Navigation and Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion: Technique, Feasibility, Safety, and Case Series

doi:10.1016/j.wneu.2021.05.097

World Neurosurgery

Volume 152, August 2021, Pages 221-230.e1

https://doi.org/10.1016/j.wneu.2021.05.097 Get rights and content

Background

Single-position prone lateral interbody fusion is a recently introduced technical modification of the minimally invasive retroperitoneal transpsoas approach for lateral lumbar interbody fusion (LLIF). Several technical descriptions of single-position prone LLIF have been published with traditional fluoroscopy for guidance. However, there has been no investigation of either three-dimensional computed tomography–based navigation for prone LLIF or integration with robotic assistance platforms with the prone lateral technique. This study evaluated the feasibility and safety of spinal navigation and robotic assistance for single-position prone LLIF.

Methods

Retrospective review of medical records and a prospectively acquired database for a single center was performed to examine immediate and 30-day clinical and radiographic outcomes for consecutive patients undergoing single-position prone LLIF with spinal navigation and/or robotic assistance.

Results

Nine patients were treated, 4 women and 5 men. Mean age was 65.4 years (range, 46–75 years), and body mass index was 30.2 kg/m² (range, 24–38 kg/m²). The most common surgical indication was adjacent segment disease (44.4%), followed by pseudarthrosis (22.2%), spondylolisthesis (11.1%), degenerative disc disease (11.1%), and recurrent stenosis (11.1%). Postoperative approach-related complications included pain-limited bilateral hip flexor weakness (4/5) and pain-limited left knee extension weakness (4/5) in 1 patient (11.1%) and right lateral thigh numbness and dysesthesia in 1 patient (11.1%). All cages were placed within quarters 2–3, signifying the middle portion of the disc space. There were no instances of misguidance by navigation.

Conclusions

Integration of spinal navigation and robotic assistance appears feasible, accurate, and safe as an alternative to fluoroscopic guidance for single-position LLIF.

Introduction

Since the initial description more than a decade ago of the minimally invasive retroperitoneal transpsoas approach for lateral lumbar interbody fusion (LLIF) in degenerative disc disease, this approach has seen an evolution in application and technical execution.¹ The LLIF technique has been used in a variety of pathologies beyond degenerative disc disease, including deformity, trauma, infection, and tumors.2, 3, 4, 5 The original LLIF approach has also been adapted for treatment of the thoracolumbar junction and thoracic spine pathologies and for use with three-dimensional (3D) computed tomography (CT)–based spinal navigation, robotic assistance, and single-position techniques for both interbody fusion and posterior instrumentation.6, 7, 8, 9, 10, 11, 12, 13, 14, 15

The most recent innovation has been the introduction of single-position prone LLIF. This is an attractive technical modification that provides the benefits of lateral cage placement with more convenient and standard patient positioning. Potential benefits include increased lumbar lordosis compared with the traditional lateral position; gravity-induced ventral displacement of peritoneal contents; reduced operative time; and ease of dorsal decompression, posterior column osteotomies, and placement of posterior instrumentation without need for a positional change.6, 7, 8^,¹⁶ Though several technical descriptions of single-position prone LLIF have recently been published, all have relied on traditional fluoroscopy for guidance.6, 7, 8, 9 3D CT spinal navigation provides increased accuracy and decreased radiation exposure to the surgeon and staff compared with traditional fluoroscopic techniques.17, 18, 19, 20, 21 Use of 3D CT spinal navigation and robotic assistance has been reported with LLIF in the traditional lateral position.11, 12, 13^,²² However, there has been no investigation of either 3D CT-based navigation for prone LLIF or integration with robotic assistance platforms with the prone lateral technique. We examined the feasibility, technique, and safety profile of the prone LLIF technique using intraoperative cone-beam CT with a traditional image-guided navigation system or a 3D navigated robotic assistance platform.

