Complications associated with L4-5 anterior retroperitoneal trans-psoas interbody fusion: a single institution series

Abstract

Background: Lateral lumbar interbody fusion (LLIF), first described in the literature in 2006 by Ozgur et al., involves direct access to the lateral disc space via a retroperitoneal trans-psoas tubular approach. Neuromonitoring is vital during this approach since the surgical corridor traverses the psoas muscle where the lumbar plexus lies, risking injury to the lumbosacral plexus that could result in sensory or motor deficits. The risk of neurologic injury is especially higher at L4-5 due to the anatomy of the plexus at this level. Here we report our single-center clinical experience with L4-5 LLIF.

Methods: A retrospective chart review of all patients who underwent an L4-5 LLIF between May 2016 and March 2019 was performed. Baseline demographics and clinical characteristics, such as body mass index (BMI), medical comorbidities, surgical history, tobacco status, operative time and blood loss, length of stay (LOS), and post-op complications were recorded.

Results: A total of 220 (58% female and 42% male) cases were reviewed. The most common presenting pathology was spondylolisthesis. The average age, BMI, operative time, blood loss, and LOS were 64.6 years, 29 kg/m², 214 min, 75 cc, and 2.5 days respectively. A review of post-operative neurologic deficits revealed 31.4% transient hip flexor weakness and 4.5% quadricep weakness on the approach side. At 3-week follow-up, 9.1% of patients experienced mild hip flexor weakness (4 or 4+/5), 0.9% reported mild quadricep weakness, and 9.5% reported anterior thigh dysesthesias; 93.2% of patients were discharged home and 2.3% were readmitted within the first 30 days post discharge. Female sex, higher BMI and longer operative time were associated with hip flexor weakness.

Conclusions: LLIF at L4-5 is a safe, feasible, and versatile approach to the lumbar spine with an acceptable approach-related sensory and motor neurologic complication rates.

Keywords: Complications; lateral interbody fusion; lumbar fusion; minimally invasive spine surgery (MISS); trans-psoas approach.

Figure 1

Preoperative diagnoses and postoperative clinical outcomes. (A) Spinal pathologies treated with L4-5 lateral lumbar interbody fusion; (B) non-neurologic post-operative complications are presented; (C) five patients required readmission within 30 days of discharge; (D) patient discharge disposition is presented, with the majority of patients being discharged to home.

Figure 2

Summary of patients with approach-related complications at discharge, 3-week, 3-month, and 6-month follow up appointments.