Supine Lateral Lumbar Interbody Fusion: Cadaveric Proof of Principle for Simultaneous Anterior and Lateral Approaches

Abstract

Background: Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) are commonly performed in separate stages with a change in patient positioning to provide arthrodesis in the lumbar spine. Interest has emerged in performing these approaches as a single-stage surgery with the patient in the lateral decubitus position. The objective of this study was to evaluate the technical feasibility of performing minimally invasive anterolateral fixation in a single supine position. Methods: Two fresh-frozen cadavers were used and placed supine. Standard minimally invasive anterior access was obtained by the approach surgeon. ALIF was performed at L5-S1 using standard techniques. A lateral incision was marked over the L4-5 disc space using fluoroscopy. Direct palpation and bimanual dissection were achieved through the same anterior incision, allowing access to the retroperitoneal space. Dilator and retractor docking was performed under fluoroscopic guidance. Direct visualization of the docking hardware through the anterior incision was used to ensure the safety of peritoneal contents and vasculature. LLIF was then performed using standard techniques at L4-5. Results: Plain radiographs confirmed acceptable positioning of both ALIF and LLIF grafts. No injury to the cadaveric peritoneum, vasculature, or lumbar plexus was observed. A slightly enlarged anterior incision also permitted retroperitoneal access and visualization of the L3-4 disc space. Conclusions: This cadaveric feasibility study demonstrates that combined minimally invasive ALIF and LLIF may be performed as a single-stage procedure with the patient in the supine position. Clinical consideration and study of this approach are warranted.