Section snippets

Materials and Methods

A retrospective analysis of medical records and a prospectively acquired database from a single academic medical center was performed to identify patients who underwent prone LLIF from 2020 to 2021 with the O-arm Surgical Imaging System (Medtronic, Minneapolis, Minnesota, USA) for 3D image acquisition with either the StealthStation guidance system (Medtronic) or the ExcelsiusGPS robotic navigation platform (Globus Medical, Audubon, Pennsylvania, USA) for spinal navigation. Nine consecutive

Results

Nine patients were treated, 4 women and 5 men, and all were included in the analysis. Table 1 presents patient demographics and procedural data. Mean age was 65.4 years (range, 46–75 years), and mean body mass index was 30.2 kg/m² (range, 24–38 kg/m²). All interbody approaches were performed from the left. Most cases were revision surgery (77.8%). All cases involved an additional posterior approach for a portion of the procedure. The additional posterior approaches involved a level other than

Discussion

Much of the impetus for the development of single-position LLIF has been due to the time-consuming nature and break in workflow of a staged procedure requiring a positional change. Though stand-alone lateral interbody cages are an option, higher rates of subsidence and the increased rigidity afforded by supplemental posterior instrumentation has led many surgeons to frequently perform staged procedures.24, 25, 26 The desire to eliminate the need for repositioning to perform circumferential

Conclusions

This short technical note with case series highlights our adaptation of 3D CT-based navigation and robotic assistance to single-position prone LLIF. Integration of spinal navigation and robotic assistance appears feasible, accurate, and safe as an alternative to fluoroscopy for single-position LLIF.

CRediT authorship contribution statement

Robert Y. North: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing - original draft, Writing - review & editing. Michael J. Strong: Data curation, Writing - review & editing. Timothy J. Yee: Data curation, Writing - review & editing. Osama N. Kashlan: Methodology, Supervision, Writing - review & editing. Mark E. Oppenlander: Methodology, Supervision, Writing - review & editing. Paul Park: Conceptualization, Formal analysis, Methodology,

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Cited by (13)

