Equipose For Lateral Access Surgery: The Asia Pacific Spine Society Members’ Experience

Abstract

Objectives: To report the results of the Asia Pacific Spine Society (APSS) questionnaire on lateral access surgery in particular related to the rate of use, surgeons’ views regarding the advantages and disadvantages of lateral access surgery compared with other techniques, and the surgical strategies of lateral access surgery, including indirect decompression, order of levels to operate on in multi-level surgery, and implant-related factors. Methods: A questionnaire was distributed to members of the APSS to collect the surgeons’ thoughts on lateral access surgery. The questionnaire consisted of several themes. First, the surgeons were asked about their past experiences with lateral access surgery. Second, a series of questions were asked regarding the advantage and disadvantages of lateral access surgery compared with other techniques. Third, the participating surgeons were asked about their specific surgical strategies for lateral access surgery, including indirect decompression, choices in implant-related factors, preoperative imaging choices, order of levels to operate on in multi-level reconstruction surgery, assistance from vascular access surgeons, intraoperative neuromonitoring, side of the operation, anterior drains, postoperative complications, and corset use after the operation. Results: Among the 102 participants who responded, 69 surgeons (67.6%) had performed lateral access surgery before. Lack of experience is the most common reason for not performing the surgery and is not associated with years of surgical experience or country of origin. Currently, anterior to psoas is the most popular technique (43/96, 44.8%), followed by open (34/96, 35.4%), mini-open (32/96, 33.3%), and transpoas techniques (25/96, 26.0%). Fifty-six participating surgeons (54.9%) agreed that anterior column reconstruction via lateral access is most of the time superior to transforaminal lumbar interbody fusion and other techniques. Regarding the patients unsuitable for this surgery, vascular concerns, severe osteoporosis, and significant comorbidities were the main concerns. Surgeons would consider laminectomy instead of indirect decompression in the presence of severe central or lateral recess stenosis, thickened ligamentum flavum, and facet joint hypertrophy. For the order of level to operate in multiple level reconstruction for deformity, 1 stands for L3/4 or higher, 2 stands for L4/5, and 3 stands for L5/S1. The three major orders were 2-1-3 (28/95, 29.5%), 1-2-3 (26/95, 27.4%), and 3-2-1 (21/95, 22.1%). Conclusions: Lateral access surgery is not commonly performed amongst APSS members. However, most consider it to be superior to posterior interbody fusions. Vascular anatomy and severity of spinal stenosis on magnetic resonance imaging are the main considerations for choosing alternative options.