Lateral decubitus anterior exposure of the L4–5 disc maintains safety compared with supine positioning

Introduction

Anterior retroperitoneal exposure for access to the lower lumbar spine is traditionally performed with the patient supine. This exposure provides direct access to the anterior spine enabling procedures including anterior lumbar interbody fusion (ALIF) and total disc replacement (TDR). Pathologies most commonly treated with these modalities are spinal deformity and degenerative spinal conditions, mainly at the L4–5 and L5–S1 disc levels (1).

Advancements in lateral single position surgery (LSPS) for circumferential fusion have demonstrated reductions in operating time, estimated blood loss (EBL), and rates of postoperative ileus, whilst maintaining safety and similar 2-year alignment and fusion results in comparison to circumferential fusion with repositioning (2-8). Consequently, anterior lumbar spinal exposure is increasingly being performed in the lateral decubitus position (LAT). While lateral decubitus ALIF at the L5–S1 disc level has been described to be safe when compared to supine ALIF (9-12), most large series of LSPS utilized lateral lumbar interbody fusion (LLIF) at the L4–5 disc level rather than ALIF. In contrast, no series specifically assessing L4–5 anterior access in the LAT have been published. ALIF has some theoretical advantages over LLIF at L4–5 due to avoidance of the psoas muscle and lumbar plexus retraction. However, this approach involves aorta and inferior vena cava (IVC) mobilization, resulting in an associated risk of vascular complications (13). The aim of this study is to evaluate the safety of anterior retroperitoneal lumbar exposure at the L4–5 disc level in the LAT compared to the supine position (SUP). This article is presented in accordance with the STROBE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-24-34/rc).

Methods

A multi-center retrospective review of prospectively collected data of consecutive patients undergoing anterior lumbar spinal exposure including the L4–5 disc level over a 5-year period at three centres (Melbourne Orthopaedic Group, Atlantic Neurosurgical and Spine Specialists and NYU Langone Orthopedic Hospital) was performed. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). All participating centres were informed and agreed to the study. Ramsay Health Care Human Research Ethics Committee (HREC) (HREC: 2020/ETH/9011) approved the Melbourne Orthopaedic Group as a site for Australian patients in the multi-center registry. Western Institutional Review Board Copernicus Group (WCG IRB) (No. 20201713) approved the participation of and registration of patients from NYU Langone Orthopedic Hospital and Atlantic Neurosurgical and Spine Specialists for the multi-center registry. Informed consent was taken from all patients. Patients who underwent procedures involving anterior exposure of the L4–5 disc for degenerative or deformity pathologies and minimum 90 days follow-up were included. Patients may have also undergone additional LLIF procedures or posterior instrumentation. Patients were excluded if they had previous lumbar interbody fusion at the L4–5 level or prior anterior lumbar spinal exposure. Patient groups were classified based on the patient positioning in which L4–5 anterior lumbar spinal exposure was performed: (I) LAT or (II) SUP. Patient positioning was determined by the spine surgeon with consideration of patient factors, surgical indication and the chosen procedure.

Patient demographics, procedural characteristics, intraoperative and postoperative complications and reoperation at 30 and 90 days were collected from anaesthetics, operative and patient’s medical chart prospectively by each institution’s research teams and maintained independently by the research teams, before compilation for review in this study. Postoperative complications were classified as major or minor according to the Clavien-Dindo Classification (14). Major postoperative complications were those that required further surgical, radiological or endoscopic intervention, life-threatening complications or death [Clavien-Dindo Classification III–V (14)]. Minor postoperative complications were those that caused minor deviations from normal postoperative course, required pharmacological intervention or blood transfusion [Clavien-Dindo Classification I–II (14)].

Surgical technique

Lateral decubitus exposure

Anterior lumbar exposure of the L4–5 disc in the lateral position was performed in accordance with previously published surgical technique (2,3,15). Patients were positioned in the LAT, with their right side on the table to enable a left-sided retroperitoneal approach. If the surgeon planned to perform additional posterior instrumentation in the lateral position, the patient was positioned more posteriorly, approximately 5 cm from the back of the table to enable appropriate medialization during down-sided pedicle screw placement.

A paramedian incision at the lateral border of the rectus sheath was made. Where single level L4–5 exposure was planned, a transverse incision was made parallel to the caudal L5 endplate (Figure 1). For L4–S1 anterior exposure, a vertical incision was made. The lateral border of the rectus sheath was identified by palpation and the pre-peritoneal plane was established via blunt dissection of the oblique muscles. The peritoneum was separated from the anterior abdominal wall by blunt dissection, then swept away and retracted from the anterior and lateral abdominal walls. A retractor frame was assembled with medial (down-sided), lateral (upper-sided) and cephalad blades (Figure 2).