Robot-navigated pedicle screw insertion can reduce intraoperative blood loss and length of hospital stay: analysis of 1,633 patients utilizing propensity score matching
2024, Spine Journal
Navigation and robotic technologies have emerged as an alternative option to conventional freehand techniques for pedicle screw insertion. However, the effectiveness of these technologies in reducing the perioperative complications of spinal fusion surgery remains limited due to the small cohort size in the existing literature.
To investigate whether utilization of robotically navigated pedicle screw insertion can reduce the perioperative complications of spinal fusion surgery—including reoperations—with a sizeable cohort.
Retrospective study.
Patients who underwent primary lumbar fusion surgery between 2019 and 2022.
Perioperative complications including readmission, reoperation, its reasons, estimated blood loss, operative time, and length of hospital stay.
Patients’ data were collected including age, sex, race, body mass index, upper-instrumented vertebra, lower-instrumented vertebra, number of screws inserted, and primary procedure name. Patients were classified into the following two groups: freehand group and robot group. The variable-ratio greedy matching was utilized to create the matched cohorts by propensity score and compared the outcomes between the two group.
A total of 1,633 patients who underwent primary instrumented spinal lumbar fusion surgery were initially identified (freehand 1,286; robot 347). After variable ratio matching was performed with age, sex, body mass index, fused levels, and upper instrumented vertebrae level, 694 patients in the freehand group and 347 patients in robot groups were selected. The robot group showed less estimated blood loss (418.9±398.9 vs 199.2±239.6 ml; p<.001), shorter LOS (4.1±3.1 vs 3.2±3.0 days; p<.001) and similar operative time (212.5 vs 222.0 minutes; p=.151). Otherwise, there was no significant difference in readmission rate (3.6% vs 2.6%; p=.498), reoperation rate (3.2% vs 2.6%; p=.498), and screw malposition requiring reoperation (five cases, 0.7% vs one case, 0.3%; p=1.000).
Perioperative complications requiring readmission and reoperation were similar between fluoroscopy guided freehand and robotic surgery. Robot-guided pedicle screw insertion can enhance surgical efficiency by reducing intraoperative blood loss and length of hospital stay without extending operative time.
Correlation Between Mental Health and Patient-Reported Outcomes After Lateral Lumbar Interbody Fusion
2023, World Neurosurgery
We sought to assess correlational relationship between mental health and outcomes following lateral lumbar interbody fusion (LLIF).
Patients who had undergone LLIF were identified. Patients with indications for surgery including infection, trauma, or malignancy were excluded. Patient-reported outcomes (PROs) included short-form (SF)-12 Mental Component Score (MCS)/Patient Health Questionnaire (PHQ)-9/Patient-Reported Outcomes Measurement Information System−Physical Function (PROMIS-PF)/12-Item Short-Form Physical Component Score (SF-12 PCS)/Visual Analog Scale (VAS) back and leg pain/Oswestry Disability Index (ODI) and were collected preoperatively and at several postoperative time points extending to 1 year. Pearson correlation tests were used to compare the 12-item Short Form Mental Component Score (SF-12 MCS) and PHQ-9 with the other PROs.
We included 124 patients. SF-12 MCS positively correlated with PROMIS-PF at 6 months (r = 0.466) and SF-12 PCS preoperatively (r = 0.287) and at 6 months (r = 0.419) (P ≤ 0.041, all). SF-12 MCS negatively correlated with VAS back preoperatively (r = −0.315), at 12 weeks (r = −0.414), and at 6 months (r = −0.746); VAS leg at 12 weeks (r = −0.378); and ODI preoperatively (r = −0.580) (P ≤ 0.023, all). PHQ-9 negatively correlated with PROMIS-PF at all periods except 12 weeks (range: r = −0.357 to −0.566, P ≤ 0.017, all) and SF-12 PCS preoperatively, at 6 weeks, and at 6 months (range: r = −0.363 to −0.562, P ≤ 0.022, all). PHQ-9 positively correlated with VAS back at all periods before 1-year (range: r = 0.415–0.690, P ≤ 0.001, all), VAS leg at 12-weeks (r = 0.467) and 6-months (r = 0.402) (P ≤ 0.028, both), and ODI at all periods except 6-months (range: r = 0.413–0.637, P ≤ 0.008, all).
Better mental health scores correlated with superior physical function, pain, and disability scores when measured by both SF-12 MCS and PHQ-9. PHQ-9 more consistently reported significant correlation to all outcomes measured when compared to SF-12 MCS.
Neuromonitoring in Lateral Approaches for Lumbar Interbody Fusion: A Systematic Review
2022, World Neurosurgery
Citation Excerpt :
Furthermore, these lateral approaches for lumbar interbody fusion techniques typically allow for greater cage placement compared with posterior approaches, such as transforaminal lumbar interbody fusion (TLIF) and have lower risk for vascular injury compared to anterior lumbar interbody fusion (ALIF).3 Despite the prevalent use of IONM in LLIF, the specific IONM modalities vary between studies.6-24 Further, some articles have examined the neurologic complications in LLIF without IONM.10,25
The modality of intraoperative neuromonitoring (IONM) in lateral approaches for interbody fusion varies. We aim to examine the types of neuromonitoring used in lateral approaches for lumbar interbody fusion and associated neurologic complications.
A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. PubMed and Embase databases were searched from inception to July 2022 for articles examining lateral approaches for lumbar interbody fusion of lateral lumbar interbody fusion (LLIF) or oblique lateral interbody fusion (OLIF) with IONM modalities. Lateral approaches for lumbar interbody fusion with/without IONM was included. Articles without original patient data, case reports with fewer than 2 patients, non-English articles, nonlateral procedures, and nonhuman studies were excluded. The Risk of Bias in Non-randomized Studies–of Interventions tool was used to assess for bias.
A total of 34 studies were included. Twenty LLIF articles had IONM, whereas 1 LLIF article did not have IONM. Three OLIF articles specified IONM, whereas 6 OLIF articles did not have IONM. Two articles had patients undergoing either LLIF or OLIF. For LLIF, overall neurologic complications, motor weakness, and sensory deficits were 19.8%, 7.6%, and 10.6%, respectively. OLIF overall neurologic complications, motor weakness, and sensory deficits were 5.9%, 2.9%, and 3.2%, respectively. Neurologic outcomes with IONM were not superior compared to without IONM in either LLIF or OLIF.
Neurologic complication rates in LLIF remain high despite utilization of IONM. Use of IONM did not benefit neurologic outcomes. More prospective studies with different IONM modalities and without IONM are needed before determining specific benefits or shortcomings of each IONM modality.
Oblique lateral interbody fusion: The fundamentals for practice
2022, Seminars in Spine Surgery
Citation Excerpt :
Alternatively, OLIF can be paired with posterior fixation to augment construct stability, so-called anteroposterior combined surgery (APCS), while still achieve foraminal and central decompression indirectly through height restoration at the disc space. Computer navigation has specifically contributed to recent advancements in single position APCS.12,13,15 Prior literature has cited the benefits for single position APCS to include an increased lumbar lordosis compared to standard lateral position; ventral displacement of retroperitoneal contents leading to a decreased rate of postoperative ileus; reduced operative time; decreased radiation exposure when using navigation over fluoroscopic techniques; improved accuracy of cage placement; and ease of dorsal decompression, posterior column osteotomies and posterior instrumentation placement.12–15
With the avoidance of dissection through the psoas, the oblique lateral interbody fusion (OLIF) offers the spine surgeon a safe option of indirect decompression of the lumbar spine. Described in 1997, the OLIF technique continues to expand its surgical indications with the advent of navigation and robotic technology. This paper will discuss the indications and contraindications of the OLIF procedure while highlighting anatomic considerations, technical aspects, outcomes and complications. From degenerative spondylosis, to sagittal and coronal deformity, the pathology that can be addressed with the OLIF continues to evolve with the aging population. Endplate fracture and subsidence and transient neuropraxias are the most common complications, with an overall rate less than that of transforaminal lumbar interbody fusion (TLIF) or posterolateral interbody fusion (PLIF) with the added benefit of a shorter hospital stay.
Advancing Prone-Transpsoas Spine Surgery: A Narrative Review and Evolution of Indications with Representative Cases
2024, Journal of Clinical Medicine
Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion: Indications, Techniques, and Outcomes
2023, JBJS Essential Surgical Techniques

