title: Anterior longitudinal ligament release using the minimally invasive lateral retroperitoneal transpsoas approach: a cadaveric feasibility study and report of 4 clinical cases.
abstract: OBJECTIVE
  Traditional procedures for correction of sagittal imbalance via shortening of the posterior column include the Smith-Petersen osteotomy, pedicle subtraction osteotomy, and vertebral column resection. These procedures require wide exposure of the spinal column posteriorly, and may be associated with significant morbidity. Anterior longitudinal ligament (ALL) release using the minimally invasive lateral retroperitoneal approach with a resultant net lengthening of the anterior column has been performed as an alternative to increase lordosis. The objective of this study was to demonstrate the feasibility and early clinical experience of ALL release through a minimally invasive lateral retroperitoneal transpsoas approach, as well as to describe its surgical anatomy in the lumbar spine.
  
  
  METHODS
  Forty-eight lumbar levels were dissected in 12 fresh-frozen cadaveric specimens to study the anatomy of the ALL as well as its surrounding structures, and to determine the feasibility of the technique. The lumbar disc spaces and ALL were accessed via the lateral transpsoas approach and confirmed with fluoroscopy in each specimen. As an adjunct, 4 clinical cases of ALL release through the minimally invasive lateral retroperitoneal transpsoas approach were reviewed. Operative technique, results, complications, and early outcomes were assessed.
  
  
  RESULTS
  In the cadaveric study, sectioning of the ALL proved to be feasible from the minimally invasive lateral retroperitoneal transpsoas approach. The structures at most immediate risk during this procedure were the aorta, inferior vena cava, iliac vessels, and sympathetic plexus. The mean increase in segmental lumbar lordosis per level of ALL release was 10.2°, while global lumbar lordosis improved by 25°. Each level of ALL release took 56 minutes and produced 40 ml of blood loss on average. Visual analog scale and Oswestry Disability Index scores improved by 9 and 35 points, respectively. There were no cases of hardware failure, and as of yet no complications to report.
  
  
  CONCLUSIONS
  This initial experience suggests that ALL release through the minimally invasive lateral retroperitoneal transpsoas approach may be feasible, allows for improvement of lumbar lordosis without the need of an open laparotomy/thoracotomy, and minimizes the tissue disruption and morbidity associated with posterior osteotomies.
authors.affiliation: Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida 33606, USA. armendeuk@gmail.com
authors.forename: Armen R
authors.initials: AR
authors.lastname: Deukmedjian
authors.forename: Tien V
authors.initials: TV
authors.lastname: Le
authors.forename: Ali A
authors.initials: AA
authors.lastname: Baaj
authors.forename: Elias
authors.initials: E
authors.lastname: Dakwar
authors.forename: Donald A
authors.initials: DA
authors.lastname: Smith
authors.forename: Juan S
authors.initials: JS
authors.lastname: Uribe
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019299:Decompression, Surgical / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D017846:Longitudinal Ligaments / Q000000981:diagnostic imaging / Q000601:surgery*; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D011859:Radiography; D012187:Retroperitoneal Space / Q000000981:diagnostic imaging / Q000601:surgery; D013123:Spinal Fusion / Q000379:methods; D016896:Treatment Outcome