Figure 1 Clinical photograph of postoperative scar following paramedial incision for anterior lumbar spine exposure of the L4–5 disc level in ‘Langer’s line’, performed in the lateral decubitus position.

Figure 2 Intraoperative clinical photograph demonstrating an assembled retractor frame for anterior lumbar exposure in the lateral decubitus position. The ‘lateral’ blade is referenced the upper retractor blade, and ‘medial blade’ is referenced as the blade at the lower side of the wound attached to a separate retractor arm.

Vessel mobilization at the L4–5 level varied depending on patient vascular anatomy, as the aortic bifurcation and IVC confluence occurs between L3 to L5 (16,17). Where the bifurcation occurred at or below the L4–5 disc level, the spine was approached lateral to the iliac vessels and IVC. This was accomplished by ligation of the iliolumbar vein, along with any lateral venous tributaries or L4 segmental vessels if necessary. The vessels were then mobilized to the right of the spine using a combination of sharp and blunt dissection. The medial retractor blade was positioned between the vessels and the right side of the spine to maintain the exposure. If the IVC bifurcation occurred above the L4–5 disc level, the middle sacral vessels were ligated and the plane developed between the left and right iliac vessels which were retracted over the lateral annulus on their respective sides.

Supine exposure

Anterior exposure in the SUP was performed similar to well-described retroperitoneal approach. A midline incision was made in contrast to the paramedial incision used in the lateral position. The plane between rectus abdominus muscles was developed to access the preperitoneal plane and dissection carried out bluntly laterally to access the retroperitoneal plane below the arcuate line. The peritoneum is then bluntly separated from the posterior rectus sheath (arcuate ligament) which is divided to permit greater excursion of the abdominal wall. Once access to the retroperitoneal plane had been achieved, the vessels were mobilized in a similar manner as described above depending upon the level of venous confluence.

Statistical analysis

Continuous numerical variables were analysed using independent samples t-tests, whilst categorical variables were analysed using chi-squared analysis. Significance was set at P<0.05 for all variables. Analysis was conducted using IBM SPSS Statistics Software (version 29.0, Armonk, NY, USA).

Results

One hundred and forty patients underwent anterior lumbar exposure involving the L4–5 disc, including 65 LAT patients and 75 SUP patients. A total of 238 anterior levels were exposed, of which 113 levels exposed in the lateral position and 125 levels in the SUP. The mean age was 58.82±14.98 years, with 42.90% male patients and 57.10% female patients. The mean body mass index (BMI) was 29.09±7.03 kg/m², 7.90% of patients were smokers and 6.50% were diabetic. A mean 2.06±1.07 levels were exposed with anterior, lateral and posterior approaches, including 1.70±0.48 levels were exposed with an anterior approach; 30.70% of patients underwent anterior exposure involving only the L4–5 disc level, whilst 66.50% involved L4–S1 exposure, 2.10% involved L3–L5 exposure and 0.70% involved L3–S1 exposure. Patients underwent surgery for degenerative pathology in 86.40% of cases and for adult spinal deformity in 13.60% of cases. Intraoperative complications were observed in 3.60% of patients, whilst 27.90% occurred postoperatively, including 18.60% minor and 10.00% major postoperative complications. Return to operating room (OR) was required within 30 days in 5.00% of patients, and 7.20% within 90 days.

On average LAT patients were older than SUP patients (66.44 vs. 52.31 years, P<0.001), whilst gender distribution (40.60% vs. 44.00%, P=0.69) and BMI (28.94 vs. 29.22 kg/m², P=0.81) were similar between groups. There were significantly fewer smokers (1.60% vs. 13.30%, P=0.01) and more diabetics (12.50% vs. 1.30%, P=0.008) in the LAT group. There were no significant differences in the age-adjusted Charlson comorbidity index (CCI) between groups (75.50 vs. 80.85, P=0.21). A summary of patient demographics is provided in Table 1.

