by Laura Freeman
Sooner or later, almost everyone experiences back pain. It’s one of the most common reasons people miss work days and ask their doctors for pain medications—which could be the first step on the road to a dangerous dependency. For some, the pain may resolve itself with rest and conservative treatment. But for others, it becomes a persistent, nagging agony that may progress to the point that surgery could be necessary to stabilize disc space and protect the spine.
“When a disc deteriorates so much that we have to consider fusion, it’s important to match the patient to the procedure we recommend. Oblique lateral interbody fusion, also known as the ante-psoas approach, was introduced a few years back, but recently the advantages it offers have made it a hot topic in spinal health,” Carl Nechtman, MD, a neurosurgeon and spine specialist with Ascension St. Vincent’s Medical Center and Neurosurgery Associates, said.
“For patients who don’t need direct dorsal decompression, it offers a high success rate for relieving back and leg pain with less recovery time and less discomfort than traditional fusion surgery. A minimally invasive lateral approach preserves the integrity of muscle structures that support the back. It also allows patients to rest better as they recover since they can sleep or lie on their back without having to avoid an incision.
“Typically, patients are out of the hospital the next day and most recover to return to their usual schedule within six to eight weeks. We continue to monitor their progress over the next six months to a year.”
In addition to fusing deteriorating discs, the lateral approach can also be helpful in correcting other spinal conditions including curvature of the spine and other anomalies that begin to cause problems.
In preparing to perform an oblique lateral interbody fusion, the surgical team positions the patient with the right side down on the table and the abdomen facing the surgeon. A three to five centimeter incision is made just above or in front of the left iliac crest, guided by imaging, navigation software and a C-arm to confirm position and protect nerves, blood vessels and key structures.
“This technique minimizes risks to muscular, neural and vascular structures. We have an excellent view of the aorta, and as we gently sweep the psoas muscle back we have a clear, 360 degree view of the spine. The lateral approach also allows us to use a graft with a larger footprint if needed,” Nechtman said. “Preoperative imaging gives us a good sense of the size range a specific patient is likely to require, but during the surgery we can try larger or smaller grafts to get the best fit. Most of the grafts we use are made of titanium, but poly can be used in some cases. The lateral approach also makes using a graft with a larger footprint easier.
“Overall, we’re seeing improvement in fusion success rates to around 90 percent, and indirect decompression of neural elements is also good. It’s an excellent way to restore alignment and it can be combined with other treatment options to give patients maximum relief.”
Back and/or leg pain, and sometimes dysfunction, are symptoms that commonly bring patients to a physician’s offices seeking an evaluation for surgery. Preexisting hernias, some previous abdominal surgeries, and degree of obesity can be factors to consider in determining whether a patient is likely to be a good candidate for the lateral approach.
“Since healing is usually faster and easier, this technique can be a better choice for patients with co-morbidities that may involve slow healing, such as diabetes,” Nechtman said. “After surgery, we often recommend back braces during the early stages of healing. Whether a physical therapy referral will be helpful during recovery is likely to depend on the individual patient’s condition at the time of surgery.
“Oblique lateral interbody fusion isn’t a magic wand. It isn’t for every case, but it is a very useful option to have in the neurosurgery toolbox. It can bring relief without the long recovery, greater discomfort and potential for problems that comes with the traditional dorsal approach to spinal fusion.
“For patients who are likely to need surgery soon, it could be well worth an evaluation to determine whether this approach could be a good option for them.”