Lateral Retroperitoneal Approach Research Articles

Microsurgical treatment of lumbar paravertebral tumors via lateral retroperitoneal approach: operative technique and a series of 6 patients

ObjectiveTo investigate the surgical techniques and postoperative therapeutic effectiveness of microsurgical treatment of lumbar paravertebral tumors via lateral retroperitoneal approach.MethodsThe clinical data of 6 cases with lumbar paravertebral tumors treated by lateral retroperitoneal approach in the Neurosurgery department of Xuanwu Hospital, Capital Medical University were analyzed retrospectively. The mean operation time, blood loss, incision length, length of hospital stay, and the resection rate of paravertebral tumors were collected, and the score of The Ability to Perform Activities of Daily Living (ADL) and incidence of postoperative complications was recorded.ResultsThe operation time ranged from 56 to 181 min, with an average of (94.8 ± 48.3) minutes. The blood loss was between 5 and 100 ml, with an average of (31.7 ± 37.5) ml. The incision length was 6–7 cm, with an average of (6.7 ± 0.5) cm. The hospitalization length was between 5 and 11 days, with an average of (8.7 ± 2.6) days. The resection rate of paravertebral tumors was 100%. Postoperative pathological diagnosis results revealed 4 cases of schwannoma, 1 case of ganglioneuroma, and 1 case of malignant small round cell tumor. During the 3-month follow-up, there were no tumor recurrence, abdominal infection, incision infection, incisional hernia, or death, and there was no significant decrease in the ADL score compared with that before the operation.ConclusionThe surgical treatment of lumbar paravertebral tumors via the lateral retroperitoneal approach has the advantages of the short operation time, minimally invasive procedures, quick postoperative recovery, and fewer complications.

L4 Corpectomy: Surgical Approaches and Mitigating the Risk of Femoral Nerve Injuries

Because of the challenging anatomic location, corpectomies are performed less often at the fourth lumbar vertebral body than at other levels. Our objective was to review the literature of L4 corpectomy and anterior column reconstruction. A literature search in the Medline/PubMed database was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify all relevant cases and cases series describing corpectomies of the L4 vertebral body using "lumbar" AND "corpectomy" as search terms. We present an illustrative case to describe the technique. We identified 18 articles with 30 patients who met the search criteria. Including our case illustration, the most common approach used was the lateral retroperitoneal approach (n= 17, 54.8%), of which 8 (26.7%) were performed via a transpsoas approach. Seven (23%) patients underwent corpectomy through a posterior approach, 4 (12.9%) through an anterior retroperitoneal approach, and 3 (10%) through combined anterior and lateral retroperitoneal. The overall complications rate was 19.3% including 1 case each of femoral nerve injury and iatrogenic lumbar nerve root injury. Corpectomies of the L4 vertebral body are challenging. None of the various approaches described clearly demonstrates any superiority in mitigating the risk of neural complications. Decision making about which surgical approach to use should be based on patient-specific characteristics.

Minimally invasive lateral retroperitoneal transpsoas approach for lumbar corpectomy and fusion with posterior instrumentation.

In this video, the authors highlight the operative treatment of a 55-year-old man with chronic osteomyelitis discitis. The operation entailed a minimally invasive lateral retroperitoneal transpsoas approach for L3 and L4 corpectomies, L2–5 interbody fusion, and L2–5 minimally invasive posterior instrumentation. The operation proceeded in two stages, beginning in the lateral position with corpectomy of the L3 and L4 vertebral bodies and placement of a corpectomy cage. After closure of this access wound, the patient was turned to a prone position for the posterior element of the operation. Posterior instrumentation was placed with pedicle screws at L2 and L5.The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2210

MIS lateral retroperitoneal transpsoas approach allows gross total resection of a giant L4 schwannoma.

