Article Figures & Data
Figures
- Figure 1
(A) Patient positioning on Jackson table. (B) Drawing the surgical incision. (C) Surgical draping for both lateral and posterior work, with incisional markings outlined.
- Figure 2
(A and B) Fingers from a number 9-sized glove covering the retractor blades before insertion. (C) Demonstration of retroperitoneal fat in the visual field without the use of the glove barrier. (D) Visualization of the surgical corridor when the gloves are around the retractor blades, and fat creep is minimized.
- Figure 3
(A) Neural mapping conducted by stimulating the posterior blade and black dilator. The dilator is rotated within the surgical corridor to ensure a safe working zone both posterior and anterior within the retractor.(B) Placement of the dilator in the surgical field.
- Figure 4
(A) The surgeon’s view of the retractor with the posterior intradiscal shim and anterior longitudinal ligament (ALL) retractor in place. (B) Anterior-posterior view of the retractor, ALL retractor (outlined in green), and posterior shim docked at the L4-L5 level. (C) View of the surgical corridor highlighting the placement of the ALL retractor (outlined in green).
- Figure 5
(A) Side view of the surgeon having to bend their neck to view down the surgical corridor. (B) Improved ergonomics and visualization can be achieved by rotating the bed approximately 5° to 10° away from the surgeon.
- Figure 6
(A and B) A high iliac crest extending to the inferior border of the L4 pedicle can be circumvented using a retractor setup with a caudal 90-mm blade (outlined in green). (C and D) The short caudal blade allows the retractor to open without pushing against the iliac crest.
Tables
- Table
Summary of the scenarios encountered during a prone lateral lumbar interbody fusion and suggested surgical tips and tricks to overcome them.
Setting Problem Consequence Solution Visualization of the surgical corridor Retroperitoneal fat can creep into the field. Fat in the field could obstruct visualization of the disc space and may result in injury to peritoneum or retroperitoneal contents. Place the cut fingers of a number 9 glove over the retractor blades to create a expandable barrier (Figure 2). Anchoring the retractor Difficult to test all 4 quadrants prior to shim placement. Shim insertion without safe passage may injure neural structures. Stimulate the posterior blade with t-EMG; next, use the black (initial) dilator to determine surrounding nerve proximity, and then insert the posterior shim over the black dilator (Figure 3). Retractor stability Unrecognized ventral migration of the retractor will force the discectomy tools even more ventral. Potential anterior implant placement or injuries to the vessels may occur. Analyze the preoperative magnetic resonance imaging to evaluate the fat plane between the anterior longitudinal ligament (ALL) and the vessels. Use a Cobb elevator to develop this plane and placement of an ALL retractor. Surgeon ergonomics Looking into the retractor during prone lateral procedures creates uncomfortable neck hyperextension. Lack of ergonomics can cause long-term frustration or neck pain. Rotating the bed 5° to 10° away from the surgeon creates a neutral neck position and optimizes visualization of the surgical corridor. High iliac crest Iliac crest extending to the L4 pedicle can make it difficult to access the L4-L5 disc. The downside retractor blade may block the angled instruments from optimal position. A 90-mm caudal retractor blade allows for a circumferential retroperitoneal retraction without blocking the angled instruments.
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