Issue link: https://beckershealthcare.uberflip.com/i/1492611
17 ORTHOPEDICS increase in the availability of educational materials related to prone transpsoas surgery, including in-person cadaveric training and case observation with experienced PTP surgeons as well as the online publication of high-quality instructional resources. Implant manufacturers have continued to innovate and refine procedure-specific retractors and patient positioners that are optimized for the prone position. is equipment mitigates early criticisms of the procedure and allows for safer and more reproducible surgery. Finally, advances in neuromonitoring technology will allow surgeons to more safely navigate the lumbar plexus. Specifically, improved processing algorithms that provide continuous, real- time saphenous nerve SSEP tracing allow the surgeon to detect a developing traction injury and take immediate corrective action. is information provides reassurance to the surgeon and addresses a major barrier to adoption. Emeka Nwodim, MD. e Centers for Advanced Orthopaedics (Bethesda, Md.): I foresee the continued growth of the prone lateral spine surgery technique in 2023. is technique provides great exposure and access to the interbody space and offers spine surgeons the opportunity to improve and enhance spinal fusion rates, spine stability, indirect decompression as well as optimize deformity correction in certain circumstances. It further optimizes the ability of achieving greater surgical success rates while minimizing OR time, blood loss and so tissue compromise. Although I have not had the opportunity to incorporate this into my own practice, this is something that I am very interested in and believe that there are many other spine surgeons that have similar interest. Ray Oshtory, MD. Pacific Heights Spine Center (San Francisco): Prone lateral, particularly with the unique and procedure- specific positioners, instruments and retractor associated with the prone transpsoas technique, is likely to be much more widely adopted than the traditional lateral decubitus position lateral surgery popularized as XLIF. e position itself is the traditional workhorse position that has been used for all manner of spine surgery for decades. Mating that with the minimally invasive and anterior column advantages of the lateral approach will prove to be robust and reproducible. It allows for the standard one- and two-level lateral/posterior reconstructions that are the bread and butter of most spine surgeons but still gives access to both approaches and exposures simultaneously. erefore, we can revise prior posterior instrumentation, we can perform lateral hyperlordotic interbody reconstructions while combining more complex posterior procedures, such as facetectomies, osteotomies or decompressions at different levels, not just the level at which the fusion is being performed. My favorite application is using the screws to reduce a high-grade spondylolisthesis first, then going in lateral to perform the interbody procedure, then coming back to the screws to lock down the rods, all with the patient in the prone position. at type of versatile procedure was not possible, at least not easily, with the prior lateral decubitus techniques. And we are just starting to discover the other possible advantages. If anyone is questioning the utility, ask yourself, "If we started doing lateral surgery with the patient in the prone position, would we have said to ourselves that we should change the technique and position the patient [in] lateral decubitus instead?" I doubt it. Frank Phillips, MD. Midwest Orthopaedics at Rush (Chicago): It has been gratifying on a personal level, to see lateral surgery evolving from the first cases I performed almost two decades ago to becoming a work horse of modern spine surgery. In those early days, when only a handful of us were performing this procedure, we placed great emphasis on defining the procedure's safety before encouraging more widespread adoption. As a result lateral spine surgery has evolved and become widely adopted with favorable safety and effectiveness well documented. Prone lateral spine surgery is a more recent variation of lateral surgery with claimed advantages by the developers of this technique. e prone lateral procedure is more complex than traditional lateral surgery with technical challenges related to lateral access to the spine in the prone position including retractor migration, much longer working corridor impairing direct visualization, and ergonomic challenges of lateral access in the prone position. Reliably addressing these issues will likely advance the field. To date the procedure has been heavily marketed but has not been critically analyzed. ere are anecdotal reports of serious complications and until safety data is provided by non- conflicted surgeons, adoption beyond the relatively small group of surgeons performing a high volume of procedures will be limited. Prone lateral surgery certainly is a promising technique and as indications, outcomes and complications are better defined I anticipate the procedure finding its appropriate place in our spine armamentarium. Alok Sharan, MD. Spine and Performance Institute (Edison, N.J): It will be challenging to get prone lateral spine surgery to grow. While PTP is good for the spine surgeon's tool chest, I don't believe it is a procedure which is following the current trends in healthcare. Increasingly I am finding that patients are looking for spine surgery that will get them out of the hospital quicker (or avoiding it altogether), minimal narcotic use and a faster recovery. is is why endoscopic surgery is seeing a lot of adoption. For PTP surgery to get widespread adoption, it will have to become a procedure that can be performed in an ambulatory surgery center. If this can be performed safely in an ASC, then we will see some of the major forces in healthcare (i.e., payers and patients) pushing for this procedure. Grant Shifflett, MD. DISC Sports & Spine Center (Newport Beach, Calif.): Prone lateral is a very interesting concept and overall not that difficult of a new approach to apply in most cases, despite the rearrangement of your standard "surgical horizon." Not just a gimmick, it brings an interesting approach to managing what can be a complex logistical nightmare in many surgical settings: patient repositioning. Adequate baseline experience with laterals, diligent completion of sufficient training, thoughtful patient selection, and careful execution are necessary to have good outcomes with this procedure and to avoid a messy learning curve. Wide adoption in 2023 will hinge on the ability to convince surgeons who don't do ANY form of lateral surgery to get on board with lateral surgery and ultimately get comfortable enough to work though the learning curve of prone lateral to gain back hours of their lives. Having said all of this, I personally don't anticipate adopting the procedure in my practice anytime soon due to the challenging physics of performing prone lateral surgery utilizing an all-microscopic approach and dynamic handheld retraction. Furthermore, operating at an efficient ASC with minimal time spent repositioning obviates one of the greatest (though, not only) benefits of the prone lateral. Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Prone lateral approach for lumbar interbody fusion is a great tool for minimally invasive spine surgery. It allows for placement of a large lateral interbody spacer and gives the surgeon access to the posterior lumbar spine without the need to reposition the patient. e approach is somewhat challenging and requires additional equipment to improve safety and efficiency as well as additional training. Intraoperative computer navigation and robotic assistance will make prone lateral surgery significantly easier to perform with less radiation exposure to the patient and the surgeon.