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31 Approaching a Deformity from the Concavity Versus Convexity
303
Fig. 31.5 Axial T2-weighted MRI showing asymmetry
of the psoas muscle in a professional golfer. The anatomy
on the side is more favorable for the approach from the
left side given the likely location of the lumbosacral
plexus as being more posteriorly located
bidity. However, surgeon experience and
appropriate preoperative planning are important for a successful outcome. The choice in
approaching from the concave versus convex
side is, to date, based on surgeon preference.
Larger studies are required to determine
which side, if either, leads to less neurologic
compromise, fewer incisions, better coronal
and sagittal balance, and overall better
outcomes.
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Awake Lateral Lumbar Fusion
Xifeng Zhang and Brandon Gaynor
3 2
Lateral lumbar fusion, performed on awake
patients, under local anesthesia with conscious
sedation, is not widely practiced. Proposed advantages of performing surgery under conscious sedation include reliable monitoring of femoral nerve
function, decreased complications of anesthesia,
decreased cost, and enhanced recovery time.
Increased availability of long- acting local anesthetics, improvements in endoscopic visualization, and
economic pressures to contain cost are likely to
encourage the expanded use of awake lumbar
fusion techniques. Particularly in China, intraoperative electrophysiologic monitoring is not commonly used in clinical practice, motivating us to
perform this procedure without general anesthesia.
Careful titration of anesthesia has been refi ned
as follows for sedation, analgesia, and anesthesia:
1. Dexmedetomidine hydrochloride injection
with a dose of 1 μg/kg body weight, 4 μg/ml
concentration, infused for at least 10 mins.
2. Droperidol 5 mg and 0.1 mg fentanyl infused for
over 2–3 mins. If the desired anesthetic effect is
not achieved in 5 min, repeat a half dose.
3. For single-level fusion, 40 ml 1 % lidocaine,
and for multilevel, 120 ml 0.25 % lidocaine.
Once the patient is optimally sedated, the
patient is positioned lateral decubitus as has been
described elsewhere in this text. Access into the
disc space is achieved after marking the entry site
with CT-guided needle placement. A guide wire
is placed through the spinal needle, and sequential tubular dilators are used to dock on the psoas
muscle at the level of interest (Fig. 32.1 ). The
discectomy and endplate preparation can then be
performed in the usual fashion with the assistance of a microscope for magnifi cation and
illumination.
X. Zhang
Beijing 301 PLA Hospital , Beijing , China
656780949@qq.com
e-mail:
B. Gaynor
Miami , FL , USA
© Springer International Publishing Switzerland 2017
M.Y. Wang et al. (eds.), Lateral Access Minimally Invasive Spine Surgery,
DOI 10.1007/978-3-319-28320-3_32
Fig 32.1 Marking the safe entrance point at the lateral
position under the CT scanner
305
306
X. Zhang and B. Gaynor
Illustrative Case 1 A 57 years old male pre-
sented with pain in the low back and leg with
intermittent claudication combined. Past medical history was signifi cant for diabetes. At fi rst,
his colon was scanned on his left side on the lateral position in the CT room, and the safe
entrance point was marked. During the operation, the long needle punctured through L45
intervertebral disc space according to the premarked entrance point. After confi rmation, the
thread was placed. Under the guidance of the
guide wire, the thread was expanded step by
step, and the appropriate working tube was set
up. Then the intervertebral disc was removed;
the endplate was stricken off. The autogenetic
iliac bone was taken from the spina iliaca posterior superior, and the cage was imbedded. The
operation was fi nished. After 5 years of followup, the patient’s symptoms were relieved, and no
further treatment was needed.
1 Aorta abdominalis, 2 intervertebral disc entrance point,
3 psoas major, 4 ischiadic nerve, 5 musculus sacrospina-
lis, 6 retroperitoneal fat, 7 colon descendents
32 Awake Lateral Lumbar Fusion
307
Preoperative MRI
Percutaneous fl uoroscopic-guided needle placement
308
Port placement docked onto the surface of the disc over
dilator
X. Zhang and B. Gaynor
Placement of the structural allograft through the tubular
dilator under fl uoroscopic guidance
32 Awake Lateral Lumbar Fusion
309
Simple closure of two small incisions
Preoperative radiographs demonstrating loss of disc
height
Illustrative Case 2 A 67 years old female with
low back pain and neurogenic claudication diagnosed with lumbar stenosis and degenerative disc
disease was treated with two-level lateral awake
lumbar fusion. A two-year follow-up demonstrated
failure of fusion; however, the patient’s symptoms
remained alleviated.
310
Intraoperative radiographs confi rming appropriate
graft placement
X. Zhang and B. Gaynor
30-month follow-up x-ray demonstrating failure of
bony fusion
Our bias is now to supplement lateral lumbar
fusion with posterior percutaneous pedicle screw
fi xation.
32 Awake Lateral Lumbar Fusion
311
Needle accessing the intervertebral disc
Placement of structural allograft through tubular port
Confi rmation of the needle placement into the center of
the disc space. Care is taken to avoid being too close to the
neural elements or viscera
312
The technique is repeated for additional levels as
indicated
X. Zhang and B. Gaynor
Postoperative AP and lateral radiographs after graft placement and segmental fi xation. Most commonly, we use
allograft cages packed with autogenous bone from the
iliac crest sized 32 × 10 × 10 mm