Conventional Anterior Approach Research Articles

A novel anterior approach that involves Retzius space development between the umbilical ligaments is associated with a lower incidence of postoperative inguinal hernia in robotic radical prostatectomy

BackgroundTo facilitate robotic radical prostatectomy (RP), we developed a novel anterior approach that utilizes a peritoneal incision between the umbilical ligaments to develop the Retzius space without contacting the internal inguinal rings, followed by closure of this space prior to prostatectomy and vesicourethral anastomosis. This approach could decrease the incidence of postoperative inguinal hernia (IH), similar to a Retzius-sparing RP (RS-RP). We compared the incidence of IH following this novel approach with that following conventional anterior RP and RS-RP. MethodsWe retrospectively reviewed 532 patients who underwent robotic RP from September 2017 to August 2022. We compared the incidence of IH following novel anterior RP (n = 153) to that following conventional anterior RP (n = 284) and RS-RP (n = 95). We also assessed the independent factors associated with postoperative IH using Cox hazard models. ResultsThe 12- and 24-month cumulative incidences of postoperative IH following novel anterior RP were 1.3% and 1.3%, significantly lower than those associated with conventional anterior RP (8.0% and 12.6%, p = 0.009) but not significantly different from those following RS-RP (1.1% and 2.1%, p = 0.782). In multivariate analysis, use of the novel anterior RP approach, RS-RP, and body mass index were independent factors negatively associated with the occurrence of postoperative IH. ConclusionsThis novel anterior approach involves developing the Retzius space between the umbilical ligaments and closure of this space following prostatectomy and vesicourethral anastomosis. It can decrease the incidence of IH compared to the conventional anterior approach. Prospective comparative studies are necessary to confirm the benefits of this approach.

Fully-Endoscopic Posterior Cervical 2-Level Foraminotomy With Total Pediculectomy for Adjacent-Level Foraminal Stenosis in Severe Degenerative Spondylolisthesis: A Technical Note With 1-Year Follow-up

Although the conventional anterior approach is the gold-standard procedure for multilevel cervical spondylotic radiculopathy, the fully-endoscopic posterior approach has recently become more popular. We present the case of a 73-year-old female patient with neck pain radiating to right shoulder and arm. The patient had adjacent-level cervical foraminal stenosis at C5–6 and C6–7 on right side and was managed with modified fully-endoscopic posterior foraminotomy at C5–6 and C6–7 with total pediculectomy of C6. The patient exhibited excellent clinical results, without any instability during long-term follow-up. Fully-endoscopic posterior cervical 2-level foraminotomy using total pediculectomy can be applied in patients for whom the anterior cervical approach is contraindicated, with the added advantages of the minimally invasive posterior approach. The technique has an extensive learning curve and needs to be selected according to the pathology.

Diaphragm sparing mini open thoracotomy with standalone expandable cage: Observational study of a safe novel approach for stabilising thoracolumbar fractures

Objective: An ideal surgical procedure to any vertebral fracture with cord compression produces maximum decompression, without producing additional deficits, achieve fixation by fusion of minimum number of motion segments and maintain the corrected kyphosis without any long-term deterioration. Although conventional posterior approach provides three column fixation, it invariably devitalizes the strong paraspinal muscles and posterior ligamentous complex of the involved vertebra and the adjacent segments necessary for maintaining erect posture. The lateral approach too, damages the strongest portion of the vertebra, the pedicle and sometimes the diaphragm has to be cut open and re-sutured. Conventional anterior approaches are mainly used either as a part of combined approach where in, there is extensive destruction of anterior longitudinal ligament and crus of the diaphragm and have the limitation that they cannot address the T11 and T12 fractures without cutting open the diaphragm. The anterior approach is not usually attempted as it is not a familiar approach to the neurosurgeon and literature reports increased morbidity. The main aim of this study is to encourage the reader to employ a new anterior approach toward thoracolumbar fracture management.Materials and Methods: The chief author has devised a novel, safe, mini open, diaphragm sparing approach to address all these issues, exploring a corridor between medial margin of psoas and left crus of the diaphragm which is sufficient enough for good decompression of the cord and that even a standalone broad foot plated expandable cage for stabilization is effective in correction of kyphosis without posterior supplementation or potential respiratory complications.Results: All 37 operated patients recovered well and their kyphotic angles were maintained on follow up. All patients improved neurologically without any respiratory complications potentially associated with thoracotomy.Conclusion: This prospective study proved that kyphotic corrections were better, no subsidence rates observed, and were maintained at 1 year follow-up with this novel approach.

