Speaker sees greater indications in the future for lateral lumbar approaches

Surgeons are beginning to develop and evolve new indications for lateral spine surgery as their experience and comfort with this approach increases, according to Andrew A. Sama, MD, who said he finds a lateral lumbar spine surgical surgery approach works well for obese patients, trauma cases, when tumor are evident, during revision surgeries and when accessing adjacent segment disease.

“These indications have evolved in my practice and have evolved more as I have become more comfortable with the approach and understand the biomechanics, and the indications have become a mainstay of my practice when I use them,” Sama said during a symposium.

Expanded indications

The lateral approach evolved after development of the extreme lateral interbody fusion (XLIF) technique and devices (NuVasive), and several other companies followed suit and developed similar products, according to Sama.

It is very effective for obese patients and for treating adjacent segment disease, he said.

At the North American Spine Society Annual Meeting in San Francisco, Sama presented the case of a 38-year-old obese man with degenerative disc disease who had a work injury 3 years earlier and came to Sama’s hospital for a disc replacement. Since that procedure was not indicated, the man opted for a standalone XLIF.

Better access, better correction

“He had segmental collapse,” Sama said, discussing the case and the indications for using a lateral fusion approach.

“His front-to-back measurements are almost 45 mm, so this is an oversize cage. These cages are 30 mm front-to-back and about 60 mm or 65 mm side-to-side, and you can see how this adequately opens up the disc space and also fills the space. I did this as a standalone, and he is about 8 months postop and is doing very well,” Sama said.

Trauma, infection and tumor are other indications he discussed where the lateral lumbar approach helps with access to perform correction and decompression of the anterior space.

Aids complicated cases

Sama presented a complicated case of an elderly woman who underwent revision surgery for a compression fracture and then had subsequent falls that damaged previously implanted hardware, and then she had a stroke.

“This is a complicated indication. You have pullout of a 78-year-old osteoporotic female with cerebral vascular events. What I opted to do for her was a very limited approach anteriorly where I did a corpectomy at L4, which was pretty uneventful. I was able to get the cement out and then extended her up to T10 and now she is about 2 years out,” Sama said.

Although the indications for lateral spine surgery can escape some surgeons, Sama said the more often a surgeon uses the technique the easier it becomes to perform and the better the surgeon is at adapting lateral lumbar techniques to various situations.

“Extending the indications of a lateral approach is a powerful tool. It does not replace what we have in our toolbox, but it does augment it,” Sama said.

He said the indications have expanded as surgeons have become more comfortable with the technique and applications for the indications. However, sometimes getting to L1-2 or L4-5 can be demanding, which makes for a difficult lateral approach. Fortunately there have been some redesigns and modifications of the current equipment that have helped considerably, according to Sama. – by Robert Linnehan

Reference:
Sama AA. Symposium: Lateral approach to the lumbar spine; Indications for lateral spine surgery. Presented at: North American Spine Society Annual Meeting. Nov. 12-15, 2014; San Francisco.

For more information:
Andrew A. Sama, MD, can be reached at Hospital for Special Surgery, 523 E. 72nd St., New York, NY 10021; email: samaa@hss.edu.

Disclosure: Sama receives royalties from Ortho Development Corporation, Life Spine and DePuy, has stock ownership in Paradigm Spine and private investments in Small Bone Innovations. He is a consultant to for Ortho Development, Osteotech, HydroCision, Life Spine, DePuy and Sentio. He has speaking arrangements with DePuy Spine, is on the scientific advisory board for Clariance and receives fellowship support from AOSpine.