technical and practical considerations of lateral lumbar ... eastlack.pdfnic lbp + rle pain •...

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

Aesculap

Alphatec

Depuy

Eli Lilly

Stryker

Carevature

DiFusion

Spine Innovations

NuTech

Globus

Invuity

Ulrich

K2M

Titan

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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

technical and practical considerations of lateral lumbar ... eastlack.pdfnic lbp + rle pain •...

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