Minimally Invasive Lateral Lumbar Interbody Fusion with Direct Psoas Visualization

Background: Minimally invasive lateral approaches to the lumbar spine have been adopted to allow access to the intervertebral disc space while avoiding the complications associated with anterior or posterior approaches. This report describes a minimally invasive technique for lateral lumbar interbody fusion LLIF that allows direct intraoperative visualization of the psoas and surrounding neurovasculature (DV-LIF).Methods: The technique utilizes a radiolucent tubular retractor and a secondary psoas retractor that allows a muscle-sparing approach while offering excellent visualization of the operative site. The unique advantage of this procedure is that the psoas muscle and surrounding nerves can be directly visualized intraoperatively to supplement neuromonitoring. We retrospectively reviewed complication rates in 34 patients treated with DV-LLIF (n = 19) or standard lateral lumbar interbody fusion (S-LLIF, n = 15).Results: There were 29 complications ( median: 1 per patient) with DV-LLIF and 20 ( median: 1 per patient) complications with S-LLIF. Postoperative sensory deficits were reported in eight (42%) and seven (47%) patients, respectively. Thigh pain or numbness was reported in eight (42%) and five (33%) patients, respectively. The percentage of the overall complications directly attributable to the procedure was 69%with DV-LLIF and 83% with S-LLIF. One severe complication (back pain) was reported in one DV-LLIF patient and four severe complications (severe bleeding, respiratory failure, deep venous thrombosis and gastrointestinal prophylaxis, and nicked renal vein and aborted procedure) were reported in two S-LLIF patients.Conclusions: Preliminary evidence suggests that minimally invasive lateral interbody fusion with direct psoas visualization may reduce the risk for severe procedural complications.