'Not just a gimmick': 16 experts on prone lateral spine surgery

Spine

Prone lateral spine surgery offers an alternative to the lateral decubitus position and eliminates the need to move a patient during the surgery. The 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.

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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. The studies have shown that the benefits include increased segmental lordosis and ability to provide anterior and posterior fusion. The limitations include surgeon ergonomics and retraction time on the lumbar plexus. There will likely be a slow growth in this technique in 2023, but not a rapid shift due to the learning curve. Companies like Alphatec are creating instrumentation and operating tables that will help the technique become more widely adopted. Their operating table encourages lordosis and brings the lumbar plexus more posteriorly into a safer position and eliminates "flip time" repositioning. Their high-tech two-blade retractor system, bone growth promoting interbodies, and integrated Jamshidi/automated EMG makes them very competitive and appealing.

Brian Gantwerker, MD. The 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. The 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.): The use of prone lateral single position spine surgery is the latest evolution in minimally invasive approaches to the anterior spine. The technique has gained adoption over the past several years, largely for degenerative conditions. The 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. These 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. These 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. The 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. The 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! 

There 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 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. This 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. This information provides reassurance to the surgeon and addresses a major barrier to adoption.

Emeka Nwodim, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): I foresee the continued growth of the prone lateral spine surgery technique in 2023. This 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 soft 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. The 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. Therefore, 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. That 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. The 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. There 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. This 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. The 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.  

The traditional lateral lumbar spine approach with the patient lying in lateral decubitus position is still easier and safer. It will likely remain the most common way to perform lateral lumbar interbody fusion for years to come. Prone lateral surgery, however, will continue becoming more common in 2023 for specific cases when access to the posterior lumbar spine is needed. The surgeons will need to ensure that they have proper equipment and training to perform this procedure safely and efficiently.  

William Taylor, MD. University of California San Diego: Unlike many new spine procedures that require special equipment, advance, training, or difficult approvals, PTP represents an extension and advancement of an existing procedure with clear benefits.

New spine procedures often require, special equipment, advanced training, or difficult approvals, PTP represents an extension of an existing procedure with while limiting the issues surrounding other options

Time savings in the OR, ease of positioning, standard bed and application to existing procedures are self evident. As more publications become available and the research condenses, I believe you will see improve. Patient outcomes due to reduction in complications, operative time and superior fusions with improved lordosis

This is an appropriate revamping of the existing lateral procedure that takes advantages of all of its positives and limits, many of the concerns that surgeons may have had.

Make sure to use equipment and a company that both prepares you, the OR and your patients for success by a dedicated prone system, rather than off-the-shelf lateral systems not designed for prone application.

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): Prone lateral is slowly gaining momentum. I think the concerns are the potential retroperitoneal and intraperitoneal complications, especially vascular injury for the prone lateral despite the fact that the incidence rate is low. Also, there are some nuances and tips to be sufficient with prone lateral. It will need more education and training from the industry side, especially to demonstrate how significant  patient outcomes compare to the lateral position. Many of us are so familiar with lateral position and flip for posterior fixation.

Kushagra Verma, MD. Verma Spine (Los Alamitos, Calif.): Prone lateral surgery is an exciting innovation in spine surgery. The challenges remain visualization, especially with obese patients. Specialized retractors are utilized that can allow the surgeon to visualize the disc space clearly. Another challenge with this technology is having appropriate abilities to manipulate the spine while in a prone position. This is especially critical at the L45 disc space. Special pads on the operating room table are being developed to manipulate the spine in the prone position. It remains an exciting and emerging technology.

The potential advantages of prone lateral surgery is that the spine is naturally in a lordotic position, which would aid the surgeon in generating lordosis while operating. In addition, there is not a need to change positions in the operating room, which could improve the efficiency of the surgery.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Ostensibly, the surgical indications for the PTP approach are growing as the market and awareness expands. Albeit the concept of enhanced surface area fusion and additional overlapping posterior instrumentation procedures are basic and enviable, yet they will certainly trigger reimbursement issues as to efficacy and outcome. Pardon the closure but "black disc disease" of two decades ago seems to have found a new home.  

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