Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach

Objective: To discuss lessons learned from an initial lateral lumbar interbody fusion (LLIF) experience with a focus on evolving surgical technique, complication avoidance, and new motor and sensory outcomes after implementation of a modified surgical approach. Methods: A retrospective analysis of a prospectively collected series of all patients undergoing LLIF by the senior author (A.D.L.) from January 2010 to January 2018 after implementation of a modified surgical mini-open technique, compared with previously reported institutional results with the originally recommended percutaneous technique. LLIF-specific complications examined included groin/thigh sensory dysfunction, flank bulge/pseudohernia, psoas-pattern weakness, and femoral nerve injury. Results: The incidence (19%, n = 98 patients) of groin/thigh sensory dysfunction in our cohort was significantly lower than that of the historical control (60%, n = 59) (P < 0.0001). The incidence of abdominal flank bulge/pseudohernia (2.0%, n = 98 patients) in our cohort was improved but not significantly lower than that of the historical control (4.2%, n = 118) (P = 0.36). The incidence of psoas-pattern weakness (3.1%, n = 98) in our cohort was significantly lower than that of the historical control (23.7%, n = 59) (P = 0.0001). The incidence of femoral nerve injury (0%, n = 98 patients) in our cohort was improved but was not significantly lower than that of the historical control (1.7%, n = 118) (P = 0.20). Conclusions: The adoption of an exclusive mini-open muscle-splitting approach with first-look inspection of the lumbosacral plexus nerve elements may improve motor and sensory outcomes in general and the incidence of postoperative groin/thigh sensory dysfunction and psoas-pattern weakness in particular.