Two Cases of Linea Alba Hernia Repaired by the Transabdominal Preperitoneal Approach and Conventional Anterior Approach

Two Cases of Linea Alba Hernia Repaired by the Transabdominal Preperitoneal Approach and Conventional Anterior Approach

Technique Tip: Correcting Malalignment of the Talus Using a Pin-Based Distracter During Arthroscopic Ankle Arthrodesis

It is technical demanding work to perform arthroscopic ankle arthrodesis to treat end-stage ankle osteoarthritis with excessive talar tilt. This article aimed to provide an effective technique tip for the treatment of Takakura stage 3b ankle osteoarthritis with a talar tilt angle more than 15 degrees under arthroscopy. A conventional anterior arthroscopic approach is used. After arthroscopic examination and debridement, one pin which is parallel to the distal tibial surface is inserted into the tibial side of the ankle, the other pin which is parallel to the talar dome surface is inserted into the talar side of the ankle, both at the coronal plane. Then a distracter is used in the medial side to open the interspace of the tibiotalar joint and correct the talar tilt through the 2 pins, under which circumstance the tibiotalar joint surface can be well prepared. Next an anti-distracter is used in the lateral side to close the tibiotalar interspace and correct the talar tilt through the 2 pins, in which condition 3 fully threaded cannulated lag screws can be inserted through guide pins in a cross pattern to fix the ankle joint. We used the pin-based distracter to open and close tibiotalar interspace, correct the talar tilt and maintain a good mechanical axis for fusion, and the outcomes were good.

Anterior cervical microforaminotomy for persistent brachialgia in a patient with multilevel cervical spondylosis; comparing PROMIS with Nurick score for outcome of surgery.

Introduction and importanceThe primal instinct of neurosurgeons has been to maintain spinal stability and motion since the beginning of spinal procedures. Conventional anterior approaches without fusion eliminate motion in time as fusion invariably sets in and hampers the vertebral column's normal dynamic physiology.Case presentationWe reported a 60 years old male patient who presented with signs of myelopathy, but his primary complaint was brachialgia. He had myelopathic features for eight years, for which he offered fusion surgery at multiple levels years ago, and he denied it. He was static since then, and the disease did not progress further. For intolerable pain, he agreed to minimally invasive surgery. Therefore, we operated for a right C6 transcorporeal microforaminotomy and removed the inciting disc material.Clinical discussionClinical implication for anterior cervical microforaminotomy for this patient was successful where there was acute disc prolapse in cervical spondylotic myelopathy.ConclusionFinally, functional preservation of the cervical spine in multilevel spondylosis can optimize the fusion. In this case, the report authors have explored the comparison between the PROMIS score and the Nurick score, reporting for the first time.

Effects of Single Low-Frequency Repetitive Transcranial Magnetic Stimulation on Motor Cortical-Subcortical-Cerebellar Circuit

The primal instinct of neurosurgeons has been to maintain spinal stability and motion since the beginning of spinal procedures. Conventional anterior approaches without fusion eliminate motion in time as fusion invariably sets in and hampers the vertebral column's normal dynamic physiology.We reported a 60 years old male patient who presented with signs of myelopathy, but his primary complaint was brachialgia. He had myelopathic features for eight years, for which he offered fusion surgery at multiple levels years ago, and he denied it. He was static since then, and the disease did not progress further. For intolerable pain, he agreed to minimally invasive surgery. Therefore, we operated for a right C6 transcorporeal microforaminotomy and removed the inciting disc material.Clinical implication for anterior cervical microforaminotomy for this patient was successful where there was acute disc prolapse in cervical spondylotic myelopathy.Finally, functional preservation of the cervical spine in multilevel spondylosis can optimize the fusion. In this case, the report authors have explored the comparison between the PROMIS score and the Nurick score, reporting for the first time.

