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.

Management of Massive Flank Hernia After Lateral Lumbar Fusion: Preoperative Botulinum Toxin Injections and Open Repair – A Case Report

“…There has been a rapid increase in the popularity of minimally invasive techniques, XLIF being one of them [15]. More than 20% of spinal fusions being performed in the United States utilize the XLIF or DLIF approach [16,17], while 14% of spinal fusions being performed in the United Kingdom utilize the XLIF or DLIF approach [18]. While there is a higher utilization of the transforaminal lumbar interbody fusion (40.4%), posterior lumbar interbody fusion (28.1%), and anterior lumbar interbody fusion (15.8%) approaches in the United Kingdom [18], the XLIF and DLIF procedures are the newest approaches and are gaining utility.…”

Comparison of standard and modified prone positioning for lateral lumbar spine fusion: a feasibility study to reduce lumbar plexus injury

“…Farber et al ( 31 ) demonstrated in a case series that the single-position PL transpsoas approach resulted in successful treatment for adult patients (n=29), with well-tolerated and acceptable clinical and radiographic outcomes. Barkay et al ( 32 ) assessed their experience with the traditional PL interbody fusion technique that was previously described by Pimenta et al ( 15 ). The most common complication experienced by patients (45%) was hip flexor pain on the ipsilateral side.…”

The Evolution of Lateral Lumbar Interbody Fusion: A Journey from Past to Present

“…Furthermore, SPS has been demonstrated to reduce manpower necessary to perform the flip and importantly improves patient safety [ 137 , 147 ]. Regarding intraoperative blood loss, radiation exposure, complications, and reoperation rates, SPS offers similar or even better outcomes as that of dual-position surgery [ 145 , 148 , 149 ].…”

“…This positioning offers a more familiar and spacious area for the surgeon to operate, facilitating easier pedicle screw placement and posterior decompression, as deemed necessary [ 151 , 152 , 153 ]. Furthermore, studies have demonstrated that adopting a prone position enables enhanced correction of sagittal plane imbalance attributed to an augmented lumbar lordosis [ 148 , 154 ], resulting in better segmental lordosis correction when compared to L-SPS ( Table 4 ) [ 155 ]. As the procedure evolved, accompanying advancements were made in the instruments designed to sustain a stable prone position amidst the new lateral forces [ 153 ].…”

“…In order to overcome this, patient positioning with the hips in a neutral to extended alignment could lengthen the psoas muscle, causing it to shift more posteriorly along with the plexus [ 153 ]. Other limitations include surgeon ergonomics, challenges related to the depth of the surgical field in obese patients, absence of counter pressure during disc preparation and cage insertion, and difficulties in accessing the L4–L5 level due to the iliac crest [ 148 , 156 ]. Considering these limitations, P-SPS may not represent a comprehensive solution, but rather a viable and safe alternative that can be adopted based on patient characteristics, indications, and surgeon preferences.…”