Background context:

Anterior Lumbar Interbody Fusion (ALIF) and Lateral Lumbar Interbody Fusion (LLIF) with percutaneous posterior screw fixation are two techniques used to address degenerative lumbar pathologies. Traditionally, these anterior-posterior (AP) surgeries involve repositioning the patient from the supine or lateral decubitus position to prone for posterior fixation. To reduce operative time (OpTime) and subsequent complications of prolonged anesthesia, single-position lumbar surgery (SPLS) is a novel, minimally invasive alternative performed entirely from the lateral decubitus position.

Purpose:

Assess the perioperative safety and efficacy of single position anterior-posterior lumbar fusion surgery (SPLS).

Study design:

Multi-center retrospective cohort study.

Patient sample:

390 patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group.

Outcome measures:

Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, estimated blood loss (EBL), length of stay (LOS), and perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and segmental lumbar lordosis.

Methods:

Patients undergoing primary ALIF and/or LLIF surgery with bilateral percutaneous pedicle screw fixation between L2-S1 were included over a 4-year period. Patients were classified as either traditional repositioned “Flip” surgery or SPLS. Outcome measures included levels fused, percentage of cases including L5-S1 fusion, fluoroscopy radiation dosage, OpTime, EBL, LOS, perioperative complications. Radiographic analysis included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), and segmental lumbar lordosis. All measures were compared using independent samples t-tests and chi-squared analyses as appropriate with significance set at p<0.05. Propensity matching was completed where demographic differences were found.

Results:

390 patients undergoing AP surgery were included, of which 237 underwent SPLS and 153 were in the Flip group. Age, gender, BMI, CCI were similar between groups. Levels fused (1.47 SPLS vs 1.52 Flip, p=0.468) and percent cases including L5-S1 (31% SPLS, 35% Flip, p=0.405) were similar between cohorts. SPLS significantly reduced OpTime (103min vs 306min, p<0.001), EBL (97 vs 313ml, p<0.001), LOS (1.71 vs 4.12 days, p<0.001), and fluoroscopy radiation dosage (32 vs 88mGy, p<0.001) compared to Flip. Perioperative complications were similar between cohorts with the exception of postoperative ileus, which was significantly lower in the SPLS group (0% vs 5%, p<0.001). There was no significant difference in wound, vascular injury, neurological complications, or VTE. There was no significant difference found in 90 day return to OR.

Conclusions:

SPLS improves operative efficiency in addition to reducing blood loss, length of stay and ileus in this large cohort study, while maintaining safety.