Dorsal approach with tailored partial sacrectomy and gluteal V\u2013Y fasciocutaneous advancement flap for the management of recurrent pelvic sepsis; case report

BackgroundPelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V–Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue.Case presentationsThree male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity.ConclusionThe dorsal approach with tailored sacrectomy and gluteal V–Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.

Endoscopy-assisted pars plana lensectomy for brunescent cataracts in eyes with microcornea with microphthalmos

ABSTRACT Purpose Conventional cataract surgeries can be a challenge in eyes with microcorneas due to difficult manipulation in a crowded anterior chamber (AC) and can lead to a high occurrence of corneal edema and an increased rate of complications. Similarly, in cases of dense brunescent cataracts even a lensectomy through posterior approach may prove to be difficult because of inadequate visualization. An endoscopyassisted pars plana lensectomy can help in obviating these difficulties. This study aims to describe the surgical technique of endoscopy-assisted pars plana lensectomy in eyes with brunescent cataract, microcornea, and microphthalmos. Methods Retrospective review of two cases where endoscopy-assisted pars plana vitrectomy and lensectomy was performed for patients with dense cataract and microcornea and microphthalmos. Result Complete clearance of the cataract was achieved without having to resort to a sclerocorneal incision. Postoperatively the cornea was clear and there was no postoperative corneal edema. Conclusion Endoscopy-assisted pars plana lensectomy can help in overcoming the challenges of conventional anterior and posterior approaches of cataract extraction in cases of microcornea with reduced intraoperative and postoperative complications.

Laparoscopic assisted hydrocelectomy of the canal of Nuck: a case report

BackgroundAccurate diagnosis and complete resection of hydrocele of canal of Nuck (HCN) is still a challenge for surgeons.Case presentationA 28-year-old woman presented with a suspected inguinal hernia due to swelling in her right groin and was introduced for surgical treatment. Computed tomography scan revealed local cyst formation in the right groin and eliminated intestinal incarceration. In order to further confirm the diagnosis, we used laparoscopic exploration; after excluding a combined hernia, HCN was surgically removed using a conventional anterior peritoneal approach and a mesh patch repair was not needed. Postoperative pathology results showed no endometriosis or malignancy.ConclusionsLaparoscopic assisted anterior approach provides both an accurate intraoperative diagnosis and a quick complete resection of HCN; it is the preferred treatment for women of childbearing age with pure HCN.

Safety and efficacy of inferoposterior access approach to the renal pedicle during transperitoneal laparoscopic radical nephrectomy: A retrospective comparative analysis at a single institution

Purpose To assess the safety and efficacy of transperitoneal laparoscopic radical nephrectomy using an inferoposterior approach to the renal pedicle. Materials and methods A retrospective review of 89 patients who underwent transperitoneal laparoscopic radical nephrectomy by a single surgeon between June 2014 and December 2019 at a single urological unit was carried out. Access to the renal pedicle was via the inferoposterior approach in 48 cases (study group) and 41 were approached via the conventional anterior approach (control group). Patient demographics, intra-operative anatomical findings, and procedural details including operative time on renal pedicles and post-operative outcomes were recorded. Post-operative complications were recorded and classified according to the Clavien-Dindo classification. A comparative analysis between the two groups was performed using Chi-square test and t-test. Results The inferoposterior approach group had a shorter operative time (132.85±26.65 min vs 153.46±39.94 min; p<0.01), which could be attributed to the shorter time spent operating on the renal vasculature (46.31±6.16 min vs 64.46±7.64 min; p<0.01). Lower average blood loss was also observed in the inferoposterior approach group (42 ml vs 62 ml; p<0.05). No significant difference was identified concerning the mean patient age, body mass index, tumor size, number of renal vessels identified, and post-operative length of stay between the two groups. None of the patients required conversion to open. Conclusion Inferoposterior approach to access the renal pedicle during transperitoneal laparoscopic radical nephrectomy is a safe and effective technique, which shortens the operative time when compared to the conventional anterior approach. Level of evidence: Level 3b.

