Single position circumferential fusion improves operative efficiency, reduces complications and length of stay compared with traditional circumferential fusion

ABSTRACT

BACKGROUND CONTEXT

Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) with percutaneous posterior screw fixation are two techniques used to address degenerative lumbar pathologies. Traditionally, these anterior-posterior (AP) surgeries involve repositioning the patient from the supine or lateral decubitus position to prone for posterior fixation. To reduce operative time (OpTime) and subsequent complications of prolonged anesthesia, single-position lumbar surgery (SPLS) is a novel, minimally invasive alternative performed entirely from the lateral decubitus position.

PURPOSE

Assess the perioperative safety and efficacy of single position AP lumbar fusion surgery (SPLS).

STUDY DESIGN

Multicenter retrospective cohort study.

PATIENT SAMPLE

Three hundred and ninety patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group.

OUTCOME MEASURES

Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence, pelvic tilt, and segmental LL.

METHODS

Patients undergoing primary ALIF and/or LLIF surgery with bilateral percutaneous pedicle screw fixation between L2-S1 were included over a 4-year period. Patients were classified as either traditional repositioned “Flip” surgery or SPLS. Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, EBL, LOS, perioperative complications. Radiographic analysis included LL, pelvic incidence, pelvic tilt, and segmental LL. All measures were compared using independent samples t-tests and chi-squared analyses as appropriate with significance set at p < .05. Propensity matching was completed where demographic differences were found.

RESULTS

Three hundred and ninety patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group. Age, gender, BMI, and CCI were similar between groups. Levels fused (1.47 SPLS vs 1.52 Flip, p = .468) and percent cases including L5-S1 (31% SPLS, 35% Flip, p = .405) were similar between cohorts. SPLS significantly reduced OpTime (103 min vs 306 min, p < .001), EBL (97 vs 313 mL, p < .001), LOS (1.71 vs 4.12 days, p < .001), and fluoroscopy radiation dosage (32 vs 88 mGy, p < .001) compared to Flip. Perioperative complications were similar between cohorts with the exception of postoperative ileus, which was significantly lower in the SPLS group (0% vs 5%, p < .001). There was no significant difference in wound, vascular injury, neurological complications, or Venous Thrombotic Event. There was no significant difference found in 90-day return to operating room (OR).

CONCLUSIONS

SPLS improves operative efficiency in addition to reducing blood loss, LOS and ileus in this large cohort study, while maintaining safety.

Introduction

Circumferential lumbar fusion surgery is an effective treatment option for degenerative and deformity related spinal conditions. Anterior lumbar interbody fusion (ALIF) and lateral interbody fusion (LLIF) surgeries offer the advantage of placement of large surface area interbody devices under direct compression of the anterior spinal column. This promotes a healthy fusion environment, has the potential to improve sagittal alignment and restore disc height, while indirectly decompressing neural elements by increasing foraminal area [[1], [2], [3], [4], [5], [6], [7], [8]]. Additionally ALIF and LLIF can be performed by a minimally invasive (MIS) approach through smaller incisions without compromising posterior tension bands or causing posterior muscular injury, yielding reduced hospital stays, operative times, blood loss, postoperative pain, fewer complications and faster recovery times [9].

In order to obtain the most biomechanically stable construct and prevent loss or correction due to cage subsidence, ALIF and LLIF surgeries are often supplemented with percutaneous pedicle screw fixation (PPSF) [1,[9], [10], [11], [12]]. A potential drawback of ALIF or LLIF with PPSF is the time consuming process of changing operating room set ups and patient positioning when moving from the supine or lateral to the prone position, so-called “flip.” To reduce operating room time (ORT) and subsequent complications of prolonged anesthesia and prone positioning, lateral decubitus single position anterior-posterior lumbar fusion surgery (SPLS) is novel, minimally invasive alternative performed entirely from the lateral decubitus position. This aim of this study was to assess the perioperative through 90-days postoperative outcomes of a large series of patients undergoing SPLS compared to patients treated with anteroposterior (AP) fusion with a “flip.”