-
JBJS Essential Surgical Techniques 2023Lateral lumbar interbody fusion (LLIF) is a widely utilized minimally invasive surgical procedure for anterior fusion of the lumbar spine. However, posterior...
BACKGROUND
Lateral lumbar interbody fusion (LLIF) is a widely utilized minimally invasive surgical procedure for anterior fusion of the lumbar spine. However, posterior decompression or instrumentation often necessitates patient repositioning, which is associated with increased operative time and time under anesthesia. The single-position prone transpsoas approach is a technique that allows surgeons to access both the anterior and posterior aspects of the spine, bypassing the need for intraoperative repositioning and therefore optimizing efficiency. The use of robotic assistance allows for decreased radiation exposure and increased accuracy, both with placing instrumentation and navigating the lateral corridor.
DESCRIPTION
The patient is placed in the prone position, and pedicle screws are placed prior to interbody fusion. Pedicle screws are placed with robotic guidance. After posterior instrumentation, a skin incision for LLIF is made in the cephalocaudal direction, orthogonal to the disc space, with use of intraoperative (robotic) navigation. Fascia and abdominal muscles are incised to enter the retroperitoneal space. Under direct visualization, dilators are placed through the psoas muscle into the disc space, and an expandable retractor is placed and maintained with use of the robotic arm. Following a thorough discectomy, the disc space is sized with trial implants. The expandable cage is placed, and intraoperative fluoroscopy is utilized to verify good instrumentation positioning. Finally, posterior rods are placed percutaneously.
ALTERNATIVES
An alternative surgical approach is a traditional LLIF with the patient beginning in the lateral position, with intraoperative repositioning from the lateral to the prone position if circumferential fusion is warranted. Additional alternative surgical procedures include anterior or posterior lumbar interbody fusion techniques.
RATIONALE
LLIF is associated with reported advantages of decreased risks of vascular injury, visceral injury, dural tear, and perioperative infection. The single-position prone transpsoas approach confers the added benefits of reduced operative time, anesthesia time, and surgical staffing requirements. Other potential benefits of the prone lateral approach include improved lumbar lordosis correction, gravity-induced displacement of peritoneal contents, and ease of posterior decompression and instrumentation. Additionally, the use of robotic assistance offers numerous benefits to minimally invasive techniques, including intraoperative navigation, instrumentation templating, a more streamlined workflow, and increased accuracy in placing instrumentation, while also providing a reduction in radiation exposure and operative time. In our experience, the table-mounted LLIF retractor has a tendency to drift toward the floor-i.e., anteriorly-when the patient is positioned prone, which may, in theory, increase the risk of iatrogenic bowel injury. The rigid robotic arm is much stiffer than the traditional retractor, thereby reducing this risk.
EXPECTED OUTCOMES
Compared with traditional LLIF, with the patient in the lateral and then prone positions, the single-position prone LLIF has been shown to have several benefits. Guiroy et al. performed a systematic review comparing single and dual-position LLIF and found that the single-position surgical procedure was associated with significantly lower operative time (103.1 versus 306.6 minutes), estimated blood loss (97.3 versus 314.4 mL), and length of hospital stay (1.71 versus 4.08 days). Previous studies have reported improved control of segmental lordosis in the prone position, which may be advantageous for patients with sagittal imbalance.
IMPORTANT TIPS
Adequate release of the deep fascial layers is critical for minimizing deflection of retractors and navigated instruments.The hip should be maximally extended to maximize lordosis, allowing for posterior translation of the femoral nerve and increasing the width of the lateral corridor.A bolster is placed against the rib cage to provide resistance to the laterally directed force when impacting the graft.The cranial and caudal limits of the approach are bounded by the ribcage and iliac crest; thus, surgery at the upper or lower lumbar levels may not be feasible for this approach. Preoperative radiographs should be evaluated to determine the feasibility of this approach at the intended levels.When operating at the L4-L5 disc space, posterior retraction places substantial tension on the femoral nerve. Thus, retractor time should be minimized as much as possible and limited to a maximum of approximately 20 minutes.A depth of field (distance from the midline to the flank) of approximately 20 cm may be the limit for this approach with the current length of retractor blades.In robotic-assisted surgical procedures, minor position shifts in surface landmarks, the robotic arm, or the patient may substantially impact the navigation software. It is critical for the patient and navigation components to remain fixed throughout the operation.In addition to somatosensory evoked potential and electromyographic monitoring, additional motor evoked potential neuromonitoring or monitoring of the saphenous nerve may be considered.In the prone position, the tendency is for the retractor to migrate superficially and anteriorly. It is critical to be aware of this tendency and to maintain stable retractor positioning.