The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BackgroundTotal hip replacement (THR) is clinically and cost-effective. The surgical approach employed influences the outcome; however, there is little generalisable and robust evidence to guide practice.MethodsA total of 723,904 primary THRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient-reported outcome measures (PROMs) data with up to 13.75 years follow-up, were analysed. There were seven surgical approach groups: conventional posterior, lateral, anterior and trans-trochanteric groups and minimally invasive posterior, lateral and anterior. Survival methods were used to compare revision rates and 90-day mortality. Groups were compared using Cox proportional hazards and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, THR fixation, thromboprophylaxis, anaesthetic, body mass index (BMI) and deprivation. PROMs were analysed with regression modelling or non-parametric methods.ResultsUnadjusted analysis showed a higher revision risk than the referent conventional posterior for the conventional lateral, minimally invasive lateral, minimally invasive anterior and trans-trochanteric groups. This persisted with all adjusted FPM and adjusted Cox models, except in the Cox model including BMI where the higher revision rate only persisted for the conventional lateral approach (hazard rate ratio (HRR) 1.12 [95% CI 1.06,1.17] P < 0·001) and trans-trochanteric approaches (HRR 1.48 [95% CI 1.14,1.91] P = 0.003). PROMs demonstrated statistically, but not clinically, significant differences. Self-reported complications were more frequent with the conventional lateral approach, and the risk of 90-day mortality was higher (HRR 1.15 [95%CI 1.01–1.30] P = 0.029).ConclusionsLateral approaches for THR are associated with worse outcomes, including more deaths and revisions, than the posterior approach. We recommend the posterior approach should be considered the current standard approach for THR. Large well-designed studies are needed to assess any potential benefits from using minimally invasive posterior approaches and the conventional anterior approach.

Stereotactic CT image guidance and biplanar fluoroscopy for transoral C2 vertebroplasty and direct anterolateral subaxial vertebroplasty: a surgical technique note on access to the axial and subaxial spine.

Metastatic cervical spine disease can cause compression fractures, cervical spine instability, and pain. Vertebroplasty can stabilize a fracture, reduce the pain associated with a compression fracture, prevent or stop the progression of a fracture, thus avoiding cervical spine fixation, and decreased mobility. Transoral C2 vertebroplasty is less invasive than open fusion surgery, but it poses its own risk of infection and cement leak in this highly sensitive area. The image guidance setup consisted of the Stryker NAV3i navigation system, Stryker CranialMask tracker, and the CranialMap3.0 software combined with biplanar fluoroscopy. The patient's neck pain has completely resolved immediately after the surgery. There were no complications. Quality of life preservation is paramount in the management of metastatic spine disease. Vertebroplasty of osteolytic lesions can both relieve pain and restore stability, thus avoiding permanent stiff cervical collar, halo vest, or upfront occipitocervical fusion. With the increasing availability of surgical navigation systems, its use combined with biplanar fluoroscopy for performing transoral C2 vertebroplasty seems to be an adequate treatment in selected cases for pain relief, stabilization, and maintaining quality of life in the complex cancer population with C2 pathological fractures. The article describes as well vertebroplasty of the subaxial spine through a conventional anterior approach which again seems to be adequate in the treatment of spinal pathological fractures. Graphical abstract.

Comparison of Anterior only and Combined Anterior and Posterior Approach in Treating Lumbosacral Tuberculosis