In this surgical video, the authors present a successful minimally invasive (MIS) lateral retroperitoneal transpsoas approach for resection of an L4 nerve root schwannoma. They describe the surgical approach in detail, with special emphasis on patient positioning for an orthogonal view, as well as technical nuances throughout the procedure. Using a sequential tubular retractor, they performed a microscopic dissection of the lesion. The tumor was debulked and the tumor capsule was disconnected from the surrounding tissue. During dissection, direct stimulation identified a functional nerve root that was carefully dissected from the tumor capsule. The tumor was then removed en bloc.The video can be found here: https://stream.cadmore.media/r10.3171/2022.3.FOCVID2220

Chronic postsurgical pain after minimally invasive adrenalectomy: prevalence and impact on quality of life

BackgroundMinimally invasive adrenalectomy is the standard of care for small adrenal tumours. Both the transperitoneal lateral approach and posterior retroperitoneal approach are widely used and have been proven to be safe and effective. However, the prevalence of chronic postsurgical pain has not been specifically investigated in previous studies. The primary goal of this study was to identify the prevalence of chronic postsurgical pain after minimally invasive adrenalectomy.MethodsA cross-sectional study was performed among all consecutive patients who had undergone minimally invasive adrenalectomy in a single university medical centre. The primary outcome was the prevalence of chronic postsurgical pain. Secondary outcomes were the prevalence of localized hypoesthesia, risk factors for the development of chronic postsurgical pain, and the Health-Related Quality of Life. Three questionnaires were used to measure the prevalence and severity of chronic postsurgical pain, hypoesthesia, and Health-Related Quality of Life. Logistic regression analysis was performed to determine risk factors for development of chronic postsurgical pain.ResultsSix hundred two patients underwent minimally invasive adrenalectomy between January 2007 and September 2019, of whom 328 signed informed consent. The prevalence of chronic postsurgical pain was 14.9%. In the group of patients with chronic postsurgical pain, 33% reported hypoesthesia as well. Young age was a significant predictor for developing chronic postsurgical pain. The prevalence of localized hypoesthesia was 15.2%. In patients with chronic postsurgical pain, Health-Related Quality of Life was significantly lower, compared to patients without pain.ConclusionsThe prevalence of chronic postsurgical pain following minimally invasive adrenalectomy is considerable. Furthermore, the presence of chronic postsurgical pain was correlated with a significant and clinically relevant lower Health-Related Quality of Life. These findings should be included in the preoperative counselling of the patient. In the absence of evidence for effective treatment in established chronic pain, prevention should be the key strategy and topic of future research.

Endoscope-Assisted Retroperitoneal Prepsoas Approach to Lumbar Intervertebral Disk Decompression. Technical Note.

Increasingly there is an impetus on the part of surgeons to find more minimally invasive approaches to treat spinal pathologies. Retroperitoneal prepsoas and transpsoas approaches to the lumbar spine are one such example gaining increased attention. Endoscope-assisted approaches may help further reduce soft tissue dissection. To describe an endoscope-assisted lateral retroperitoneal prepsoas approach for lumbar diskectomy. Two fresh-frozen thoracolumbar cadaveric specimens were obtained and placed in the right lateral decubitus position. Using a left-sided, retroperitoneal prepsoas approach to the lumbar spine and under endoscopic visualization, diskectomies were performed at the L2/3, L3/4, L4/5, and L5/S1 intervertebral spaces. Qualitative assessment of the extent of central and contralateral foraminal decompression was performed. The endoscope was found to provide effective visualization at all disk spaces and combined with the anterior retroperitoneal prepsoas approach allowed for effective decompression of all explored disk spaces. Both operators noted difficulty obtaining visualization of the ipsilateral foramen, but adequate central and contralateral foraminal decompression was achievable for central, paracentral, and contralateral far lateral disk protrusions. Endoscope assistance may improve visualization of the lumbar intervertebral disk spaces during retroperitoneal prepsoas approaches and thereby help to expand the surgical indication for anterior and oblique lumbar interbody fusion.

Comparison and optimization of sheep in vivo intervertebral disc injury model.