ACRONYMS AND ABBREVIATIONS
LLIF = lateral lumbar interbody fusionMIS = minimally invasive surgeryPTP = prone transpsoasy.o. = years oldASIS = anterior superior iliac spinePSIS = posterior superior iliac spineALIF = anterior lumbar interbody fusionTLIF = transforaminal lumbar interbody fusionMEP = motor evoked potentialSSEP = somatosensory evoked potentialEMG = electromyographyCT = computed tomographyMRI = magnetic resonance imagingOR = operating roomPOD = postoperative dayIVC = inferior vena cavaA. = aortaPS. = psoas.
PubMed: 38357472
DOI: 10.2106/JBJS.ST.22.00022 -
Revista de Neurologia Feb 2024
Topics: Humans; Abscess; Psoas Muscles
PubMed: 38349320
DOI: 10.33588/rn.7804.2023327 -
BMC Musculoskeletal Disorders Feb 2024This study aimed to investigate the relationship between femoral neck fractures and sarcopenia.
BACKGROUND
This study aimed to investigate the relationship between femoral neck fractures and sarcopenia.
METHODS
This was a retrospective analysis of 92 patients with femoral neck fractures, from September 2017 to March 2020, who were classified into high ambulatory status (HG) and low ambulatory status (LG) groups. Ambulatory status was assessed before surgery, one week after surgery, at discharge, and during the final follow-up. To evaluate sarcopenia, muscle mass and fatty degeneration of the muscles were measured using preoperative CT. An axial slice of the superior end of the L5 vertebra was used to evaluate the paraspinal and psoas muscles, a slice of the superior end of the femoral head for the gluteus maximus muscle, and a slice of the inferior end of the sacroiliac joint for the gluteus medius muscle. The degeneration of the muscles was evaluated according to the Goutallier classification.
RESULTS
The cross-sectional area of the gluteus medius and paraspinal muscles was significantly correlated with ambulatory status before the injury, at discharge, and during the final follow-up.
CONCLUSIONS
Measurement of the gluteus medius and paraspinal muscles has the potential to evaluate sarcopenia and predict ambulatory status after femoral neck fractures.
Topics: Humans; Sarcopenia; Retrospective Studies; Tomography, X-Ray Computed; Psoas Muscles; Buttocks; Femoral Neck Fractures; Paraspinal Muscles
PubMed: 38347481
DOI: 10.1186/s12891-024-07251-1 -
Cureus Feb 2024When a malignant tumor infiltrates the psoas muscle, it is termed malignant psoas syndrome (MPS). We are reporting this case because the malignancy led to atrophy of the...
When a malignant tumor infiltrates the psoas muscle, it is termed malignant psoas syndrome (MPS). We are reporting this case because the malignancy led to atrophy of the psoas muscle, and the clinical course differed from the typical presentation of MPS. A 72-year-old Japanese female with advanced sigmoid colon cancer and multiple metastases had been undergoing systemic chemotherapy for four years. She complained of severe back pain on a numeric rating scale (NRS) of 4-5, left groin pain, and hip flexion weakness. Although she could stand up, she started experiencing difficulties while walking and became reliant on a wheelchair. At the time of referral to our department, her performance status was 2. On examination, she was capable of hip adduction and abduction, and flexion was impossible on the left side and possible on the right side. Imaging revealed metastases to the 11th and 12th thoracic vertebrae, extending to the upper portion of the first lumbar vertebra, leading to atrophy of the left psoas major muscle and impairment of hip flexion. She received palliative radiation therapy (RT) of 30 Gy in 10 fractions over a period of 2 weeks. Following RT, she had grade 1 skin inflammation but no severe complications. Two weeks after RT, her pain improved (NRS 0-1) and she regained hip flexion. When hip flexion failure occurs in patients with malignant tumors, it is important to recognize that it may be caused by a tumor located near the lower thoracic or upper lumbar spine, even if the psoas muscle itself is not directly infiltrated by the tumor.