A combined anterior and posterior (AP) surgical approach is a popular treatment modality of lumbosacral tuberculosis, but it is often traumatic and complicated. The present study aims to find whether the anterior only approach with the ARCH plate system is less invasive than the AP approach in treating lumbosacral tuberculosis. The ARCH plate system is an innovative anatomic lumbosacral anterior multi-directional locking plate system which was devised with due consideration to the anatomic features of the lumbosacral spine and irregular destruction of involved vertebral endplates. In this retrospective study, 32 patients with lumbosacral tuberculosis underwent surgeries via either the anterior only approach (ARCH group, 18 patients) using the ARCH system or the conventional combined anterior and posterior approach (AP group, 14 patients). American Spinal Injury Association (ASIA) scores, Visual Analogue Scale (VAS) scores, Oswestry Disability Index (ODI), bone union status, ESR, CRP, intervertebral foraminal height between L5 and S1, the vertical height between the anterior upper edge of L5 and S1 vertebral body, lumbosacral angle, and the physiological lordosis of between L1 and S1 from both groups were recorded and compared. All patients were followed up for at least two years. The average duration of operation, blood loss, and length of hospital admission of the ARCH group (154.6 min, 361.1 ml&18.3days) was significantly smaller and shorter(p < 0.001, p < 0.001 & p = 0.008) that those of the AP group(465.5 min, 814.3 ml & 24.6days). The ODI score(p = 0.08, 0.471, 0.06, 0.07, 0.107), the VAS score(p = 0.099, 0.249, 0.073, 0.103, 0.273), the intervertebral foraminal height between L5 and S1(p = 0.826, 0.073, 0.085), L5-S1 height(p = 0.057, 0.234, 0.094), lumbosacral angle(p = 0.052, 0.242, 0.825), and L5-S1 lordosis(p = 0.146, 0.129, 0.053) of both groups showed no significant difference in any of the time points. The anterior only approach using the ARCH system is as effective as the combined anterior and posterior approach and is less traumatic in treating lumbosacral tuberculosis.

Mini-open anterior approach focal cleaning combined with posterior internal fixation for thoracolumbar tuberculosis: Follow-up of 149 cases

To investigate the clinical efficacy and safety of mini-open anterior approach focal cleaning combined with posterior internal fixation for thoracolumbar tuberculosis. A total of 149 patients with thoracolumbar tuberculosis were reviewed retrospectively and divided into 3 groups: mini-open anterior approach (group A), conventional anterior extraperitoneal approach (group B), and posterior approach (group C). After the operation, drainage tubes were routinely placed and the draining fluid was collected on the 4th day for the PCR detection of Mycobacterium tuberculosis (MTB), Mycobacterium tuberculosis DNA test (MTD), and Roche culture. Patients' surgical information, Cobb's angles, and postoperative complications were also compared. There was no significant difference in operation time, blood loss, hospital stay, or preoperative Cobb's angle among three groups. There existed obvious differences in the postoperative Cobb's angle and incidence of postoperative complications between group A and group C, as well as group B and group C. There was no obvious difference in the positive rate of MTB among the three groups by rapid culture plus Roche culture test. However, statistically significant differences in the positive rate of MTB were found between group A and group C by PCR detection, and between group A and group B by MTD. Mini-open anterior approach focal cleaning combined with posterior internal fixation resulted in small Cobb's angles, low incidence of postoperative complications and low positive rates of MTB, without increasing operation time, blood loss and hospital stay, rendering it as a safe and effective method to treat patients with thoracolumbar tuberculosis.

Contralateral Transfalcine Versus Ipsilateral Anterior Interhemispheric Approach for Midline Arteriovenous Malformations: Surgical and Anatomical Assessment

The contralateral anterior interhemispheric approach (CAIA) is considered to provide surgical advantages to access deep midline lesions: wider working angle, gravity enhanced dissection and retraction, more efficient lighting, and ergonomics. Our team has previously published on the merits of using a contralateral trajectory for medial frontoparietal arteriovenous malformations (AVMs) compared with the conventional anterior interhemispheric approach (IAIA). In this article, we compare the IAIA and CAIA for the resection of medial frontoparietal AVMs using quantitative surgical and anatomical analysis. Two models were designed mimicking the most common features of midline AVMs. The CAIA and IAIA were performed bilaterally in 10 specimens. Variables to compare technical feasibility (surgical window [SW] and surgical freedom [SF], target exposure, and angle of attack) were independently assessed using stereotactic navigation. The average SW, SF, and angle of attack were compared with the Student t test. Significance threshold was set at 0.05. The CITA and IAIA were similar in terms of SW, target exposure, and SF in the superior aspect of the AVM. In the depth of the interhemispheric fissure, the CAIA was significantly superior to IAIA in both AVM models: 77% wider AA for the inferior aspect of the AVM (P < 0.01) and greater SF for the draining vein (54%, P= 0.01), ipsilateral (98%, P= 0.02), and contralateral ACA (117%, P < 0.01). This study suggests technical superiority of the CAIA for the resection of deep midline AVMs. No objective difference was noted in the superficial areas of our models, denoting that IAIA is a safer choice for superficial AVMs. Our results set the foundation for further clinical analysis comparing both approaches.

