Becker's ASC Review

16 ORTHOPEDICS 'Not just a gimmick': 16 experts on prone lateral spine surgery By Carly Behm P rone lateral spine surgery offers an alternative to the lateral decubitus position and eliminates the need to move a patient during the surgery. e technique has yet to be widely adopted, and while some surgeons see potential, others don't see it taking a grip on the industry any time soon. Editor's note: Responses were lightly edited for clarity and length. Question: How do you anticipate prone lateral spine surgery to grow in 2023? What will be needed for it to become more widely adopted? Harel Deutsch, MD. Midwest Orthopaedics at Rush (Chicago): I don't see much growth due to the prone lateral position, because surgeons doing a lot of laterals are likely set in their ways. I don't think new surgeons will adopt the prone lateral if they were on the sidelines before on the lateral procedure. Brian Fiani, DO. Weill Cornell Medicine/ NewYork-Presbyterian Hospital (New York City): Single position prone transpsoas lateral lumbar interbody fusion is a newer technique to perform a two-approach surgery from a single position. Many surgeons feel that their capable co-surgeons can complete the posterior instrumentation while they perform the lateral surgery simultaneously. e studies have shown that the benefits include increased segmental lordosis and ability to provide anterior and posterior fusion. e limitations include surgeon ergonomics and retraction time on the lumbar plexus. ere will likely be a slow growth in this technique in 2023, but not a rapid shi due to the learning curve. Companies like Alphatec are creating instrumentation and operating tables that will help the technique become more widely adopted. eir operating table encourages lordosis and brings the lumbar plexus more posteriorly into a safer position and eliminates "flip time" repositioning. eir high-tech two-blade retractor system, bone growth promoting interbodies, and integrated Jamshidi/automated EMG makes them very competitive and appealing. Brian Gantwerker, MD. e Craniospinal Center of Los Angeles: Prone lateral presents an interesting approach to solving the problem of needing to reposition the patient during surgery. Currently, I do not find it necessary as in many cases it's a solution looking for a problem. What would convince me to use it is making it easier to move the rib cage out of the way in problematic levels of the spine. e ribs may sometimes be in the way regardless of how well you preoperatively plan an operation. Until that problem is addressed, I have no desire to alter my practice and I think prone lateral will remain not as highly adopted. Sohaib Hashmi, MD. UCI Health (Orange, Calif.): e use of prone lateral single position spine surgery is the latest evolution in minimally invasive approaches to the anterior spine. e technique has gained adoption over the past several years, largely for degenerative conditions. e advantages realized have included minimally invasive access for larger interbody preparation, implant placement and fusion surface area while [performing] single prone position surgery, allowing maximum lordotic alignment and simultaneous access to the anterior and posterior spine. ese benefits of prone lateral access surgery will allow the procedure to have a greater presence and utility in the outpatient setting in the next few years. Additionally, as our instrumentation and techniques have advanced, we are now able to use prone lateral surgery in complex pathology including deformity, trauma and tumor settings, including prone lateral corpectomies. As the current generation of spine surgery fellows and trainees continues to have greater exposure to this technique and its workflow, we will see increased use of single position lateral spine surgery. In my practice, prone lateral surgery allows me to perform single-stage surgeries for patients requiring posterior decompression, revision or extension of instrumentation/fusion, and deformity correction through osteotomies. ese single-stage procedures have allowed patients to start their postoperative recovery earlier and avoid multiple anesthetic administrations in a short period of time, especially in our geriatric patient population. Adam Kanter, MD. Pickup Family Neurosciences Institute at Hoag (Orange, Calif.): Lateral spine surgery has increasingly become a go-to hammer in the tool belt of modern spine surgeons, enabling a less invasive option to obtain durable indirect decompression and fusions of the thoracolumbar spine. e initial adoption curve two decades ago was protracted as spine surgeons were less familiar in training and practice with lateral techniques, and if a complication occurred, we were ill- equipped to fix them ourselves, necessitating the assistance of vascular or general surgery. e advent of performing lateral surgical techniques in the prone position resolves some of the "familiarity" constraints and improves surgical efficiencies by enabling single-position access to both the lateral and posterior corridors without having to flip the patient. Surprisingly or not, prone position lateral surgery has not radically increased the adoption curve of the technique to date. Why is this? Two decades ago, it took us time to gather the data to support the claims of LLIF safety and outcomes, and I believe that is what the spine community is again waiting for — the data! ere are assertions that the prone transpsoas approach decreases the risk of lumbar plexus injury, that natural lordosis is more easily achieved, and that the well-published benefits of an MIS approach are preserved, with even shorter operative times due to the lack of repositioning needs of concomitant posterior interventions. In fact, some are even touting simultaneous performance of the lateral and posterior procedures. What the spine community is waiting for today is what we did two decades ago to prove decubitus LLIF was safe, feasible, and led to excellent outcomes with few complications. We need that same body of literature to support the prone lateral approach, and we need it to come from both those that paved the way for its introduction as well as those employing the technique in our communities. We need to see reproducible results in large series with all the promised benefits, and then perhaps we will see our lateral surgeon cohorts more eagerly turn to the prone position for the anticipated time, alignment and safety advantages. Zachary NaPier, MD. Sierra Spine Institute (Roseville, Calif.): I expect prone transpsoas (PTP) spine surgery to grow precipitously in 2023 due to increased surgeon education, refinement of procedure-specific equipment including retractors and patient positioners, and finally advances in neuromonitoring that facilitate safe navigation of the lumbar plexus and prevention of traction injuries. Surgeon demand has led to a significant

• Cover