PubMed: 38343705
DOI: 10.7759/cureus.53931 -
Cureus Jan 2024Tuberculosis is prevalent in high-burden countries. Extrapulmonary drug-resistant tuberculosis is exceedingly rare. Simultaneous involvement of the spine with psoas...
Multidrug-Resistant Tuberculosis of the Spine With Bilateral Psoas and Pre- and Paravertebral Abscesses in an Immunocompetent Indian Female With Multiple Adverse Drug Reactions: The World's First Report.
Tuberculosis is prevalent in high-burden countries. Extrapulmonary drug-resistant tuberculosis is exceedingly rare. Simultaneous involvement of the spine with psoas muscles in the absence of pulmonary seeding with a drug-resistant strain of in an adult female is never reported. A 33-year-old Indian female presented with complaints of chronic back pain for eight months. She was on antituberculous treatment for Pott's spine for six months. The diagnosis was challenging due to the paucibacillary nature of the disease, and it required a high index of suspicion backed by radiometric investigations, liquid culture, a line probe assay, and cartridge-based nucleic acid amplification of the pus. Further, her treatment was associated with multiple adverse drug reactions like a rise of QTcF (QT corrected for heart rate by Fridericia's cube root formula) on the electrocardiogram, peripheral neuropathy, and abnormal behavior (decreased awareness and anger outbursts with restlessness), which were addressed by a team of experts including a cardiologist, a psychiatrist, a neurologist, and an infectious disease expert. She was managed conservatively, with an 18-month-long antituberculous treatment, which was stopped after consultation with an orthopedist at a nodal drug-resistant tuberculosis center with the advice to consult the orthopedic outpatient department; however, she was lost to follow-up.
PubMed: 38327909
DOI: 10.7759/cureus.51835 -
BMC Geriatrics Feb 2024Osteosarcopenia is a common geriatric syndrome with an increasing prevalence with age, leading to secondary diseases and complex consequences such as falls and... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Osteosarcopenia is a common geriatric syndrome with an increasing prevalence with age, leading to secondary diseases and complex consequences such as falls and fractures, as well as higher mortality and frailty rates. There is a great need for prevention and treatment strategies.
METHODS
In this analysis, we used magnetic resonance imaging (MRI) data from the randomised controlled FrOST trial, which enrolled community-dwelling osteosarcopenic men aged > 72 years randomly allocated to 16 months of twice-weekly high-intensity resistance training (HIRT) or a non-training control group. MR Dixon imaging was used to quantify the effects of HIRT on muscle fat infiltration in the paraspinal muscles, determined as changes in muscle tissue, fat faction and intermuscular adipose tissue (IMAT) in the erector spinae and psoas major muscles. Intention-to-treat analysis with multiple imputation was used to analyse the data set.
RESULTS
After 16 months of intervention, 15 men from the HIRT and 16 men from the CG were included in the MRI analysis. In summary, no positive effects on the fat infiltration of the erector spinae and psoas major muscles were observed.
CONCLUSIONS
The previously reported positive effects on lumbar spine bone mineral density (BMD) suggest that mechanotransduction induces tropic effects on bone, but that fat infiltration of the erector spinae and psoas major muscles are either irreversible or, for some unknown reason, resistant to exercise. Because of the beneficial effects on spinal BMD, HIRT is still recommended in osteosarcopenic older men, but further research is needed to confirm appropriate age-specific training exercises for the paraspinal muscles. The potential of different MRI sequences to quantify degenerative and metabolic changes in various muscle groups must be better characterized.
TRIAL REGISTRATIONS
FrOST was approved by the University Ethics Committee of the Friedrich-Alexander University of Erlangen-Nürnberg (number 67_15b and 4464b) and the Federal Office for Radiation Projection (BfS, number Z 5-2,246,212 - 2017-002). Furthermore, it fully complies with the Declaration of Helsinki and is registered at ClinicalTrials.gov: NCT03453463 (05/03/2018). JAMA 310:2191-2194, 2013.
