Abstract
Minimally invasive anterolateral interbody fusions are becoming increasingly utilized for the treatment of lumbar degenerative and adult spinal deformity conditions. There remains contention whether a prepsoas or transpsoas approach is superior. Several small studies have compared these interventions; however, the quality of evidence to date is low and is comprised of a large number of independent, uncontrolled case series dedicated to each specific approach.
We sought to combine the results of the published studies for modern minimally invasive lateral approaches to compare the safety and complication rates for the prepsoas and transpsoas techniques.
Systematic review and meta-analysis.
Eligible studies were those in which minimally invasive prepsoas or transpsoas (LLIF, ELIF, DLIF, XLIF) approaches were used to treat degenerative and/or scoliosis or deformity lumbar conditions. Studies evaluating anterior column realignment (ACR) were excluded.
Complication rates for each complication type were calculated per patient for each approach.
A systematic review was performed to identify eligible studies reporting outcomes for each approach type. Each study was individually evaluated to determine whether it could be included in the meta-analysis. Complication reporting was variable and only studies that directly reported the specific complication were included in each analysis.
A total of 19 pre-psoas studies with 1,854 patients and 36 transpsoas studies with 3,978 patients were included. The pre-psoas approach was significantly associated with a higher rate of major vascular injury (1.2vs. 0.2 %, p<.001) and sympathetic damage (2.7vs. 0 %, p<.001). The trans-psoas approach was significantly associated with a higher rate of transient thigh or groin numbness or pain (27.1vs. 5.2 %, p<.001) and transient hip flexor weakness (18.9vs. 1.7 %, p<.001). The risk of lasting motor neurological deficit from nerve root injury or traction was higher for the transpsoas approach (1.7vs. 0.7 %, p<.01). There was no significant difference in the rates of access-related peritoneal (bowel) or urinary (kidney or ureter) injury or postoperative ileus, infection or hematoma development.
Based on the large collective sample size reported in the literature, complication rates for both procedures remain low, and largely present as transient deficits inherent to each access trajectory. Higher rates of major vascular injury for the prepsoas approach and motor neurological deficit for the transpsoas approach present as the major delineating risks.