BackgroundThe current standard of care for intervertebral disc (IVD) herniation, surgical discectomy, does not repair annulus fibrosus (AF) defects, which is partly due to the lack of effective methods to do so and is why new repair strategies are widely investigated and tested preclinically. There is a need to develop a standardized IVD injury model in large animals to enable comparison and interpretation across preclinical study results. The purpose of this study was to compare in vivo IVD injury models in sheep to determine which annulus fibrosus (AF) defect type combined with partial nucleus pulposus (NP) removal would better mimic degenerative human spinal pathologies.MethodsSix skeletally mature sheep were randomly assigned to one of the two observation periods (1 and 3 months) and underwent creation of 3 different AF defect types (slit, cruciate, and box‐cut AF defects) in conjunction with 0.1 g NP removal in three lumbar levels using a lateral retroperitoneal surgical approach. The spine was monitored by clinical CT scans pre‐ and postoperatively, at 2 weeks and euthanasia, and by magnetic resonance imaging (MRI) and histology after euthanasia to determine the severity of degeneration (disc height loss, Pfirrmann grading, semiquantitative histopathology grading).ResultsAll AF defects led to significant degenerative changes detectable on CT and MR images, produced bulging of disc tissue without disc herniation and led to degenerative and inflammatory histopathological changes. However, AF defects were not equal in terms of disc height loss at 3 months postoperatively; the cruciate and box‐cut AF defects showed significantly decreased disc height compared to their preoperative height, with the box‐cut defect creating the greatest disc height loss, while the slit AF defect showed restoration of normal preoperative disc height.ConclusionsThe tested IVD injury models do not all generate comparable disc degeneration but can be considered suitable IVD injury models to investigate new treatments. Results of the current study clearly indicate that slit AF defect should be avoided if disc height is used as one of the main outcomes; additional confirmatory studies may be warranted to generalize this finding.

A preliminary safety assessment of vertebral augmentation with 32P brachytherapy bone cement

Comprehensive treatment for vertebral metastatic lesions commonly involves vertebral augmentation (vertebroplasty or kyphoplasty) to relieve pain and stabilize the spine followed by multiple sessions of radiotherapy. We propose to combine vertebral augmentation and radiotherapy into a single treatment by adding 32P, a β-emitting radionuclide, to bone cement, thereby enabling spinal brachytherapy to be performed without irradiating the spinal cord. The goal of this study was to address key dosimetry and safety questions prior to performing extensive animal studies. The 32P was in the form of hydroxyapatite powder activated by neutron bombardment in a nuclear reactor. We performed ex vivo dosimetry experiments to establish criteria for safe placement of the cement within the sheep vertebral body. In an in vivo study, we treated three control ewes and three experimental ewes with brachytherapy cement containing 2.23–3.03 mCi 32P ml−1 to identify the preferred surgical approach, to determine if 32P leaches from the cement and into the blood, urine, or feces, and to identify unexpected adverse effects. Our ex vivo experiments showed that cement with 4 mCi 32P ml−1 could be safely implanted in the vertebral body if the cement surface is at least 4 mm from the spinal cord in sheep and 5 mm from the spinal cord in humans. In vivo, a lateral retroperitoneal surgical approach, ventral to the transverse processes, was identified as easy to perform while allowing a safe distance to the spinal cord. The blood, urine, and feces of the sheep did not contain detectable levels of 32P, and the sheep did not experience any neurologic or other adverse effects from the brachytherapy cement. These results demonstrate, on a preliminary level, the relative safety of this brachytherapy cement and support additional development and testing.

A MORPHOMETRIC STUDY OF VENTRAL NERVE ROOTS AND RETROPERITONEAL VESSELS IN RELATION TO A MINIMALLY INVASIVE LATERAL APPROACH TO DETERMINE SAFE WORKING ZONE

Background: The minimally invasive lateral retroperitoneal transpsoas approach is a new method that was designed to minimize problems related with standard or minimally invasive anterior or posterior lumbar spine techniques. The current work used magnetic resonance imaging to determine the anatomic location of the ventral root and retroperitoneal arteries in respect to the vertebral body and to establish the anatomical safe zones. We examined lumbar spine MRI in 50 individuals retrospectively (L1-L2 to L5-S Method: 1 levels). The ventral root and surrounding major arteries were identied using axial T1 and T2 scans. Axial MR scans were utilized to determine the anterior-posterior (AP) diameter of the vertebral endplate, the overlap between the ventral root and the posterior border of the vertebra, and the overlap between the retroperitoneal big vessels and the anterior edge of the vertebra. The safe zone was then determined. From L1–L2 Results: to L5–S1, the mean AP diameter of the vertebral body and the overlap of the vertebral body with the nerve roots and retroperitoneal arteries grew gradually. When we examined the extent of overlap of retroperitoneal arteries with the ventral border of the lower vertebral body endplate, we discovered that the right vascular structures were more posterior than the left vascular structures. The safe working zone was 81.86 percent of the lower endplate of the sagittal diameter of the vertebral body at L1–L2, 70.03 percent at L2–L3, 69.32 percent at L3–L4, 50.08 percent at L4–L5, and 17.92 percent at L5–S1 levels. The Conclusion: retroperitoneal transpsoas method is a less invasive and more efcient alternative to the conventional posterior, open lumbar procedures. It can be used to treat trauma, degenerative disc disease, adult degenerative scoliosis, spondylosis with instability, spondylolisthesis, lumbar stenosis, and neighboring segment failure.