Topics: Aged; Male; Humans; Paraspinal Muscles; Mechanotransduction, Cellular; Bone Density; Adipose Tissue; Research Design; Magnetic Resonance Imaging
PubMed: 38326734
DOI: 10.1186/s12877-024-04736-5 -
Heart, Lung & Circulation Mar 2024Frailty is a well-recognised predictor of outcomes after transcatheter aortic valve implantation (TAVI). Psoas muscle area (PMA) is a surrogate marker for sarcopaenia...
BACKGROUND
Frailty is a well-recognised predictor of outcomes after transcatheter aortic valve implantation (TAVI). Psoas muscle area (PMA) is a surrogate marker for sarcopaenia and is a validated assessment tool for frailty. The objective of this study was to examine frailty as a predictor of outcomes in TAVI patients and assess the prognostic usefulness of adding PMA to established frailty assessments.
METHODS
Frailty assessments were performed on 220 consecutive patients undergoing TAVI. These assessments used four markers (serum albumin, handgrip strength, gait speed, and a cognitive assessment), which were combined to form a composite frailty score. Preprocedural computed tomography scans were used to calculate cross-sectional PMA for each patient. The primary outcomes were all-cause mortality at 1-year and post-procedure length of hospital stay.
RESULTS
Frailty status, as defined by the composite frailty score, was independently predictive of length of hospital stay (p=0.001), but not predictive of 1-year mortality (p=0.161). Albumin (p=0.036) and 5-metre walk test (p=0.003) were independently predictive of 1-year mortality. The PMA, when adjusted for gender, and normalised according to body surface area, was not predictive of 1-year mortality. Normalised PMA was associated with increased post-procedure length of stay within the female population (p=0.031).
CONCLUSIONS
A low PMA is associated with increased length of hospital stay in female TAVI patients but does not provide additional predictive value over traditional frailty scores. The PMA was not shown to correlate with TAVI-related complications or 1-year mortality.
Topics: Humans; Female; Transcatheter Aortic Valve Replacement; Frailty; Hand Strength; Psoas Muscles; Cross-Sectional Studies; Aortic Valve Stenosis; Aortic Valve; Risk Factors; Treatment Outcome
PubMed: 38320880
DOI: 10.1016/j.hlc.2023.10.016 -
International Journal of Spine Surgery Mar 2024Our objective is to describe a minimally invasive endoscopic surgical technique for performing lateral lumbar interbody fusion (LLIF). LLIF is a common approach to...
BACKGROUND
Our objective is to describe a minimally invasive endoscopic surgical technique for performing lateral lumbar interbody fusion (LLIF). LLIF is a common approach to lumbar fusion in cases of degenerative lumbar disease; however, complications associated with psoas and lumbar plexus injury sometimes arise. The endoscopic modification presented here diminishes the requirement for sustained muscle retraction, minimizing complication risk while allowing for adequate decompression in select cases.
METHODS
Endoscopic LLIF (ELLIF) was performed in 3 patients from 2019 to 2021. Surgeries were performed in the lateral position under general anesthesia with neurophysiological monitoring. Discectomy, endplate preparation, and harvesting of iliac crest bone were performed through a working channel endoscope. The introduction of an interbody cage (Joimax EndoLIF) was performed over a nitinol blunt-tip wire (Joimax). No expandable blade retractors were required.
RESULTS
At 2-year follow-up of these 3 patients, the mean visual analog scale (VAS) score for leg pain improved from 9.3 to 1.7, and the mean Oswestry Disability Index (ODI) score improved from 40 to 8.3. There were no complications, readmissions, or recurrence of symptoms during the 2-year follow-up period. Patients spent an average of 36 hours in the hospital postoperatively and returned to normal daily activities after an average of 48 days.
CONCLUSIONS
A minimally invasive modification to the LLIF procedure is presented that offers several potential advantages due to the application of endoscopic techniques: reduced muscle retraction, smaller incision, and the opportunity to perform both indirect decompression and endoscopically visualized discectomy in the same fusion procedure.
CLINICAL RELEVANCE
The proposed endoscopic lateral lumbar interbody fusion and decompression is a minimally invasive technique that may provide patients with minimal complications, quick recovery, and good functional recovery.
PubMed: 38320807
DOI: 10.14444/8572 -
Neurospine Mar 2024The effect on fat infiltration (FI) of paraspinal muscles in degenerative lumbar spinal diseases has been demonstrated except for spinopelvic parameters. The present...