View all citing articles on Scopus

: Supplementary digital content available online.

: Conflict of interest statement: P. Park is a consultant to Globus and NuVasive, receives royalties from Globus, and is involved in non–study-related research funded by ISSG and DePuy Synthes. M. E. Oppenlander is a consultant for Globus Medical and Bioventus Surgical. The remaining authors declare no commercial or financial interests that could be construed as potential conflicts of interest.

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Technical NoteNavigation and Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion: Technique, Feasibility, Safety, and Case Series

Background

Methods

Results

Conclusions

Introduction

Section snippets

Materials and Methods

Results

Discussion

Conclusions

CRediT authorship contribution statement

Spine J

Int J Surg

Orthop Traumatol Surg Res

Lateral access to paravertebral tumors

J Neurosurg Spine

Clinical outcomes of extreme lateral interbody fusion in the treatment of adult degenerative scoliosis

ScientificWorldJournal

Direct lateral retroperitoneal approach for the surgical treatment of lumbar discitis and osteomyelitis

Neurosurg Focus

Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral approach in the thoracic and lumbar spine

Spine (Phila Pa 1976)

Single-position prone lateral approach: cadaveric feasibility study and early clinical experience

Neurosurg Focus

Prone single-position extreme lateral interbody fusion (Pro-XLIF): preliminary results

Eur Spine J

The prone transpsoas technique: preliminary radiographic results of a multicenter experience

Eur Spine J

Prone transpsoas technique for simultaneous single-position access to the anterior and posterior lumbar spine

Oper Neurosurg (Hagerstown)

Extreme lateral interbody fusion (XLIF) in the thoracic and thoracolumbar spine: technical report and early outcomes

HSS J

Navigated robot-guided pedicle screws placed successfully in single-position lateral lumbar interbody fusion

J Robot Surg

Use of 3D CT-based navigation in minimally invasive lateral lumbar interbody fusion

J Neurosurg Spine

Technical Note
Navigation and Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion: Technique, Feasibility, Safety, and Case Series