Dynamic Posture-Related Preoperative Pain as a Single Clinical Criterion in Patient Selection for Extreme Lateral Interbody Fusion Without Direct Decompression

Abstract

Study Design: Prospective cohort study. Objectives: Evidence on predicting the success of indirect decompression via extreme lateral interbody fusion (XLIF) is scarce. The authors investigated if patients who could achieve a pain-free position preoperatively would derive clinical benefit from XLIF without direct decompression. Methods: Data from 50 consecutive patients who underwent XLIF with and without direct decompression by a single surgeon from January 2014 to August 2017 was collected. Primary outcome is the rate of failure of patients who underwent XLIF without direct decompression, characterized by persistence of pain postoperatively that required reoperations within 6 months postoperatively. Secondary outcomes are clinical outcomes and patient-reported quality of life outcome data, including visual analogue scale for leg (VASL) and back (VASB) pain, Oswetry Disability Index (ODI), and Physical Component Score (PCS) and Mental Component Score (MCS) of SF-12, for up to 2 years postoperatively. Results: One patient with preoperative dynamic posture-related pain who underwent XLIF without direct decompression subsequently had a reoperation due to persisting pain. Statistically significant improvement was achieved across all patient reported outcomes ( P < .05): improvement of 68% for VASL, 61% for VASB, 50% for ODI, 33% for PCS, and 11% for MCS of SF-12 at last follow-up. Six patients had thigh symptoms that resolved. Conclusion: The simple clinical criterion based on postural pain status preoperatively may help clinicians in patient selection for indirect decompression of XLIF without the need for direct decompression. Further studies with larger cohorts are warranted to establish the validity of the algorithm.

Predictors for second-stage posterior direct decompression after lateral lumbar interbody fusion: a review of five hundred fifty-seven patients in the past five years

“…Khalsa et al [36] reported that pre-operative assessment of rest pain level in the supine position has a significant association with reduction in leg and back sores in patients undergoing indirect decompression. Two studies [19,37] claimed that patients with radicular symptoms unimproved with flexion may require direct decompression, and it is proposed that if patients are able to achieve dynamic symptom relief in a sitting or lying position, they may benefit from LLIF without requiring direct decompression, which is consistent with our experience.…”

Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review

“…All 3 studies reporting direct decompression groups utilized radiographs. 14 , 16 , 17 For the direct decompression cohort, lumbar lordosis (LL) increased by 133.9% from 22.8 o to 48.7 o ( Table 3 ). For the indirect decompression cohort, LL increased by 8.9% from 41.9 o to 45.5 o .…”

“…MIS posterior lumbar decompression utilizes a tubular retractor system to minimize dissection and destabilization of posterior midline structures such as the paraspinal musculature and stabilizing ligaments. 1,2,14 The aim of this review is to analyze the existing literature and identify any significant differences in outcomes or complications between isolated indirect decompression from lateral interbody fusion and combined indirect decompression with additional direct posterior decompression surgery. As this type of analysis has not yet been performed, better understanding of the relative outcomes of indirect decompression and indirect decompression with additional direct posterior decompression may allow for an expansion of indications for isolated lateral interbody fusion as well as a better understanding for when additional posterior decompression is warranted.…”

“…MIS posterior lumbar decompression utilizes a tubular retractor system to minimize dissection and destabilization of posterior midline structures such as the paraspinal musculature and stabilizing ligaments. 1 , 2 , 14 …”

Rate of failure of indirect decompression in lateral single-position surgery: clinical results

“…Sixth, various authors have reported that the presence of pain while recumbent leads to worse clinical outcomes with reliance on indirect decompression after LLIF. 38,39 We did not stratify our patients on the basis of the presence of pain while upright versus at rest, and therefore we cannot comment on this question. Lastly, Nakashima et al reported on 3 cases of neurological deterioration (in 158 patients) after attempted indirect decompression during LLIF for severe stenosis.…”