What's next for prone lateral spine surgery?


Prone lateral spine positioning has gained attention in recent years and has been touted for its efficiency in the operating room. But its future isn't completely clear yet.

A multicenter study published April 27 in Spine evaluated single-position prone lateral lumbar interbody fusion in revision cases and found it improved operative efficiency without any increase in complications. In a study of 72 patients for the North American Spine Society Journal, prone transpsoas lateral interbody fusion with anterior docking was found to potentially "address shortcomings associated with traditional lateral interbody fusion by producing safe and reproducible access with improved restoration of segmental lordosis and optimization of spinopelvic parameters."

One setting where the procedure could thrive is the ASC. In 2021 Samuel Joseph, MD, of Joseph Spine Institute in Tampa, Fla. completed the first outpatient prone transpsoas case in the U.S.

"Prone transpsoas lateral interbody fusion is most likely to have a larger footprint in ambulatory surgery centers," Sohaib Hashmi, MD, of UCI Health in Orange, Calif. said. Single-level PTP procedures are currently performed in ASC settings; however, there are several factors why there will be an even greater shift of PTP to the outpatient setting. Simplicity of prone positioning streamlines setup and turnover of the procedure for staff as well as minimizing diverse equipment needs in the ASC. Simultaneous minimally invasive access to the anterior and posterior columns of the spine allows for predictable outcomes in treatment of lumbar spinal stenosis and instability. Indirect decompression of neurologic stenosis allows for percutaneous posterior instrumentation insertion. Also, prone positioning allows for concurrent anterior spinal column work and posterior spinal instrumentation placement with or without enabling technology. It also offers efficient and short surgical duration, which allows for optimizing resource utilization with multiple PTP procedures performed throughout the day."

However, prone lateral positioning isn't without its flaws. For Brian Gantwerker, MD, of The Craniospinal Center of Los Angeles, he hasn't needed to use it in his practice and described the positioning as "a solution looking for a problem" in some cases.

"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," Dr. Gantwerker said. "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."

In terms of future adoption and growth, it may be in the hands of the next generation of spine surgeons.

"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," Harel Deutsch, MD, of Midwest Orthopaedics at Rush in Chicago, said. "I don't think new surgeons will adopt the prone lateral if they were on the sidelines before on the lateral procedure."

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