Liu JC. Minimally invasive lateral lumbar interbody fusion and transpsoas approach-related morbidity. Neurosurg Focus. 2011. 31: E4-
6. Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme lateral interbody fusion (XLIF): A novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006. 6: 435-43
7. Park A, Deukmedjian AR, Uribe JS. Minimally invasive anterolateral corpectomy for spinal tumors. Neurosurg Clin N Am. 2014. 25: 317-25
8. Selznick LA, Shamji MF, Isaacs RE. Minimally invasive interbody fusion for revision lumbar surgery: Technical feasibility and safety. J Spinal Disord Tech. 2009. 22: 207-13