Comparison of lateral transperitoneal and retroperitoneal approaches for homolateral laparoscopic adrenalectomy

BackgroundThere is a lack of data regarding the appropriateness of transperitoneal and retroperitoneal approaches for homolateral laparoscopic adrenalectomy. The aim of this study is to compare lateral transperitoneal and retroperitoneal approach for left-sided and right-sided laparoscopic adrenalectomy respectively.MethodsBetween January 2014 and December 2019, 242 patients underwent left-sided and 252 patients underwent right-sided laparoscopic adrenalectomy. For left side, transperitoneal approach was used in 132 (103 with tumors < 5 cm and 29 with tumors ≥ 5 cm) and retroperitoneal approach in 110 (102 with tumors < 5 cm and 8 with tumors ≥ 5 cm). For right side, transperitoneal approach was used in 139 (121 with tumors < 5 cm and 18 with tumors ≥ 5 cm) and retroperitoneal approach in 113 (102 with tumors < 5 cm and 11 with tumors ≥ 5 cm). Patient characteristics and perioperative outcomes were recorded. For each side, both approaches were compared for tumors < 5 cm and ≥ 5 cm respectively.ResultsFor left-sided tumors < 5 cm, transperitoneal approach demonstrated shorter operative time, less blood loss and longer time to oral intake. For left-sided tumors ≥ 5 cm, the peri-operative data of both approaches was comparable. For right-sided tumors < 5 cm, transperitoneal approach demonstrated shorter operative time and less blood loss. For right-sided tumors ≥ 5 cm, the peri-operative data was comparable.ConclusionsLateral transperitoneal and retroperitoneal approach are both effective for laparoscopic adrenalectomy. Lateral transperitoneal approach is faster with less blood loss for tumors < 5 cm.

Retroperitoneoscopic Nephrectomy in Pediatric Patients.

Minimally invasive surgery (MIS) in pediatric population is becoming more and more popular among pediatric urologists and now it can be considered the best treatment for nephroureterectomy that is one of the most frequent urological procedures. The main indications to MIS ureteronephrectomy in children are congenital or acquired benign conditions such as nonfunctional and/or damaging kidney, renal dysplasia, and destroyed kidneys due to obstructive or refluxing uropathy. Since ever in open urological surgery, the lateral retroperitoneal approach represents the typical way to approach this kind of surgery. Although different surgical approaches can be chosen (i.e., posterior retroperitoneal, lateral retroperitoneal, laparoscopic transperitoneal, and robotic approach), the lateral retroperitoneal approach represents the typical way to perform this kind of surgery, also with minimally invasive techniques. In this article, we illustrate the technique of retroperitoneoscopic nephroureterectomy in infants and children, reporting our experience with this technique in the past 20 years.

Surgical approaches in juxtarenal and pararenal aortic aneurysms repair.

In this study, surgical tactic features and juxtarenal and pararenal treatment immediate results were analyzed depending on the use of various surgical approaches. Between 2015 and 2019, a total of 89 patients received surgical treatment, of which 52(58%) had juxtarenal aneurysms and 37 (42%) - pararenal aneurysms. During repairs, three types of surgical approaches were used: midline laparotomy, extended retroperitoneal approach and thoraco-phreno-retroperitoneal approach. The patients were divided into three groups accordingly. At the immediate postoperative period, mortality rate equaled 2 (2.2%). The reasons were pulmonary embolism and sepsis. Statistically reliable data were obtained, confirming the advantages of midline laparotomic approach over the lateral retroperitoneal ones, which consisted in a shorter operative time, less pronounced pain syndrome, lesser blood loss, fewer postoperative days. The disadvantages were that enteroparesis occurred more often when the midline laparotomy was used in comparison to extended retroperitoneal or thoraco-phrenoretroperitoneal approaches. Thus, open repairs of juxtarenal and pararenal aortic aneurysms have some specific technical and strategical features which are associated with intraoperative renal ischemia. During open surgical intervention, it is important to first consider the possibility of repair with midline laparotomy. However, lateral retroperitoneal approaches can also be used on a case-by-case basis noting their advantages and disadvantages.

