Answer to the Letter to the Editor of C. Mehren et al. entitled “Technical Innovation?” Letter to the Editor regarding the article “Mini-open lateral retroperitoneal lumbar spine approach using psoas muscle retraction technique. Technical report and initial results on six patients” (by K. Aghayev and F. D. Vrionis: Eur Spine J, 2013. 22(9): p. 2113–9)

Abstract

Thank you for critically reviewing our article entitled “Mini-open lateral retroperitoneal lumbar spine approach using psoas muscle retraction technique. Technical report and initial results on six patients”. The anterior approach to the lumbar spine has a long history. It was originally reported by Capener for spondylolisthesis in 1932 [1]. Ito et al. in 1934 [2] reported an anterior extraperitoneal extrapsoas approach to the lumbar spine. Careful review of his paper clearly shows that little has changed in the surgical technique since then. The reviewer should be congratulated on his pioneering work to apply minimally invasive oblique technique to degenerative spine disease [3, 4]. In our opinion it is the natural evolution of any surgical technique to be critically revised by different surgical schools to “field test” its strengths and weaknesses, especially in the light of new technologies. We, by no means, claim credit for the invention of the extrapsoas approach. Our contributions are limited to the some technical aspects of the procedure: such as abdominal wall dissection, especially preservation of the abdominal wall innervation, preservation of the sympathetic chain, oblique placement of the interbody cage, with possible compromise of the contralateral foramen, using stand-alone devices and therefore avoiding posterior stabilization. The reviewer’s articles on the anterior extraperitoneal extrapsoas approach to the lumbar spine were published before the introduction of the transpsoas approach. The transpsoas approach itself has reached maturity and has become quite popular. The complications of the transpsoas approach are also well known. Therefore, we focused on comparing the transpsoas and extrapsoas techniques to emphasize that sometimes new is not necessarily good and remind to our surgical audience that there are minimally invasive choices other than industry-driven ones.