More levels were exposed in the LAT group (2.52 vs. 1.67 levels, P<0.001), however, anterior levels exposed were similar between groups (1.74 vs. 1.67 levels, P=0.37). A smaller proportion of procedures involved ALIF exposure only (7.70% vs. 36.00%, P<0.001) in the LAT group. However, a larger proportion of procedures in the LAT group involved additional LLIF (21.50% vs. 0.00%, P<0.001). Furthermore, more patients in the LAT group underwent surgery to treat adult spinal deformity (21.50% vs. 6.70%, P=0.01) and underwent planned staged procedures (21.50% vs. 6.70%, P=0.01) compared to the SUP group. Similar proportions of surgeries involved anterior exposure of the L4–5 disc level only (26.20% vs. 34.70%, P=0.28), L4–S1 disc levels (72.30% vs. 61.30%, P=0.17), L3–L5 disc levels (1.50% vs. 2.70%, P=0.65) and L3–S1 disc levels (0.00% vs. 1.30%, P=0.35) were observed. The average operative time (192.77 vs. 283.41 minutes, P<0.001) and EBL (199.76 vs. 309.66 mL, P=0.006) was significantly lower in the LAT group. The mean length of stay (LOS) was similar between groups (4.83 vs. 5.01 days, P=0.82). Additionally, sub-analysis of patients who did not undergo staged procedures found similar mean LOS between groups (3.40 vs. 4.57 days, P=0.11). Table 2 provides a summary of the surgical characteristics.

Intraoperative complications occurred at similar rates between both groups (3.10% vs. 4.00%, P=0.77). A similar proportion of patients experienced intraoperative vascular (1.50% vs. 0.00%, P=0.28) and instrumentation-related complications (0.00% vs. 2.70%, P=0.19). No intraoperative visceral injury was observed during the course of this study. A significantly lower rate of postoperative complications (15.40% vs. 38.70%, P=0.002) were observed in the LAT group. Minor complication rates were lower in the LAT group (10.80% vs. 25.30%, P=0.03), whilst major complication rates were similar between groups (6.20% vs. 13.30%, P=0.16). Significantly fewer patients in the LAT group experienced postoperative ileus (0.00% vs. 6.70%, P=0.03) The frequency of reoperation within 30 days (3.10% vs. 6.70%, P=0.33) and 90 days (3.10% vs. 10.70%, P=0.09) were similar between groups. An outline of complications and revision surgeries is included in Table 3.

Discussion

Anterior lumbar exposure in the LAT is becoming more widely accepted following advancements in LSPS for circumferential fusion (Figure 3). Whilst anterior lumbar exposure at the L5–S1 level has been well-described to be a safe and effective technique to restore spinal alignment (9-12), this is the first study to the authors’ knowledge to evaluate the safety of this technique at the L4–5 disc level. The anterior retroperitoneal approach to the L4–5 disc space can be utilized when a lateral approach is contraindicated due to the presence of a high iliac crest or where the patient has unfavorable psoas and lumbar plexus morphology (16). Furthermore, LSPS decreases the number of incisions required and reduces the number of instrument trays requiring processing where L4–S1 multilevel fusion is indicated, as both discs may be accessed with single anterior exposure rather than performing LLIF at L4–5. The present study demonstrated that anterior lumbar exposure in the lateral position is safe compared to when performed in the SUP, with similar intraoperative (3.10% vs. 4.00%) and major postoperative complication rates (6.20% vs. 13.30%, P=0.16).

Figure 3 (A) Anteroposterior and (B) lateral postoperative radiographic images demonstrating an interbody cage and pedicle screws inserted by anterior lumbar interbody fusion and percutaneous pedicle screw fixation at the L4–5 level in the lateral decubitus position. R corresponds to the right side.

Vascular injury is a known complication associated with anterior access surgery, with rates ranging between 0.4% to 24.0% and similar rates when comparing ALIF and TDR (13,18-21). Vascular injuries more commonly affect venous structures and occur at the L4–5 level due to the confluence of the IVC commonly occurring at this level, requiring mobilization to access the disc space (15-17,22). Arterial injuries occur less commonly as arterial structures are more robust and elastic, thus more tolerant of traction and less likely to become scarred down to the spine (15-17,22,23). This study found a total vascular injury rate of 0.70%, with one patient experiencing a vascular injury in the LAT group (1.50% vs. 0.00%, P=0.45), suggesting that vessel mobilization in the LAT is safe. The patient who experienced a left common iliac vein injury when removing a retractor pin, required primary suture repair with a resultant EBL of 1,000 mL and subsequently developed a deep vein thrombosis (DVT) postoperatively requiring anticoagulation. Previous studies comparing single position lumbar surgery and circumferential lumbar fusion with repositioning, have also found similar vascular injury rates between patients undergoing ALIF in the lateral and SUPs (2,3,6). It is important for surgeons to consider that patients with abnormal or challenging vascular anatomy may be more suitable for supine anterior exposure if the exposure surgeon is less familiar with the exposure in the lateral position. Vascular injury can be avoided by thorough preoperative assessment and careful mobilization of vascular structures. Furthermore, the LAT can actually assist in L4–5 anterior exposure due to anterior and medial translation of the aorta, IVC and iliac vessels when the patient is lateral compared to when supine (22,24).

