The Prone Lateral Approach for Lumbar Fusion-A Review of the Literature and Case Series

Abstract

Lateral lumbar interbody fusion is an evolving procedure in spine surgery allowing for the placement of large interbody devices to achieve indirect decompression of segmental stenosis, deformity correction and high fusion rates through a minimally invasive approach. Traditionally, this technique has been performed in the lateral decubitus position. Many surgeons have adopted simultaneous posterior instrumentation in the lateral position to avoid patient repositioning; however, this technique presents several challenges and limitations. Recently, lateral interbody fusion in the prone position has been gaining in popularity due to the surgeon's ability to perform simultaneous posterior instrumentation as well as decompression procedures and corrective osteotomies. Furthermore, the prone position allows improved correction of sagittal plane imbalance due to increased lumbar lordosis when prone on most operative tables used for spinal surgery. In this paper, we describe the evolution of the prone lateral approach for interbody fusion and present our experience with this technique. Case examples are included for illustration.

Keywords: lateral approach; minimally invasive spine surgery; prone lateral; spinal fusion.

Figure 1

Case 1: (A) parasagittal T2 MRI image demonstrating severe foraminal stenosis; (B) axial T2 MRI image of L3–4 demonstrating rt facet cyst; (C) axial T2 MRI image of L4–5 demonstrating foraminal stenosis; (D) preoperative lateral X-ray demonstrating grade-2 lytic spondylolisthesis at L4–5; (E) intraoperative fluoroscopy demonstrating partial reduction following posterior instrumentation in the prone position; (F) postoperative lateral X-ray demonstrating posterior instrumentation and anterior interbody at L4–5 with complete reduction of lysthesis and widening of the neuroforamina.

Figure 2

Case 2: (A) preoperative AP and lateral X-rays demonstrating sagittal and coronal imbalance; (B) postoperative AP and lateral images demonstrating posterior fixation and interbody cages as L1-L5 with correction of sagittal and coronal malalignment; (C) intraoperative lateral fluoroscopy demonstrating partial correction of lordosis following prone positioning.