Salzmann Stephan N, Fantini Gary A, Okano Ichiro, Sama Andrew A, Hughes Alexander P, Girardi Federico P
Spine and Scoliosis Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY.
JBJS Essent Surg Tech. 2019 Nov 1;9(4). doi: 10.2106/JBJS.ST.19.00013. eCollection 2019 Oct-Dec.
Lateral lumbar interbody fusion (LLIF) is a relatively new procedure. It was established as a minimally invasive alternative to traditional open interbody fusion. LLIF allows the surgeon to access the disc space via a retroperitoneal transpsoas muscle approach. Theoretical advantages of the LLIF technique include preservation of the longitudinal ligaments, augmentation of disc height with indirect decompression of neural elements, and insertion of large footprint cages spanning the dense apophyseal ring bilaterally. The original 2-incision LLIF technique described by Ozgur et al., in 2006, had some inherent limitations. First, it substantially limited direct visualization of the surgical field and may have endangered nerve and vascular structures. Additionally, it often required multiple separated incisions for multilevel pathologies. Finally, for surgeons with experience in traditional open retroperitoneal surgery, utilization of their previously acquired skills may have been difficult with this approach. To overcome these limitations, we adopted the mini-open lateral approach, which allows for visualization, palpation, and electrophysiologic neurologic confirmation during the procedure.
As detailed below, the patient is positioned in the lateral decubitus position and a single incision is carried out centered between the target discs. For single-level LLIF, the incision spans approximately 3 cm and can be lengthened in small increments for multilevel procedures. After blunt dissection, the retroperitoneal space is entered. The psoas muscle is split under direct visualization, carefully avoiding the traversing nerves with neurosurveillance. A self-retaining retractor is used, and after thorough discectomy, the disc space is sized with trial components. The implant is filled with bone graft materials and is introduced using intraoperative fluoroscopy.
The 2-incision LLIF technique or traditional anterior or posterior lumbar spine interbody fusion techniques might be used instead.
LLIF offers the reported advantages of minimally invasive surgery, such as reduced tissue trauma during the approach, low blood loss, shorter length of stay, decreased recovery time, and less postoperative pain. LLIF allows for the placement of a relatively larger interbody cage spanning the dense apophyseal ring bilaterally. The lateral approach preserves the anterior longitudinal ligament and posterior longitudinal ligament. These structures allow for powerful ligamentotaxis and provide extra stability for the construct. Compared with other approaches, LLIF has a reduced risk of visceral and vascular injuries, incidental dural tears, and perioperative infections. Although associated with approach-related complications such as motor and sensory deficits, LLIF can be a safe and versatile procedure.
腰椎外侧椎间融合术（LLIF）是一种相对较新的手术方法。它被确立为传统开放性椎间融合术的微创替代方法。LLIF允许外科医生通过腹膜后经腰大肌入路进入椎间盘间隙。LLIF技术的理论优势包括保留纵向韧带、通过间接减压神经元件增加椎间盘高度以及插入跨越双侧致密骨突环的大尺寸椎间融合器。2006年Ozgur等人描述的原始双切口LLIF技术存在一些固有局限性。首先，它极大地限制了手术视野的直接可视化，可能会危及神经和血管结构。此外，对于多节段病变，它通常需要多个分开的切口。最后，对于有传统开放性腹膜后手术经验的外科医生来说，采用这种方法可能难以运用他们之前获得的技能。为了克服这些局限性，我们采用了迷你开放性外侧入路，该入路在手术过程中允许可视化、触诊和电生理神经确认。
如下详述，患者取侧卧位，在目标椎间盘之间的中心位置做一个单一切口。对于单节段LLIF，切口长度约为3厘米，对于多节段手术可小幅度延长。钝性分离后，进入腹膜后间隙。在直接可视化下劈开腰大肌，使用神经监测小心避开穿行的神经。使用自持牵开器，在彻底切除椎间盘后，用试模组件测量椎间盘间隙大小。椎间融合器填充骨移植材料，并在术中透视引导下置入。
可使用双切口LLIF技术或传统的腰椎前路或后路椎间融合技术。
LLIF具有微创手术的诸多优势，如入路过程中组织创伤小、失血少、住院时间短、恢复时间缩短以及术后疼痛减轻。LLIF允许放置一个相对较大的椎间融合器跨越双侧致密骨突环。外侧入路保留了前纵韧带和后纵韧带。这些结构可产生强大的韧带整复作用，并为植入物提供额外的稳定性。与其他入路相比，LLIF导致内脏和血管损伤、意外硬膜撕裂及围手术期感染的风险降低。虽然与诸如运动和感觉功能障碍等与入路相关的并发症有关，但LLIF可以是一种安全且通用的手术方法。