PE42 - Early and long term continence after robotic radical prostatectomy:conventional anterior approach x retzius sparing approach

PE42 - Early and long term continence after robotic radical prostatectomy:conventional anterior approach x retzius sparing approach

Treatment of Lumbar Tuberculosis by Mini-Open Anterior Approach Focal Cleaning Combined with Posterior Internal Fixation.

BackgroundThe aim of this study was to evaluate the efficiency and clinical outcomes of mini-open anterior approach focal cleaning combined with posterior internal fixation compared to conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in the treatment of lumbar tuberculosis (TB).Material/MethodsMedical records from 124 patients were collected from February 2010 to April 2015; patients were divided into two groups: group A (mini-open anterior approach focal cleaning combined with posterior internal fixation) and group B (conventional anterior extraperitoneal approach focal cleaning combined with posterior internal fixation in period I). The data on postoperative mechanical ventilation time, preoperative, postoperative, and last follow-up Cobb angle, visual analog scale (VAS), erythrocyte sedimentation rate (ESR), and Frankel classification were collected and analyzed. Operative complications, internal stability, and bone graft fusion were also observed.ResultsAll patients were followed-up for 12 to 36 months (average 22.5 months). Seven cases (five in group A and two in group B) had side psoas abscess and were cured after secondary drainage surgery. The rest of the cases were all cured after primary surgery, with no formation of sinus, incisional hernia, cerebrospinal fluid leakage, or recurrence of spinal TB, with no TB symptoms. Bone graft fusion ranged from 3 to 8 months (average 4.7 months). Compared to group B, group A, which had less time on postoperative mechanical ventilation, had a higher VAS score. Both groups had distinct improvements in Cobb angle, ESR, and Frankel classification after surgery.ConclusionsTreating lumbar TB by mini-open anterior approach focal cleaning combined with posterior internal fixation was safe and effective.

Lateral lumbar interbody fusion at the lumbosacral junction

Due to the obstruction of the iliac crest and the retroperitoneal vessels, lateral lumbar interbody fusion (LLIF) is generally considered contraindicated at the lumbosacral junction (LSJ). In particular the ‘rise’ of the psoas from the vertebral column in the lower lumbar segments has been associated with significant overlap of the lumbar plexus with the vertebral body and exclusion of a safe transpsoas entry. However in selected individuals anatomical variations may help circumvent the difficulties and the anatomical corridor posterior to the lumbar plexus may provide an alternative to the conventional anterior approach. Currently there is a dearth of information in informing the feasibility. We therefore reviewed the records of three patients in whom LLIF was successfully conducted at the LSJ. The patients’ spinopelvic parameters and psoas anatomy were analysed by whole spine standing X-rays and MRI respectively. Intraoperative findings and postoperative outcome were examined. We found that in keeping with published morphometric data, low pelvic incidence (40–50°) appeared associated with ‘low-lying’ iliac crests which had facilitated lateral access to the LSJ in all cases. Patients with scoliosis provided added advantage when the concave side of the curve was utilised for the approach. A very high ‘rising’ psoas was found conducive to a novel posterior surgical corridor. No significant neurovascular sequelae were noted. In conclusion, LLIF can be safely performed at the LSJ in selected cases. To our knowledge this is the first report to describe the possibility of a safe LLIF working zone posterior to the lumbar plexus.

Application of Lateral Approach for the Removal of Migrated Interbody Cage: Taphole and Fixing Technique.

When a revision surgery related with removal of failed interbody cage is required, going through the previous passage can lead to a higher risk of neurological deficits or incidental dural injuries. Recently, the lateral approach has become a popular method instead of the conventional anterior or posterior approaches. The lateral approach is also useful method to remove failed interbody cage previously placed and re-do interbody fusion with lower risks compared to revision surgery via previous passage. However, there is still some difficulty in retrieving the interbody cage from the intervertebral space because of no spacious passage, subsidence, and uncontrolled movable cage. In this study, we introduce our experience that we removed failed interbody cage more easily with only the simple additional steps of making a taphole and fixing the cage using a thread-tipped stick.