Considerations of Lateral Lumbar Interbody Fusion (LLIF) in Spinal - - PDF document

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11/13/2015 Technical and Practical Considerations of Lateral Lumbar Interbody Fusion (LLIF) in Spinal Deformity Surgery Robert K. Eastlack MD Scripps Clinic Co-Director, Fellowship Training Program San Diego Spine Foundation DISCLOSURES

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11/13/2015 1 Robert K. Eastlack MD Scripps Clinic Co-Director, Fellowship Training Program San Diego Spine Foundation

Technical and Practical Considerations of Lateral Lumbar Interbody Fusion (LLIF) in Spinal Deformity Surgery DISCLOSURES

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BASELINE

SAGITTAL/CORONAL ALIGNMENT

ANTICIPATED CORONAL

PLANE CHANGE

– Beware of compensatory upper lumbar curve – Look for lumbosacral fractional curves – Anticipate effect of dysmorphic vertebral bodies

Preoperative Planning

Careful review of

vascular, neural, renal/ureter anatomy (axial MRI/CT images)

Staged vs. same

day posterior recon

L5-S1

– Interbody? – TLIF vs. ALIF?

PREOP PLANNING

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Beware Fractional Curves!

73yo physician
LBP
Bilateral variable

distribution radiculopathy

Progressive

Case Example

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No right L5 radiculopathy symptoms

MRI

L3-4 L4-5

T-score: -0.3
PI 48
LL 28
SVA 29mm
PT 28

Options?

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Intraop LLIF L2-5

EBL 30cc

Immediate Postop

PI 48 LL 28 PT 28 Resolved leg pain

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Need lordosis?
Correct coronal

alignment

Osteotomies?
L5-S1?
Length of

fusion/construct?

Options?

ALIF L5-S1
Perc fixation

L2-S1

Facet

releases L2- 5

Second Stage

PI 48 LL 50 PT 19

EBL 250cc

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73yo female

with progressive/chro nic LBP + RLE pain

Neuro intact
T score = -1.4

Case Example Multilevel DDD/foraminal stenosis

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Look for balance

– Coronal – Sagittal

What measures

necessary to achieve alignment

bjectives?

Case Example

2.5hrs
EBL 50cc

Intraop

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Ambulating POD 1
Home POD 2
TLSO
Mild hip flexion

discomfort- resolved<10days

No neuro abnl
2yrs postop--very

pleased

POSTOP

Greater scrutiny on

visceral/vascular structures on axial images

Determine renal/liver

locations

Prior surgeries?

– retroperitoneal

Preop Planning

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MRI

2014/5/19-20

L4 L4 L1 L1 S1 S1

L1/2

2014/5/19-20

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L2/3

2014/5/19-20

L3/4

2014/5/19-20

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L3/4

2014/5/19-20

L4/S1

2014/5/19-20

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11/13/2015 13 Concave or Convex Sided Approach in Scoliosis? Evaluate the degree of rotation Vascular/neural anatomy For degenerative scoliosis cases:

Approach on the concave side
Better access to L4-L5 and collapsed

side

Small incision and exposure to access

to multiple levels

Psoas and plexus is more relaxed
Better deformity correction
Concave release

Clears the crest Minimizes number of incisions, but tight access to disc L4-5 not accessible from convex side

Patient Positioning Considerations

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Sequence of Laterals

L1-2 or L4-5 first

– L1-2 first unless L4-5 aids in angle of approach to L1-2

Then, work down

– Avoids building away from your advantaged vector of approach/incision location

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Sample Case OR execution Review of Advanced Imaging

L3-4 L4-5 Assess rotation of each level and potential effect of approach side

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Intraoperative Preparation

New AP optimized

imaging for each level

Use caudal level as

proxy for neutral rotation

Angled approach

PRN

Intraoperative Preparation

Table

Trendelenberg for

btaining lateral

profile view of disk space

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Next Level L4-5

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Dealing with Overhangs Getting Docked

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Opening the Disk Space

Dealing with Overhangs

Osteotome or Cobb if needed to access disk space

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Using Cobb Elevators Safely

Flip the cobb

to use the ‘soft’ edge

POSTOP

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67yo female
10 yrs prog

LBP/leg pain

s/p B THA
T score -1.3
Coronal cobb 33

deg

Case Example

Choice in mgt?

– Post only – A/P – LLIF/post – open vs. MIS

Staged vs. same

day

PI 52 LL 26 PT 30

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POSTOP 1yr

PI 52 LL 53 PT 19 EBL = 500 cc

X ray

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X ray MRI

L2/3 L3/4

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CT

BEWARE THE FRACTIONAL CURVE

Plan LLIF with radiographs and advanced

imaging

– Assess vascular/plexus anatomy – Beware fractional curves!

Typically go to concavity
Sequence laterals according to disk space

accessibility and curve unfolding

Consider staging if alignment outcome