Lateral retroperitoneal approach for surgical treatment of lumbar diskitis/osteomyelitis with post-infectious spinal deformity

Lumbar diskitis/osteomyelitis (LDO) can cause destruction of the anterior and middle spinal column leading to loss of structural integrity further compounded by iatrogenic violation of the posterior tension band during initial decompressive surgeries. Progressive deformity and/or medically refractory infection may necessitate aggressive debridement and reconstructive arthrodesis. Anterior debridement and reconstruction with posterior stabilization is an effective treatment option; however, existing open surgical techniques have limited efficacy for correction of the focal deformity, which can expose the patient to long term sagittal imbalance, pain, and disability. The aim of this chapter is to briefly review the epidemiology, pathophysiology, clinical presentation, and the role of medical versus surgical management in LDO. The role of the lateral retroperitoneal approach to the lumbar spine is then discussed and illustrated with two clinical cases.

41. Surgical outcomes for upper lumbar disc herniations: a systematic review and meta-analysis of the literature

BACKGROUND CONTEXT Upper lumbar disc herniations (ULDH) represent approximately 10% of lumbar disc herniations and are known to have distinct clinical presentations from lower lumbar disc herniations (LLDH), yet surgical outcomes are not well understood. PURPOSE To review the surgical outcomes of discectomy for ULDH, compare standard open laminectomy and microdiscectomy (OLM) vs minimally invasive surgical (MIS) techniques, and compare results of disc herniations at L1-3 v. L3-4. STUDY DESIGN/SETTING A systematic review of articles reporting outcomes of nonfusion surgical treatment of L1-2, L2-3, and/or L3-4 disc herniations was performed. Abstracts were identified through a search of the PubMed/Medline database along with a review of bibliographies of examined articles. The inclusion and exclusion of studies was performed according to the latest version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. PATIENT SAMPLE Fourteen studies encompassing 773 patients reported outcomes of conventional OLM. Nine case series on minimally invasive approaches to ULDH collected described total of 4 techniques: percutaneous endoscopic lumbar discectomy (PELD), oblique paraspinal (OP), tubular microdiscectomy (TM), and lateral retroperitoneal approach (LRA). PELD was the most reported with 4 studies that describe experience for a total of 126 patients. OUTCOME MEASURES Studies were divided into conventional OLM or MIS technique. Average age of patients, follow-up duration, and gender were recorded. Reported outcomes were collected and divided into groups by level as provided. Outcome measures varied greatly, and in order to perform a combined analysis, outcomes were reassigned into either satisfactory or unsatisfactory. Factors such as length of surgery, blood loss, and hospital length of stay were largely undescribed and thus not available for analysis. METHODS Two methods were used for the meta-analysis and forest plots: the classical inverse variance method, which yields weight for each study, and the Generalized Linear Mixed Model (GLMM) method. Fixed effects model was used and the pooled proportion was computed using the R package, meta, using the statistical computing software R. For comparisons, GLMM was used to compare using the SAS procedure, GLIMMIX. Statistical significance level was set as p RESULTS A total of 23 articles were included in the analysis (14 OLM and 9 MIS techniques). A range of 58% to 92% of patients reported favorable outcomes for all L1-4 disc levels. There was no significant improvement with MIS techniques compared with standard OLM, OR=0.86, 95% CI: (0.42, 1.74), p=0.66. Among MIS techniques outcomes of PELD vs OLM yielded a slight trend toward significance favoring OLM with an OR=0.50, 95% CI: (0.21, 1.16), and p= 0.10. OP and TM were not significantly different from OLM regarding the outcome of satisfactions with the surgery, OP vs OLM: OR=1.04, 95% CI: (0.20, 5.25), p=0.96, and TM vs OLM: OR=2.15, 95% CI: (0.38, 12.38), p=0.36. Comparisons for LRA could not fit the maximum likelihood model as all surgeries were reported as 100% satisfactory. Separating results by levels a trend toward significance of higher satisfaction with L3-4 vs L1-3 with standard OLM surgery, OR=0.46, 95% CI: (0.19, 1.12), p=0.08. CONCLUSIONS Our analysis supports that ULDH have an overall success rate of approximately 80%, but has not improved with MIS techniques. Discectomy for herniations at L3-4 trends toward better outcomes compared with disc herniations at L1-2 and L2-3, but was not significant. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The Safe Entry Zones through the Transpsoas Approach to Lumbar Discs: A Cadaver Study

