technical and practical considerations of lateral lumbar ... eastlack.pdfnic lbp + rle pain •...
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11/13/2015
1
Robert K. Eastlack MD
Scripps Clinic
Co-Director, Fellowship Training Program
San Diego Spine Foundation
Technical and Practical
Considerations of Lateral Lumbar
Interbody Fusion (LLIF) in Spinal
Deformity Surgery
DISCLOSURES Nuvasive
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• BASELINE
SAGITTAL/CORONAL
ALIGNMENT
• ANTICIPATED CORONAL
PLANE CHANGE
– Beware of compensatory upper
lumbar curve
– Look for lumbosacral fractional
curves
– Anticipate effect of dysmorphic
vertebral bodies
Preoperative Planning
• Careful review of
vascular, neural,
renal/ureter anatomy
(axial MRI/CT
images)
• Staged vs. same
day posterior recon
• L5-S1
– Interbody?
– TLIF vs. ALIF?
PREOP PLANNING
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Beware Fractional Curves!
• 73yo physician
• LBP
• Bilateral variable
distribution
radiculopathy
• Progressive
Case Example
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No right L5
radiculopathy
symptoms
MRI
L3-4 L4-5
• T-score: -0.3
• PI 48
• LL 28
• SVA 29mm
• PT 28
Options?
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Intraop LLIF L2-5
EBL 30cc
Immediate Postop
PI 48 LL 28 PT 28 Resolved leg pain
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• Need lordosis?
• Correct coronal
alignment
• Osteotomies?
• L5-S1?
• Length of
fusion/construct?
Options?
• ALIF L5-S1
• Perc fixation
L2-S1
• Facet
releases L2-
5
Second Stage
PI 48 LL 50 PT 19
EBL 250cc
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• 73yo female
with
progressive/chro
nic LBP + RLE
pain
• Neuro intact
• T score = -1.4
Case Example
Multilevel DDD/foraminal stenosis
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• Look for balance
– Coronal
– Sagittal
• What measures
necessary to
achieve
alignment
objectives?
Case Example
• 2.5hrs
• EBL 50cc
Intraop
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• Ambulating POD 1
• Home POD 2
• TLSO
• Mild hip flexion
discomfort-
resolved<10days
• No neuro abnl
• 2yrs postop--very
pleased
POSTOP
• Greater scrutiny on
visceral/vascular
structures on axial
images
• Determine renal/liver
locations
• Prior surgeries?
– retroperitoneal
Preop Planning
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MRI
2014/5/19-20
L4
L4
L1
L1
S1
S1
L1/2
2014/5/19-20
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L2/3
2014/5/19-20
L3/4
2014/5/19-20
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L3/4
2014/5/19-20
L4/S1
2014/5/19-20
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Concave or Convex Sided Approach in Scoliosis?
Evaluate the degree of rotation
Vascular/neural anatomy
For degenerative scoliosis cases: Approach on the concave side Better access to L4-L5 and collapsed side Small incision and exposure to access to multiple levels Psoas and plexus is more relaxed Better deformity correction
Concave release
Clears the
crest
Minimizes number of
incisions, but tight
access to disc
L4-5 not accessible
from convex side
Patient Positioning Considerations
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Sequence of Laterals
• L1-2 or L4-5 first
– L1-2 first unless L4-5 aids in angle of approach to L1-2
• Then, work down
– Avoids building away from your advantaged vector of approach/incision location
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Sample Case
OR
execution
Review of Advanced Imaging
L3-4
L4-5
Assess rotation of each level and potential effect of approach side
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Intraoperative Preparation
• New AP optimized imaging for each level
• Use caudal level as proxy for neutral rotation
• Angled approach PRN
Intraoperative Preparation
• Table Trendelenberg for obtaining lateral profile view of disk space
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Next Level
L4-5
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Dealing with Overhangs
Getting Docked
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Opening the Disk Space
Dealing with Overhangs
Osteotome or Cobb if needed to access disk space
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Using Cobb Elevators Safely
• Flip the cobb to use the ‘soft’ edge
POSTOP
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• 67yo female
• 10 yrs prog
LBP/leg pain
• s/p B THA
• T score -1.3
• Coronal cobb 33
deg
Case Example
• Choice in mgt?
– Post only
– A/P
– LLIF/post
– open vs. MIS
• Staged vs. same
day
PI 52 LL 26 PT 30
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POSTOP 1yr
PI 52 LL 53 PT 19
EBL = 500 cc
X ray
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X ray
MRI
L2/3
L3/4
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CT
BEWARE THE FRACTIONAL CURVE
• Plan LLIF with radiographs and advanced
imaging
– Assess vascular/plexus anatomy
– Beware fractional curves!
• Typically go to concavity
• Sequence laterals according to disk space
accessibility and curve unfolding
• Consider staging if alignment outcome
uncertain
SUMMARY
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