Neurologic Injury after Lateral Lumbar Interbody Fusion [Neurosurgery Wiki]

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====== Neurologic Injury after Lateral Lumbar Interbody Fusion ======
{{ ::llif.png|}}
Since the first description of [[LLIF]] in [[2006]], the indications for LLIF have expanded and the rate of LLIF procedures performed in the [[USA]] has increased. LLIF has several theoretical advantages compared to other approaches including the preservation of the anterior and posterior annular/ligamentous structures, insertion of wide [[cage]]s resting on the dense apophyseal ring bilaterally, and augmentation of [[disc height]] with indirect decompression of neural elements. Favorable long-term [[outcome]]s and a reduced risk of visceral/vascular injuries, incidental [[dural tear]]s, and perioperative [[infection]]s have been reported. However, approach-related complications such as motor and sensory deficits remain a concern. In well-indicated patients, LLIF can be a safe procedure used for a variety of indications
((Salzmann SN, Shue J, Hughes AP. Lateral Lumbar Interbody Fusion-Outcomes and
Complications. Curr Rev Musculoskelet Med. 2017 Dec;10(4):539-546. doi:
10.1007/s12178-017-9444-1. Review. PubMed PMID: 29038952; PubMed Central PMCID:
PMC5685966.
)).

Hijji et al. published a systematic review analyzing the complication profile of [[LLIF]]. Their study included a total of 63 articles and 6819 patients. The most commonly reported complications were transient neurologic injury (36.07%). The clinical significance of those transient findings, however, is unclear since the rate of persistent neurologic complications was much lower (3.98%)
((Hijji FY, Narain AS, Bohl DD, Ahn J, Long WW, DiBattista JV, Kudaravalli KT,
Singh K. Lateral lumbar interbody fusion: a systematic review of complication
rates. Spine J. 2017 Oct;17(10):1412-1419. doi: 10.1016/j.spinee.2017.04.022.
Epub 2017 Apr 26. Review. PubMed PMID: 28456671.
))

The risk of [[lumbar plexus injury]] is particularly concerning at the L4-5 disc space.
Although LLIF is associated with an increased prevalence of anterior thigh/groin pain as well as motor and sensory deficits immediately after surgery, our results support that pain and neurologic deficits decrease over time. The level treated appears to be a risk factor for lumbosacral plexus injury
((Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa 
FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of
919 treated levels with identification of risk factors. Spine J. 2014 May
1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 
24012428.)).

Interestingly, the use of rhBMP-2 was associated with higher rates of persistent motor deficits, which might be explained by a direct deleterious effect of this agent on the lumbosacral plexus
((Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa 
FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of
919 treated levels with identification of risk factors. Spine J. 2014 May
1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 
24012428.
)).

In a retrospective chart review of 118 patients, Cahill et al. determined the incidence of [[femoral nerve injury]], which is considered one of the worst neurological complications after LLIF. The authors reported an approximate 5% femoral nerve injury rate of all the LLIF procedures performed at L4-5. There were no femoral nerve injuries at any other levels
((Cahill KS, Martinez JL, Wang MY, Vanni S, Levi AD. Motor nerve injuries
following the minimally invasive lateral transpsoas approach. J Neurosurg Spine. 
2012 Sep;17(3):227-31. doi: 10.3171/2012.5.SPINE1288. Epub 2012 Jun 29. PubMed
PMID: 22746272.
)).

During a 6-year time period of performing LLIF Aichmair et al., noted a learning curve with a decreasing proportional trend for anterior thigh pain, sensory as well as motor deficits
((Aichmair A, Lykissas MG, Girardi FP, Sama AA, Lebl DR, Taher F, Cammisa FP,
Hughes AP. An institutional six-year trend analysis of the neurological outcome
after lateral lumbar interbody fusion: a 6-year trend analysis of a single
institution. Spine (Phila Pa 1976). 2013 Nov 1;38(23):E1483-90. doi:
10.1097/BRS.0b013e3182a3d1b4. PubMed PMID: 23873231.))

Le et al. also observed a learning curve with a significant reduction in the incidence of postoperative thigh numbness during a 3-year period (from 26.1 to 10.7%)
((Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus
injury after lumbar retroperitoneal transpsoas minimally invasive lateral
interbody fusion. Spine (Phila Pa 1976). 2013 Jan 1;38(1):E13-20. doi:
10.1097/BRS.0b013e318278417c. PubMed PMID: 23073358.
)).

Levi AD from the [[University of Miami Hospital]], adopted an exclusive mini-open muscle-splitting approach in [[LLIF]] with first-look inspection of the [[lumbosacral plexus]] nerve elements taht may improve motor and sensory outcomes in general and the [[incidence]] of postoperative [[groin]]/[[thigh]] sensory dysfunction and [[psoas]]-pattern [[weakness]] in particular
((Sellin JN, Brusko GD, Levi AD. Lateral Lumbar Interbody Fusion Revisited:
Complication Avoidance and Outcomes with the Mini-Open Approach. World Neurosurg.
2019 Jan;121:e647-e653. doi: 10.1016/j.wneu.2018.09.180. Epub 2018 Oct 3. PubMed 
PMID: 30292030.
)).
===== References =====