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49 Executive Roundtable Sponsored by Lateral Approaches to Spine Surgery – Decisions and Challenges By Mary Rechtoris S pine surgeons are using less invasive procedures to take patient care to the next level — and lateral spine surgery is one such example of surgeons pushing the envelope through innovative techniques. Surgeons well-versed in the thoracolumbar spine's anatomy can yield superior patient outcomes through a lateral approach, such as reduced infection rates and minimal blood loss. Choll Kim, MD, of the Spine Institute of San Diego, and Rob- ert Eastlack, MD, a spine surgeon in San Diego within Scripps Clinic's division of orthopedic surgery, dive into their approach and the many components involved in successfully employing lateral spine surgery. Question: Which are the main surgical procedures that you undertake using a lateral approach, and how do you decide which are the most suitable patients and cases? Dr. Robert Eastlack: I use the lateral approach most often for reconstruction/arthrodesis in the lumbar spine above the fifth lumbar vertebra. This is most often done for instability, such as spondylolisthesis, and occasionally for more complex deformities. Dr. Choll Kim: The lateral lumbar interbody fusion procedure is particularly well-suited to treat patients with stenosis due to degenerative scoliosis. With the increasing age of the U.S. population, the population of patients with stenosis due to degenerative scoliosis is rapidly growing. Q: How long have you been doing lateral spine surgery and what were the key challenges as you learned the pro- cedures? RE: I have been using this approach since 2004. The biggest challenge in performing the technique safely is being familiar with the anatomy. The lateral approach is a unique pathway to access the thoracolumbar spine, but the anatomy involved in the surgical approach was not historically well-understood. Greater awareness of this anatomy and well-designed instrumentation systems now allow for tremendous utility and safety in lateral spine surgery. CK: I have been doing lateral spine surgery for about 12 years. When we originally did the procedure, we did it completely percutaneously through two incisions. In the more contemporary method, spine surgeons make one incision. This was a challenge we had to overcome because spine surgeons generally don›t like performing blind surgery. The second challenge we overcame was related to good imag- ing. It took a lot of positioning and understanding of the anat- omy of the lumbar spine and nerves to go through the psoas muscle. When we get the direct vision, we can be much gentler with that muscle and traumatize it less. It took between about 20 to 30 cases to overcome these challenges. Q: What benefits do you see from your lateral approach surgeries? CK: The LLIF approach is minimally invasive so it provides significant improvements in pain, blood loss and infection in this normally frail population of patients. Furthermore, the large size of the implant, together with its position spanning the disc space, provides better implant stability. This is very important in older patients with osteoporotic bone. The LLIF implant is very stable and resistant to subsidence. The LLIF procedure is a cornerstone of my practice. RE: The main benefits are superior disc removal and endplate coverage, less subsidence than posterior interbody cages, greater fusion rates than posterior interbody approaches with equivalent biologics, greater improvement and maintenance of segmental alignment. [Other benefits include] less morbidity than traditional anterior lumbar interbody approaches, greater stability than posterior interbody cages, less subsidence than posterior interbody devices and offering the potential for indi- rect decompression of neural elements. Q: How do you decide whether to stage the lateral and posterior parts of the surgery over more than one day and when to carry them out in a single surgical case? RE: For the majority of one-level to three-level reconstructions, the procedure can be accomplished in one day. Staging of the procedure is more commonly considered when utilizing "The lateral approach is a unique pathway to access the thoracolumbar spine, but the anatomy involved in the surgical approach was not historically well-understood." - Dr. Robert Eastlack