OBJECTIVE
The effect on fat infiltration (FI) of paraspinal muscles in degenerative lumbar spinal diseases has been demonstrated except for spinopelvic parameters. The present study is to identify the effect of spinopelvic parameters on FI of paraspinal muscle (PSM) and psoas major muscle (PMM) in patients with degenerative lumbar spondylolisthesis.
METHODS
A single-center, retrospective cross-sectional study of 160 patients with degenerative lumbar spondylolisthesis (DLS) and lumbar stenosis (LSS) who had lateral full-spine x-ray and lumbar spine magnetic resonance imaging was conducted. PSM and PMM FIs were defined as the ratio of fat to its muscle cross-sectional area. The FIs were compared among patients with different pelvic tilt (PT) and pelvic incidence (PI), respectively.
RESULTS
The PSM FI correlated significantly with pelvic parameters in DLS patients, but not in LSS patients. The PSM FI in pelvic retroversion (PT > 25°) was 0.54 ± 0.13, which was significantly higher in DLS patients than in normal pelvis (0.41 ± 0.14) and pelvic anteversion (PT < 5°) (0.34 ± 0.12). The PSM FI of DLS patients with large PI ( > 60°) was 0.50 ± 0.13, which was higher than those with small ( < 45°) and normal PI (0.37 ± 0.11 and 0.36 ± 0.13). However, the PSM FI of LSS patients didn't change significantly with PT or PI. Moreover, the PMM FI was about 0.10-0.15, which was significantly lower than the PSM FI, and changed with PT and PI in a similar way of PSM FI with much less in magnitude.
CONCLUSION
FI of the PSMs increased with greater pelvic retroversion or larger pelvic incidence in DLS patients, but not in LSS patients.
PubMed: 38317553
DOI: 10.14245/ns.2347136.568 -
Diagnostic and Interventional Radiology... Jan 2024Computed tomography (CT)-based body composition parameters and the hepatic venous pressure gradient (HVPG) are key characteristics in patients with liver cirrhosis. The...
Correlation between computed tomography-based body composition parameters and hepatic venous pressure gradient in patients with cirrhosis: a systematic review and meta-analysis.
PURPOSE
Computed tomography (CT)-based body composition parameters and the hepatic venous pressure gradient (HVPG) are key characteristics in patients with liver cirrhosis. The present study aims to explore the correlation between CT-based body composition parameters and HVPG, as well as the difference in HVPG between patients with and patients without sarcopenia.
METHODS
A literature search for studies reporting the correlation between HVPG and CT-based body composition parameters published in English up to August 2023 in four databases, Embase, MEDLINE (via PubMed), Web of Science, and Cochrane Library, was conducted. The correlation coefficient between HVPG and CT-based body composition parameters was the primary outcome, and the difference in the HVPG value between the sarcopenia and non-sarcopenia groups was the secondary outcome. A meta-analysis was conducted using a random-effects models. The methodologic quality was assessed using the Quality Assessment of Diagnostic Studies instrument.
RESULTS
A total of 652 articles were identified, of which nine studies (n = 1,569) met the eligibility criteria. Among them, seven studies reported the primary outcome via the muscle index, five via the skeletal muscle index (SMI), two via the psoas-muscle-related index (PRI), and three via two adipose tissue indexes. A total of five studies reported the secondary outcome: four via SMI and one via PRI. No evidence of a significant correlation was determined between the various body composition parameters and the HVPG value, either in the muscle index or the adipose tissue index. Higher HVPG values were observed in patients with sarcopenia than in patients without sarcopenia [pooled standardized mean difference (SMD): 0.628 (-0.350, 1.606), < 0.001; = 92.8%; < 0.001] when an Asian sarcopenia definition was adopted. In contrast, when a Western cut-off value was applied, the HVPG value was higher in patients without sarcopenia than in patients with sarcopenia [pooled SMD: -0.201 (-0.366, -0.037), = 0.016; = 0.00%; = 0.785].
CONCLUSION
No sufficient evidence regarding a correlation between the CT-based body composition and HVPG value was discovered. The difference in the HVPG value between the sarcopenia and non-sarcopenia groups was likely dependent on the sarcopenic cut-off value.
PubMed: 38293897
DOI: 10.4274/dir.2023.232553