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Single Position Spinal Surgery — Prone Lateral L3-L4

History

The patient is a 47-year-old female with intractable low back pain and proximal lower extremity pain that has continued to worsen for several years. She was referred to our practice from pain management. No prior surgeries.

Examination

The patient has 5/5 motor strength in her bilateral lower extremities. Her low back pain, assessed using the Visual Analogue Scale (VAS), was an 8/10 with pain radiating bilaterally into her thighs and legs (sciatica) but not below the knees. She has no sensory deficits, but does have an antalgic gait. Her reflexes are normal.

Prior Treatment

Previous nonsurgical treatments did not provide significant or satisfying pain relief. Conservative treatments included:

  • 12 weeks of organized physical therapy
  • Several rounds of spinal steroid injections
  • Over the counter anti-inflammatory medications
  • Prescription muscle relaxants
  • Narcotic pain medications provided moderate pain control

Pretreatment Imaging

 

Anteroposterior and lateral X-rays demonstrate L3-L4 spondylosis without abnormal sagittal balance or coronal deformity Figure 1: Anteroposterior and lateral X-rays demonstrate L3-L4 spondylosis without abnormal sagittal balance or coronal deformity. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Lumbar MRI and CTs show severe L3-L4 spondylosis and degenerative disc disease Figure 2: Lumbar MRI and CTs show severe L3-L4 spondylosis and degenerative disc disease. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Diagnosis

L3-L4 spondylosis caused by degenerative disc disease

Suggest Treatment

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Selected Treatment

The patient underwent a minimally invasive prone retroperitoneal transpsoas lumbar interbody fusion at L3-L4 with L3-L4 percutaneous pedicle screw fixation. The procedure was performed in the prone position.

  1. Robotically assisted percutaneous lumbar pedicle screws were placed with modular heads.
  2. A prone retroperitoneal transpsoas approach was used.
  3. Lumbar interbody fusion was performed using a titanium interbody graft (22mm x 55mm x 8mm with 10° of lordosis) filled with allograft (hydroxyapatite [HA] tricalcium phosphate [TCP]). The anterior longitudinal ligament was carefully preserved.
  4. Following implant placement, rods were attached and with final tightening.

See figures 3 through 10 below.

Surgeons' Treatment Rationale

We elected to proceed with circumferential fusion via a lateral approach with percutaneous screw fixation. Our choice of lateral interbody fusion was to maximize implant footprint to provide greater fusion area, while the decision to perform circumferential fusion with pedicle screw fixation was selected to increase biomechanical stability and increase odds of fusion.

Furthermore, our rationale in performing this surgery in the prone position includes:

  1. Maximizing surgical efficiency and reducing operative time
  2. Decreasing economic impact of repositioning and cost of disposables
  3. Maximizing lordosis in the prone position
  4. Facilitating surgical ergonomics

In our experience, prone positioning results in shorter operative time and improved screw accuracy, with a more natural position for the patient and the surgeon. Furthermore, in our institution we have introduced the use of CT navigation and robotics in an effort to improve screw accuracy, reduce surgical time, and reduce X-ray use.

Placement of robotic reference marks for surgical navigation Figure 3: Placement of robotic reference marks for surgical navigation . Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Robotic navigation guidance used to fine tune pedicle screw trajectory and skin entry points Figure 4: Robotic navigation guidance used to fine tune pedicle screw trajectory and skin entry points. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

 

Using the robotic arm with sentinel fluoroscopy in pedicle screw placement Figure 5: Using the robotic arm with sentinel fluoroscopy in pedicle screw placement. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

The percutaneous modular screws are placed Figure 6: The percutaneous modular screws are placed. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

In the prone position, and laterally, the lumbar interbody device was placed with navigation assistance Figure 7: In the prone position, and laterally, the lumbar interbody device was placed with navigation assistance . Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Demonstrating the retractor docking Figure 8: Demonstrating the retractor docking. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Figure 9: Placement of the interbody device Figure 9: Placement of the interbody device. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Intraoperative imaging demonstrates implant placement with pedicle screw fixation Figure 10: Intraoperative imaging demonstrates implant placement with pedicle screw fixation. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Confirmatory postoperative CT scans demonstrate ideal screw placement without pedicle breach Figure 11: Confirmatory postoperative CT scans demonstrate ideal screw placement without pedicle breach. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Outcome

The patient was discharged home on the first postoperative day. Her postop X-rays at immediate postop period demonstrated stable and well-positioned instrumentation (Figure 12).

At her 6-week follow-up, VAS in her legs had decreased to 1/10 and to 2/10 in her low back. Improvement in her antalgic gait was seen at that time as well.

Figure 12Figure 12. Image © Used with Permission. Jakub Godzik, MD, MSc, and SpineUniverse.com.

Disclosures: Drs. Godzik and Ohiorhenuan have no disclosures to report. Dr. Uribe is a consultant for NuVasive, Inc., Misonix, Inc., and SI-BONE, Inc.

I read this case with great interest and I found that this particular patient illustrates so many different learning points. First of all, this case shows a focused pathology at the L3-L4 level with the rest of the spine being relatively normal.

The symptoms match the pathology, and the patient has completed a full course of comprehensive conservative treatments and interventional treatments, which can provide therapeutic and diagnostic information. The patient appears to be an appropriate surgical candidate, with the pathology identified, and with appropriate symptoms.

The primary point of the case is which surgical treatment to consider, and the reasons why some would prefer one of the approaches versus one of the others. It is important to realize that all of these approaches are viable surgical options for this patient, and one should always offer the surgery which they feel comfortable and would give the best outcome in their own hands. We all have our own preferences and the authors have picked a relatively novel option, which I think makes a lot of sense in this situation.

The choice of using an interbody cage placed into the anterior disc space has a lot of advantages. The placement of a cage allows for reconstitution of the normal disc height, which in turn restores a more normal alignment to the segment. The cage also restores the foraminal height.

In the setting of a collapsed disc, it is difficult to fully decompress the nerve roots in the neuroforamen without restoring the foraminal height. The use of posterior pedicle screws to stabilize the segment, ensures an optimal chance of healing, but some would wonder if the added morbidity is necessary. The use of the minimally invasive approach for the screws, makes the addition of the screws a shorter surgery with less morbidity.

The novel approach to this surgical procedure lies in the positioning of the patient prone and doing the entire procedure in this position. This shortens the operative time, eliminating the need to reposition the patient, and allowing for maximizing the time spent in the surgery.

I congratulate the authors for showing this case and illustrating using the maximal amount of stability, accompanied by an optimal use of minimally invasive techniques.

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