Lateral lumbar interbody fusion (LLIF) in the prone position is a minimally invasive technique for treating degenerative lumbar diseases by achieving arthrodesis and lumbar lordosis through the anterior column. We build on this single-position surgery and present a simultaneous anterior and posterior approach for prone LLIF, which allows the patient to remain in the prone position while 2 operative windows into the spine are created. This enables one surgeon to place pedicle screws in the posterior spinal column while the other surgeon simultaneously performs LLIF in the anterior spinal column through a transpsoas approach.
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Jon J.W. Yoon, MD, MSc Today I'll be presenting a case where we did simultaneous anterior and posterior approach sapa for single position prone lateral lumbar nobody fusion with robotically assisted poster instrumentation. The patient is a 74 year old male with B. M. I. Of a 31 past medical history significant for hypertension type two diabetes and CKD and obstructive sleep apnea and prior stroke. He presented with a significant low back pain with radiating pain into the right into your thigh which is stopped above his knee. Neurological exam was significant for four out of five right knee extension, numbness and tingling to enter medial thigh. He required a cane to amputate. He underwent prior endoscopic far little disk ectomy inform anatomy on the right side at L. 23. But the pain came back despite six weeks of physical therapy and transformational epidural injection at L. 23 times to the pain continued to be a problem. O. D. I. Was 60 and promised pain interference with 67 M. R. I. Of his lumbar spine demonstrated he had a recurrent herniated disc at L. 23 on the right side and significant compression of the L. Two nerve root on the right X ray of the lumbar spine showed he had a great one retros thesis of L. Two and L. Three. Given that the patient failed the physical therapy and multiple rounds of epidural injections, we offer a lateral fusion in a prone position with simultaneous per cutaneous instrumented fusion. This has the benefit of indirectly decompressing the L. Two nerve roots and avoid a scar tissue around the exiting nerve root from prior surgery, it also eliminates the need for repositioning between the lateral and poster instrumented fusion. We could reduce the scandalous thesis at L. 23 and performing arthur thesis in both anterior and posterior column. The risk of the operation included potential injury to the lumbar plexus so as muscles, vascular injury, injury to the retro Palestinian content. Alternatively this surgery can be performed in two stages with the lateral fusion in a lateral position and per catania's instrumented fusion and prone or the transformational Lombardi nobody fusion at all to three is an option or redo decompressing lemon ectomy from anatomy and instrumented fusion. The setup includes the patient position in the prone position and from the side of the approach one of the hip pads of the open Jackson table is removed and necessary equipment includes the open Jackson table, universal adapter that allows the communication between the arm and the curve navigation and we use the O. Arm for obtained the images and also the C. Arm for the lateral inter body fusion part and the circle robotic arm was used to place the screws in the back and then lighted handle retractors. The surgical steps includes the patient positioning and then obtaining the three D. Spin. After obtaining the images. We use the navigation system to plan the incision and while the assistant is planning for the surgery in the back. Using the robotic assistance the primary surgeon makes an incision in the abdomen and gets the retro repaired um retractor in place. This placement of the retractor blade can be done using a navigation information. After the screw placement is done then the lateral disc ectomy is completed using the C. Arm and inner body cage is placed and then the rod is placed at the end so the patient is positioned in a prone position. One of the hip pad is removed and all the pressure points are well padded. We taped the patients so that they don't rotate and this is the fiduciaries attached. We place the iliac crest reference frame that's the universal adapter that's being taped to the patient using a. I. Oban. Then we obtain an alarm spin. Warm spin allows the three D. Reconstructed images. And after this we plan the medical screws from the posterior approach using the navigation information. And after we plan the medical screw trajectory on the skin we do the same thing for the planning the approach for the lateral. And now while the assistant is placing the medical screws I start my dissection through the abdominal wall to setting through the external internal transfers of dominance and obtain the retro patina access. Um And the whole surgery can be done through a very small opening on the side of the flank between the rib and the iliac crest. And while the assistant is placing the screw using robotics and navigation. Primary surgeon is able to obtain the access through the retro peritoneum to the lumbar disc on the lateral side and then I like to use the lighted handle retractor to visualize the so as muscles and then obtain the access. Even with robotic surgery, you can get a tactile feedback by placing the K. Wire and then feeling the bones and the while the navigation can be used for the medical screw placement. Again the navigation information can be used to place the retractor and dilator. Here I'm using the initial dilator as with the navigation arc and then putting the K. Wire into the disk space based on the navigation information. So once the retractor is position satisfactory into the retro peritoneum through the so as muscles. I place my retractor into, into the L. 23 this space and we hook up the retractor into the place. And while the retractor is in good location based on the navigation information, we finished putting the screws in. The screws can be placed over the K wires and then the screws can be placed under navigation. Now, as my assistant is finishing putting the screws in, I already have the retractor in place in a prone position and then start my disk ectomy. The disk ectomy steps are standard. Uh You start with the uh the cop dissector on the um on each end plates. Then I use a Flora Skopje to make sure that I'm going all the way across to the other side. Uh Here I'm melting the flat cop across to each template and then checking with the Flora Skopje. The important difference between the pro lateral and the lateral. Traditional lateral surgery is that the angle of the disc ectomy and then the cage placement is the parallel to the floor, not perpendicular to the floor. So I gotta pay attention to the drift in your angle. If you angle it uh towards the floor then you could injure the vessels if you go towards the ceiling, then you're heading towards the nerve. In this case we used a peek cage with the extra small Bmp that's covering a telegraph party. And this is placed parallel to the floor at L. 23 in the middle of this space. And this is melted into this space again parallel to the floor under Flora Skopje guidance after the cage placement. We per Catania slee placed the rods uh And then the all the rods were final tighten and thats the incision for the prone position, lateral and then the perpetrators screw placement. So degenerative spondylitis thesis commonly presents with the actual back pain that increases with movement. Oftentimes have a ridiculous apathy from criminal stenosis. Sometimes they can present with neurological medication from central canal stenosis. Non operative first line therapy including physical therapy, pain management or injections. Uh The treatment can be escalated to surgical intervention if they fail. Despite this intervention and the postoperative outcome in this case. These are the inter operative images of the cage placement at all to three. With a medical school replacement and postoperative follow up. He had a increase in the lumbar lower doses and then the disc height went from 5.4 10.3 od I went down uh 60 to 46 then promised pain score went down 67 to 60. And um the correction of the eight millimeter retro. This thesis pre operatively was corrected. So the simultaneous um anti approach approach in a prone position um eliminates the need for repositioning. Uh It's relatively straightforward access to the lumbar disc through a standard retro patina approach. This kept me in her body cage placement is parallel to the floor. Unlike in a traditional lateral surgery where everything is done perpendicular to the floor, there's increase efficiency of the O. R. Workflow. Assistant surgeon can place the medical screws using a robotic assistance while the primary surgeon performs the retro peritoneal access uh to the lumbar spine navigation. Are can be attached to the initial dilator. Which can be helpful in identifying the midpoint of the disk. And that allows the placement of the retractor in a good position so that there is no deviation interior lee or post dearly operative time. Uh took about 166 minutes from skin to closure. That this included the fixation of navigation are to the pelvis obtaining the three D. Images registration verification this novel technique. This explore because it increases the efficiency of the or workflow and potentially benefit the patients.