Abstract Background Data: Low back pain (LBP) is a common musculoskeletal disorder. In Egypt, patients with LBP constitute a high percentage of patients seeking medical care at outpatient clinics. Spinal fusion is a common treatment for spinal disorders such as disc degeneration, deformity, spondylolisthesis, or fracture. The minimally invasive lateral retroperitoneal transpsoas approach is a recent technique developed to avoid complications associated with traditional or minimally invasive anterior or posterior approaches to the lumbar spine. This technique provides a small incision that avoids significant abdominal muscle injury and lateral access to the disc space from L1-L2 to L4-L5. Purpose: To define a safe entry zone in the psoas muscle to prevent lumbar plexus injury during the transpsoas approach. Study Design: A descriptive cadaveric study. Material and Methods: A total of 30 cadavers were used in this study where each cadaver was dissected from both sides. Each cadaver was placed in lateral decubitus and a skin incision in the midaxillary line from the last rib to iliac crest was made. Then, the peritoneum was dissected, psoas muscle was exposed, and nerve roots were identified and reported at each disc space from L1-L2 to L4-L5. The safe entry zone was defined by the absence of crossing of a lumbar plexus branch. Results: Each disc space was divided into four zones: zone 1, the posterior quadrant; zone 2, the middle anterior quadrant; zone 3, the middle posterior quadrant; zone 4, the posterior quadrant. The safe working zone includes zones 2 and 3 at level L1-L2, zone 3 at level L2-L3, zone 3 at level L3-L4, and zone 2 at level L4-L5. There was no variance observed between either side regarding the relationships between the lumbar plexus and the intervertebral disc. Conclusion: Knowledge of the anatomy of lumbar plexus roots in psoas muscle is mandatory to prevent injury to lumbar plexus roots during entry of dilator through psoas muscle. This anatomical study suggests that there are certain safe zones at the lumbar disc spaces that allow passage of dilator inside psoas muscle to reduce direct nerve injury of the lumbar plexus. (2020ESJ200) Background data: Low back pain (LBP) is a common musculoskeletal disorder. In Egypt, patients with LBP constitutes a high percentage of patients seeking medical care at outpatient clinics. Spinal fusion is a common treatment for spinal disorders such as disc degeneration, deformity, spondylolisthesis or fracture. The minimally invasive lateral retroperitoneal transpsoas approach is a recent technique developed to avoid complications associated with traditional or minimally invasive anterior or posterior approaches to the lumbar spine. This technique was popularized by Pimenta and Ozgur. This technique provides small incision that avoids significant abdominal muscle injury and provides lateral access to the disc space from L1–L2 to L4–L5. Purpose: This study aims to define safe entry zone in psoas muscle to prevent lumbar plexus injury during transpsoas approach. Study design: This study is descriptive cadaveric study. Methods: Cadavers number: 10 cadavers, each cadaver was dissected from both sides. Each cadaver is placed in lateral decubitus, skin incision in midaxillary line from last rib to iliac crest. Incision of abdominal muscle then retraction of peritoneum, psaos muscle exposed. The psoas muscle is dissected, and nerve roots are identified and reported at each disc space from L1_2 to L4_5. The safe entry zone is defined by the absence of crossing of a lumbar plexus branch. Results: Our results are comparable to previous anatomical studies. Each disc space divided into four zones; zone 1 the posterior quadrant, Zone 2 the middle anterior quadrant, Zone 3 the middle posterior Quadrant, Zone 4 the posterior quadrant. The safe working zone includes zones 2 and 3 at level L1L2, zone 3 at level L2L3, zone 3 at level L3L4, and zone 2 at level L4L5. There is no variance was observed between either side as regards the relationships between the lumbar plexus and the intervertebral disc. Conclusion: The tranpsoas approach is minimally invasive approach developed to prevent major complications of traditional approaches. However, the proximity of lumbar plexus is the main limitation of the approach. Knowledge of anatomy of lumbar plexus roots in psoas muscle is mandatory to prevent injury to lumbar plexus roots during entry of dilator through psoas muscle.

