Complications of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicenter Study

Abstract

BACKGROUND AND OBJECTIVES: The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of information in the literature on the complications of this procedure, with all published data consisting of small samples. We aimed to report the intraoperative and postoperative complications of PTP in the largest study to date. METHODS: A retrospective electronic medical record review was conducted at 11 centers to identify consecutive patients who underwent LLIF through the PTP approach between January 1, 2021, and December 31, 2021. The following data were collected: intraoperative characteristics (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries]), postoperative complications, and hospital stay. RESULTS: A total of 365 patients were included in the study. Among these patients, 2.2% had ALL rupture, 0.3% had cage subsidence, 0.3% had a vascular injury, 0.3% had a ureteric injury, and no other visceral injuries were reported. Mean operative time was 226.2 ± 147.9 minutes. Mean EBL was 138.4 ± 215.6 mL. Mean hospital stay was 2.7 ± 2.2 days. Postoperative complications included new sensory symptoms—8.2%, new lower extremity weakness—5.8%, wound infection—1.4%, cage subsidence—0.8%, psoas hematoma—0.5%, small bowel obstruction and ischemia—0.3%, and 90-day readmission—1.9%. CONCLUSION: In this multicenter case series, the PTP approach was well tolerated and associated with a satisfactory safety profile.

Advancing Prone-Transpsoas Spine Surgery: A Narrative Review and Evolution of Indications with Representative Cases

“…Authors cite inconsistent reporting standards for this wide range, stating that many authors of the included studies view transient neurologic symptoms as side-effects of required psoas manipulation rather than a true complication. Comparatively, in a 365 PTP-patient retrospective study by Soliman et al, the authors showed that prone lateral fusion resulted in new onset radiculopathy or lower-extremity sensory symptoms in only 8.2% of patients [51]. Farber et al and Patel et al reported similarly low rates of new onset of thigh neuropraxia among their PTP cohorts, at 13.3% and 11.9% respectively [46,50].…”

“…In the aforementioned lateral-decubitus meta-analysis by Hijji et al, the rate of inadvertent anterior longitudinal ligament (ALL) release was reported to be 2.9% [5]. Similarly, in their PTP cohort, Soliman et al reported an ALL rupture incidence of 2.2%, totaling 8 of the 365 patients [51]. Farber et al (5, 2.3%) and Buckland et al (3, 1.2%) describe similar rates of ALL release in their PTP cohorts [13,50].…”

“…With respect to motor deficits in lateral position surgery, Hijji et al, in a meta-analysis of nearly 7000 patients, cited an incidence of 14.1% for new onset transient motor weakness and 5.1% for permanent motor or sensory loss [5]. Comparatively, in Soliman et al's multicenter PTP study, only 21 of 365 (5.8%) patients developed ipsilateral motor weakness-5 (1.3%) of which were persistent after 7-month follow-up [51]. Likewise, Farber et al and Patel et al reported few long-term post-operative motor deficits during one-year follow up, 1.2% and 0%, in their respective retrospective studies [46,50].…”

“…As an emerging surgical technique with known and well-established alternatives, it is important to characterize the complication profile of prone-transpsoas access-spine surgery early and often to ensure the benefits are conferred while maintaining an acceptable safety profile. To date, in cases where prone lateral surgery is undertaken, its novelty has precluded a large number of studies, but the recent literature from Farber et al, Soliman et al, and pooled analyses have shown that complications, of all causes, are comparable to those in conventional, two-position, lateral surgery [50,51]. Likewise, looking at individual complications, it has been demonstrated that critical complications, including post-operative neurologic deficit, inadvertent anterior longitudinal ligament release, vascular or ureter injury, spinal fluid leak, and psoas hematoma, are comparable or decreased in relation to traditional lateral surgery.…”

“…Hijji et al cited a single (0.12%) aortic injury and two (0.25%) common iliac vein lacerations in their meta-analysis of lateral interbody fusions [5]. Similarly, Soliman et al cited the incidence of major vascular injury, common iliac vein laceration, at 1 (0.3%) in their multicenter study [51]. Notably, this occurred during ALIF access, not the prone-transpsoas portion of the procedure.…”