title: Point-Counterpoint: The Use of Neuromonitoring in Lateral Transpsoas Surgery.
abstract: METHODS
  Expert opinion.
  
  
  OBJECTIVE
  The objective of this study is to debate the requirement for intraoperative neuromonitoring in 90° lateral transpsoas spine surgery (lateral lumbar interbody fusion [LLIF]) in a point-counterpoint style with an argument made for each side followed by a brief rebuttal of each. Dr. Ivan Cheng will argue in favor of the use of neuromonitoring in LLIF, and Dr. Frank Acosta will argue against the requirement for the use of neuromonitoring in LLIF.
  
  
  BACKGROUND
  The lateral approach to the lumbar spine has been used since at least the 1990s and requires passage near or adjacent to the lumbar plexus. The mini-open lateral transpsoas approach was introduced in the literature in 2006 and uses evoked electromyography integrated into the approach and procedural instrumentation that stimulates in directional orientations and provides discrete threshold responses to avoid the nerves of the lumbar plexus. More recently, lateral transpsoas approaches to the lumbar spine have been developed that do not require or advocate for the use of neuromonitoring, instead relying on direct visualization and avoidance of nerves (shallow-docking).
  
  
  METHODS
  Two experienced lateral approach surgeons who regularly perform lateral transpsoas approaches with integrated neuromonitoring (IC) and without neuromonitoring (FA) present arguments for and against the requirement for neuromonitoring.
  
  
  RESULTS
  Advocating for the use of neuromonitoring, points made include the broader literature validation of the lateral transpsoas approach with the use of advanced neuromonitoring and the relatively low rate of neural complications in neuromonitored transpsoas lateral approaches compared to those rates in shallow-docking literature. Advocating against the requirement for neuromonitoring in lateral transpsoas, points made include the potentially higher reliability of nerve avoidance with direct visualization as well as the favorable early results in the literature with respect to both new postoperative motor and sensory deficits.
  
  
  CONCLUSIONS
  There are arguments to be made on both sides of this debate. There is substantially more literature describing the use of neuromonitoring in lateral transpsoas surgery though shallow-docking reports continue to emerge.
  
  
  METHODS
  5.
authors.affiliation: *Department of Orthopedic Surgery, Stanford University Hospital and Clinics, Redwood City, CA †Keck Medicine, University of Southern California, Los Angeles, CA.
authors.forename: Ivan
authors.initials: I
authors.lastname: Cheng
authors.forename: Frank
authors.initials: F
authors.lastname: Acosta
authors.forename: Ki
authors.initials: K
authors.lastname: Chang
authors.forename: Martin
authors.initials: M
authors.lastname: Pham
mesh_terms: D006801:Humans; D064795:Intraoperative Neurophysiological Monitoring / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control; D016658:Psoas Muscles / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects / Q000379:methods