Retroperitoneal Approach for Ureteropelvic Junction Obstruction: Encouraging Preliminary Results With Robot-Assisted Laparoscopic Repair.

Introduction stating the aim of the study: Robot-assisted laparoscopic pyeloplasty (RALP) is gaining acceptance among pediatric urologists. Few studies have evaluated the retroperitoneal approach for RALP. We share our experience from the first 2 years of a multidisciplinary pediatric robotic program in our center.Patients (or Materials) and Methods: We performed a retrospective analysis of prospectively collected data of children undergoing RALP for ureteropelvic junction obstruction (n = 50). Diagnosis was confirmed by ultrasound and Tc-99m mercaptoacetyltriglycine renal scan or MRI; the same criteria were used to evaluate outcome. Surgical approach was chosen according to a specific algorithm. Transperitoneal approach (n = 13) was reserved for horseshoe kidney, ectopic kidney, and redo surgery. We analyzed the 37 cases performed by a lateral retroperitoneal approach. Dismembered pyeloplasty was done for all cases and anastomosis was performed using a running monofilament 6/0 absorbable suture. All were drained by double J stent. Patient data, operating room parameters and postoperative course were recorded.Results: The median age was 7.9 years (5.1–13.8); the youngest was 2 years old. The median weight was 23 kg (17–41) with the smallest weighing 12.4 kg. Aberrant crossing vessels were present in 18 children. Median set-up time, from skin incision until the end of the 4-port insertion, was 33 min (29–48). Median surgeon's console time was 151 min (136–182). No conversion to an open procedure was necessary. The postoperative course was free of complications, except urinary tract infection in 6 children. All but 4 patients were discharged on day one. Median follow-up was 9 months (5–13). Redo pyeloplasty was not required. Practical training of other colleagues was possible after 10 cases performed by the same surgeon.Conclusion: These preliminary results suggest that retroperitoneal RALP in children is feasible, safe and effective. It is an excellent option with ideal anatomical exposure. Longer term results as well as continued practice will identify and overcome any challenges and enable surgical mastery of this procedure which is still evolving.

Lateral Approach to the Lumbar Spine of Sprague Dawley Rat: Development of a Novel Animal Model for Spine Surgery

Background: Low back pain is a common ailment affecting individuals all around the globe. Animal models are required to study and further explore the treatment modalities. Lumbar spinal surgeries and disc repair is an important tissue engineering research domain. Dorsal and ventral approaches to access rat spine have been traditionally performed but suffer from a number of shortcomings such as higher morbidity, loss of neurology, high postoperative pain, and longer surgery. Methods: We used ten male Sprague Dawly rats, 3 months of age, and weighing an average of 280 gm. The surgeries were performed under dissociative anesthesia (ketamine: 50 mg/kg body weight). The spine was approached by left lateral incision extending from iliac crest and centering the level to be exposed. Skin and subcutaneous tissues were cut, external and internal oblique muscles were split in the direction of fibers, transverse abdominis was split vertically, and psoas was sacrificed. This made the spine and disc levels visible from the left lateral aspect. The muscles were approximated, and skin was closed with nonabsorbable mattress sutures. Postoperative analgesics (meloxicam 5 mg/kg body weight) and antibiotics (ceftriaxone 30 mg/kg body weight) were used. Results: This work has led to the development of a novel in vivo rat model using lateral retroperitoneal approach. This approach provides less pain and faster recovery in the postoperative stage. Moreover, it allows easy exposure and little surgery-related peri- or post-operative complications. Conclusion: Lateral retroperitoneal approach is a novel and safe method of spinal exposure in rats which may pave way for various live rat spine surgery models and experiments in future.