No intraoperative bowel injury, visceral injury or ureteric injuries were observed in the present study, and postoperative abdominal bulge was similar between groups (1.50% vs. 4.00%, P=0.38). The manipulation of abdominal contents in anterior lumbar surgery is associated with an increased incidence of ileus (23,25). However, anatomical studies have demonstrated that the retroperitoneal viscera are translated further outside the operative field when the patient is positioned in the LAT (22,24). Consequently, less peritoneal retraction is required to gain access to the anterior spinal column. As a result, many studies on LSPS have shown significantly lower rates of postoperative ileus in patients who underwent ALIF in the lateral position compared to the SUP (2,3,6). Unsurprisingly, the present study demonstrated a similar trend, as no patients in the LAT group experienced ileus, compared to 5 patients (6.70%) in the SUP group (P=0.03).

The postoperative complication rate (15.40% vs. 38.70%, P=0.002) found in the present study was significantly lower among LAT patients. The high rate of postoperative complications in the supine group was largely attributable to the significant difference in minor complication rates (10.80% vs. 25.30%, P=0.03). This discrepancy in the rate of minor complications is attributable to the significant difference in the rate of ileus (0.00% vs. 6.70%, P=0.03) and renal and genitourinary complications (0.00% vs. 6.70%, P=0.03). The significant difference in the rate of renal and genitourinary complications (0.00% vs. 6.70%, P=0.03) involved 5 patients in the SUP group who experienced acute kidney injury or urinary retention postoperatively, with no patients experiencing retrograde ejaculation. All patients who experienced urinary retention has an operative time of greater than 290 minutes, which may have increased their risk (26). Additionally, increased EBL in the SUP group may also contribute to decreased renal perfusion, potentially leading to acute kidney injury postoperatively. In contrast, the rate of major postoperative complications (6.20% vs. 13.30%, P=0.16) were similar between groups. Ultimately, the procedural flexibility of performing anterior exposure in the LAT enables surgeons to reduce operative time and EBL, which in turn reduces the rate of associated sequelae. The rate of perioperative complications reported for ALIF in the SUP in the literature ranges between 4% to 31%, which is comparable to the frequency of postoperative complications observed in the LAT group in this study (23,27,28).

The rate of revision surgeries within 90 days (3.10% vs. 10.70%, P=0.09) was similar between groups. The rate of reoperation for supine ALIF can range between 0.0% and 15.4%, whilst for TDR can range between 3.7% and 11.4% (28,29). A large proportion of reoperations in the supine group were attributable to persistent postoperative radicular pain due to foraminal stenosis or instrumentation-related complications. Although there is a trend towards a lower rate of reoperations in the LAT group, it is unclear as to the reason why. Nonetheless the rate of reoperations at 90 days for both groups is comparable to that of prior literature and demonstrates that anterior exposure in the lateral position is a safe alternative to when performed supine.

A significantly larger proportion of LAT patients underwent surgery for spinal deformity (21.50% vs. 6.70%, P=0.01), compared to the SUP group, which had a larger proportion of patients who underwent surgery for degenerative spinal conditions (78.50% vs. 93.30%, P=0.01). Furthermore, a larger proportion of LAT patients underwent procedures that included additional LLIF (21.50% vs. 0.00%, P<0.001), with more mean total levels exposed (2.52 vs. 1.67 levels, P<0.001). This suggests that patients in the LAT group underwent cases with higher procedural complexity in comparison to the SUP group. Despite this, operative time (192.77 vs. 283.41 minutes, P<0.001) and EBL (199.76 vs. 309.66 mL, P=0.006) was significantly lower in the LAT group. For patients who underwent a planned two-stage procedure, the operative time and EBL only included the anaesthetic event involving anterior exposure and excluded the second stage procedure for posterior fusion. Less exposure is typically required when performing anterior lumbar access in the LAT due to the assistance of gravity in moving the peritoneal sac away from the surgical corridor, decreasing the amount of dissection required to access the anterior column (2,6,24,30). Anterior lumbar exposure in the lateral position also enables spinal surgeons the flexibility to additionally perform LLIF and/or posterior instrumentation without repositioning, enabling more complex surgical procedures to be performed under a single anaesthetic event. The decreased exposure and ability to perform multiple approaches without the need for repositioning enables surgeons to reduce operative time and blood loss experienced during the procedure. Thus, patients who underwent anterior lumbar surgery in the lateral position were able to undergo more complex surgeries with improved operative efficiency. A comparison of L4–5 anterior and lateral exposure in the LAT was beyond the scope of this study. However, further studies are planned to assess this.

