Elsevier

World Neurosurgery

Volume 149, May 2021, Pages e225-e230
World Neurosurgery

Original Article
The Safety and Efficacy of Stand-Alone Lateral Lumbar Interbody Fusion for Adjacent Segment Disease in a Cohort of 44 Patients

https://doi.org/10.1016/j.wneu.2021.02.046Get rights and content

Background

A mainstay of treatment for symptomatic adjacent segment disease (ASD) has consisted of revision with posterior decompression and fusion. This carries significant morbidity and can be technically difficult. An alternative is stand-alone lateral lumbar interbody fusion (LLIF), which may avoid complications associated with revision surgery. We describe the largest cohort of patients treated with LLIF for ASD to our knowledge.

Methods

We conducted a retrospective cohort study on all patients who underwent transpsoas LLIF for ASD at a single academic center between 2012 and 2019. Postoperative improvement was measured using the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI).

Results

Forty-four patients who underwent LLIF for ASD were identified. Median age was 65 years. Median time from index surgery to ASD development was 78 months. Median levels fused via LLIF was 1. Our median follow-up was 358 days. At follow-up, the median VAS back pain score was 0 (mean, 0.884), median VAS leg pain score was 1 (mean, 0.953), and median ODI was 8. The median improvement for VAS back pain was 8, for VAS leg pain was 6, and for ODI was 40. No patients suffered new neurologic symptoms postoperatively. Of the 17 patients who initially presented with non-pain neurologic symptoms, 8 (47.1%) experienced complete resolution of symptoms, and 5 (29.4%) experienced only some improvement.

Conclusions

To our knowledge, this is the largest cohort study of patients to date evaluating stand-alone LLIF for ASD. Our patient outcomes show it is safe and effective with low risk of morbidity.

Introduction

Lumbar fusions are a mainstay of treatment offered by spinal surgeons in the United States for a variety of spinal pathology. Fusions were first described by the Greeks in the 5th century BC, and these crude procedures laid the foundation for the techniques that we have today.1 In the more recent past, lumbar fusions have exponentially increased in the United States over the past several decades.2, 3, 4 An unintended consequence of these fusions, however, is the development of adjacent segment disease (ASD) as they alter the biomechanics of the spine. Regrettably, these fusion masses create increasing biomechanical stress on motion segments above and below the constructs, which is likely leading to ASD.5, 6, 7, 8

It is well documented in the literature that the typical treatment for ASD is posterior decompression with extension of hardware and fusion.9, 10, 11, 12, 13 However, as with any revision surgery, there is significant morbidity to the patient, and it is more technically difficult for the surgeon to define planes secondary to scar tissue in addition to previous hardware. There are multiple studies evaluating the high blood loss, incidence of dural injury, surgical site infections, and perioperative complication rates in those patients undergoing posterior approach revision surgery.9, 10, 11, 12, 13

A potential alternative to the posterior approach is the lateral lumbar interbody fusion (LLIF), which was first described by Ozgur et al.14 It is a less invasive retroperitoneal approach that traverses the psoas muscle to reach diseased spinal levels. An obvious advantage of this approach is the avoidance of dissecting through a previous incision with adherent scar tissue to place a sizeable interbody into the disk space facilitating indirect decompression of neural elements.15 In the literature, there are a few articles describing the stand-alone LLIF for the treatment of ASD. In particular, Louie et al.16 described their experience with 25 patients. To add to the growing body of literature on the utility and safety of LLIF for ASD, the purpose of our study was to describe our experience with the stand-alone LLIF for ASD, with what is to our knowledge the largest known cohort.

Section snippets

Patient Population and Study Design

After receiving institutional review board approval (IRB# Pro00023643), we compiled a series of all patients who underwent transpsoas LLIF for ASD at a single academic tertiary care referral center between 2012 and 2019. To identify these patients, we reviewed case request orders for the keywords, “lateral lumbar interbody fusion” and “extreme lateral interbody fusion.” Then, with review of operating room radiographs, patients were excluded if there was no previous hardware or if the laterally

Results

During the specified time period, we identified 44 patients who underwent LLIF for ASD between 6 different board-certified neurologic surgeons at our center. The baseline characteristics of these patients are outlined in Table 1. The median age in our population was 65 years (interquartile range, 58.5–73; range, 32–83). At the time of surgery, 12 patients (27.3%) were current smokers, 3 (6.8%) were former smokers, and 29 (65.9%) had never smoked. In patients' index cases, there was a median 2

Discussion

Our findings confirm previous reports that stand-alone LLIF is a safe and appropriate treatment for ASD in what is to our knowledge the largest cohort of such described patients.16,17 In our series, 91% of patients experienced significant improvement of their back, radicular, and claudication pains. Some 47% of patients who developed new-onset non-pain-related neurologic complaints experienced complete resolution after stand-alone LLIF. During follow-up, only 1 patient (2.2%) required a

Conclusions

To our knowledge, this is the largest cohort study of patients to date evaluating stand-alone LLIF for ASD. Our patient outcomes show this is a safe and effective operation with a low risk of morbidity for patients with ASD following previous posterior lumbar instrumentation and fusion. A future study analyzing patients with longer follow-up time may be helpful in confirming the long-term success of LLIF in treating ASD.

CRediT authorship contribution statement

Ryan Screven: Conceptualization, Methodology, Validation, Investigation, Data curation, Writing - original draft, Writing - review & editing, Visualization. Elliot Pressman: Methodology, Validation, Investigation, Data curation, Writing - original draft, Writing - review & editing, Visualization. Gautam Rao: Conceptualization, Methodology, Investigation, Data curation, Writing - review & editing, Visualization. Thomas B. Freeman: Conceptualization, Writing - review & editing, Visualization,

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  • Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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