Latent spondylodiscitis following elbow cellulitis: A case report and literature review

Spondylodiscitis is usually caused by hematogenous spread, and recently there have been only a few published reports citing the soft tissue as the hematogenous source. We present an unusual case of pyogenic spondylodiscitis following elbow cellulitis. In addition to white blood cell (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) values, we checked the procalcitonin (PCT) level to confirm if the infection was in acute phase. Although the patient’s fever subsided after administration of antibiotics, the neurologic claudication worsened, and we performed an anterior debridement and interbody fusion combined with posterior instrumentation. The direct lateral retroperitoneal approach, which we adapted, has the advantage of excellent exposure for irrigation, debridement, and reconstruction without requiring blood vessel mobilization or manipulation of the peritoneal contents. After surgery, intravenous antibiotics were administered for 6 weeks, followed by oral antibiotics until the CRP normalized and the ESR was decreasing. The patient made an uneventful recovery, with no significant neurologic sequelae reported at outpatient follow-up evaluations. The purpose of this case report is to inform clinicians of the potentially severe complication of spondylodiscitis following cellulitis and describe a modified approach to surgical treatment.

Laparoscopic adrenalectomy using the lateral retroperitoneal approach: Is it a safe and feasible treatment option for pheochromocytomas larger than 6 cm?

To evaluate the surgical feasibility of laparoscopic adrenalectomy using the lateral retroperitoneal approach for the treatment of large pheochromocytomas, and to identify the preoperative risk factors for intraoperative hypertension. We retrospectively reviewed 51 patients who underwent laparoscopic adrenalectomy using the lateral retroperitoneal approach for the treatment of pheochromocytomas. Patient characteristics and perioperative outcomes were analyzed and compared between the two study groups based on tumor size: group A (n = 27, ≤6 cm) and group B (n = 24, ˃6 cm). There was no significant difference in preoperative characteristics between the two groups except for tumor size (P = 0.001) and urinary metanephrine (P = 0.011). Group B patients required longer operating time (P = 0.008), had a greater estimated blood loss (P = 0.001) and hemoglobin change (P = 0.002). However, no significant differences were observed in perioperative complications and mortality. Multivariate analysis showed that symptomatic pheochromocytomas (P = 0.004) and tumor size (P = 0.007) were significant risk factors for intraoperative hypertension. Laparoscopic adrenalectomy using the lateral retroperitoneal approach for pheochromocytomas can be regarded as a treatment option, even for tumors measuring >6 cm. Symptomatic pheochromocytomas and large tumor size seem to represent risk factors for intraoperative hypertension.

Adequate cage placement for a satisfactory outcome after lumbar lateral interbody fusion with MRI and CT analysis.

Introduction Through an extreme lateral retroperitoneal and transpsoas approach to intervertebral disc and fusion surgery, a large lordosis cage can be placed for solid and stable intervertebral fusion and to provide strong anterior support, disc height restoration, favorable alignment, and indirect nerve decompression. However, appropriate placement of the interbody cage remains insufficiently researched. We sought to determine both appropriate cage placement as well as other factors affecting nerve decompression in extreme lateral interbody fusion (XLIF) surgery. Methods We included 53 consecutive patients suffering from lumbar degenerative diseases with an indication for XLIF. Radiographic analysis using a sagittal computed tomography (CT) and axial magnetic resonance imaging (MRI) views was conducted to determine intervertebral disc height and angle, degree of disc bulging and thickness of the flavum, the area of the dural tube, cage height, pre- and postoperative disc bulging, change of disc bulging after surgery, cage subsidence, and cage placement at the rostral and caudal endplates. Results Intervertebral disc height and angle were significantly increased at all levels (L2/3, 3/4, 4/5) (p < 0.05). The area of the dural tube was significantly increased (p < 0.05), whereas the degree of disc bulging and thickness of the flavum were significantly decreased at all disc levels (p < 0.05). The enlarged area of the dural tube showed significant correlation with increased disc height (p = 0.019), preoperative flavum thickness (p = 0.008), change of flavum thickness (p < 0.0001), and cage placement at the rostral endplate (p = 0.014). Conclusions A decrease in flavum buckling is more important than disc protrusion as a consideration for obtaining indirect decompression. Central placement may be advantageous for indirect decompression.