A significantly larger proportion of patients in the LAT group underwent staged procedures (21.50% vs. 6.70%, P=0.01), where the second stage was typically performed 3 days after the anterior column procedure. The decision to perform a staged procedure was made on a case-by-case basis with considerations of surgical factors—levels fused, revision surgeries and surgical approaches required—in addition to patient and anaesthetic factors—age and comorbidities. Previous studies comparing same day and staged circumferential fusion—where anterior fusion was performed in the SUP—found that staged patients were more likely to have a longer hospitalization and increased risk of postoperative complications, particularly venous thrombotic events (31-33). Despite significant difference in proportion of staged procedures, the LOS was similar between groups (4.83 vs. 5.01 days, P=0.82) with sub-analysis of non-staged procedure patients also demonstrating similar LOS (3.40 vs. 4.57 days, P=0.11). Additionally, the rate of thromboembolic events was similar between groups (1.50% vs. 1.30%, P=0.92). Hence, the increased procedural complexity observed in the LAT group did not result in significant compromise to the patients’ postoperative course.

This study was limited by its retrospective nature, resulting in a risk of selection bias. However, the impact of selection bias was minimised by the inclusion of consecutive patients and the prospective collection of data used for this study. While it is not possible to account for all selection bias—particularly as it pertains to surgeon preference—these results demonstrate safety of exposure of the L4–5 disc in the LAT nonetheless.

Significant differences in patient age (66.44 vs. 52.31 years, P<0.001), smoking status (1.60% vs. 13.30%, P=0.01) and diabetes status (12.50% vs. 1.30%, P=0.008) may have confounded results as age, smoking and diabetes can increase the risk and severity of complications (34-37). Studies by Polanczyk et al. and McNicol et al. have demonstrated that older patients are at higher risk of postoperative complications such as pneumonia and acute renal failure (38,39). Additionally, smoking and diabetes may increase the risk of major postoperative complications and reoperation (35,36). However, these factors are unlikely to have contributed to the significant difference in complication rates. The difference in complication rates was largely attributable to the significant difference in the rate of ileus and genitourinary complications, which the authors believe are more likely to be related to the anterior approach technique. While the present study found comparable rates of intraoperative (3.10% vs. 4.00%, P=0.77) and major postoperative complications (6.20% vs. 13.30%, P=0.16) between groups, surgeons should factor in patient age, diabetes and smoking status when considering management options for patients.

Conclusions

Anterior lumbar exposure of the L4–5 disc in the LAT is safe compared to supine exposure, despite higher case complexity in the lateral position. Lateral decubitus ALIF is a viable alternative to lateral approaches at the L4–5 disc for anterior column reconstruction and LSPS.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-24-34/rc

Data Sharing Statement: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-34/dss

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-34/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-34/coif). J.A.T. is a paid consultant for and receives research support and royalties from NuVasive, and is a paid consultant and owns stock options for TrackX. D.R. is involved in education with NuVasive. M.M. receives royalties and is involved in education with Globus Medical, is involved in education with Medtronic and is a paid consultant and involved in education with NuVasive. A.J.B. receives royalties from Atlus Spine and Evolution Spine, receives travel support from Medtronic, and is a paid consultant, receives royalties and travel support from NuVasive. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). All participating centres were informed and agreed to the study. Ramsay Health Care Human Research Ethics Committee (HREC) (HREC: 2020/ETH/9011) approved the Melbourne Orthopaedic Group as a site for Australian patients in the multi-center registry. Western Institutional Review Board Copernicus Group (WCG IRB) (No. 20201713) approved the participation of and registration of patients from NYU Langone Orthopedic Hospital and Atlantic Neurosurgical and Spine Specialists for the multi-center registry. Informed consent was taken from all patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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