Single-position lumbar surgery improved operative efficacy vs repositioned surgery
Patients who underwent single-position lumbar surgery had improved operative efficacy as well as reduced blood loss, length of stay and ileus compared with traditional repositioned “flip” surgery, according to published results.
“There is always going to be a debate about whether doing one-stage posterior is better than doing two-stages with a patient in one position, like a lateral and a posterior or an anterior and then a posterior, but I think that now there is one more check-box in favor of doing the procedure anterior and posterior or lateral and posterior as opposed to just posterior,” Themistocles S. Protopsaltis, MD, associate professor of orthopedic surgery and neurosurgery and chief of the division of spine surgery at NYU Langone Health, told Healio Orthopedics.
Protopsaltis and colleagues categorized 390 patients undergoing either primary anterior or lateral lumbar interbody fusion with bilateral percutaneous pedicle screw fixation between L2-S1 into groups based on whether they received traditional repositioned “flip” surgery (n=153) or single-position lumbar surgery (n=237). Researchers included levels fused, percentage of cases (including L5-S1 fusion), fluoroscopy radiation dosage, operative time, estimated blood loss, length of stay and perioperative complications as outcome measures. Researchers also performed radiographic analysis on lumbar lordosis, pelvic incidence, pelvic tilt and segmental lumbar lordosis.
Results showed patients in the flip group and the single-position group had similar levels fused and percent cases including L5-S1. Researchers found significantly reduced operative time, estimated blood loss, length of stay and fluoroscopy radiation dosage among patients in the single-position group vs. the flip group. Although the groups had similar perioperative complications, researchers noted significantly lower postoperative ileus in the single-position group. The groups had no significant differences in wound, vascular injury, neurological complications or venous thromboembolism, as well as no significant differences in 90-day return to the OR, according to results.
“We were excited that the data showed the new approach was better because it is innovative, but you do not want to embrace an innovative approach unless you can prove that it is better for your patients,” Protopsaltis said.
Perspective
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The authors present a well-written retrospective review of traditional anterior/posterior (AP) lumbar fusion in comparison to single-position AP instrumented fusion. Traditional AP lumbar techniques require patient repositioning between the two stages of the surgical procedure, a factor which contributes to overall operative and anesthesia time and presents the potential for risks associated with repositioning and maintenance of the sterile technique during the case. Significant findings associated with single-position surgery include diminished operative time, decreased intraoperative blood loss, diminished intraoperative radiation dosage and no measured increase in complications in comparison to the traditional AP technique.
The authors’ technique makes use of novel bone-grafting technologies, modern minimally invasive surgical exposure techniques and percutaneous placement of some spinal implants. Strengths of the study include the multi-surgeon study design. Weaknesses include a lack of long-term outcome measures and the retrospective nature of the study. Independent of this investigation, refined utilization of computer and/or robotic-assisted spine technologies, a continued focus on bone graft and fusion science, and attention to enhanced recovery after surgery techniques will play an important role in refining surgical techniques and outcomes.
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