Minimally Invasive Direct Lateral Transpsoas Approach for the Resection of a Lumbar Plexus Schwannoma: Technique Report

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Abstract

Objective Traditional techniques for resection of lumbar plexus tumors have been associated with approach-related morbidity. We describe a case utilizing a minimally invasive transpsoas lateral access approach to resect a retroperitoneal tumor of the lumbar plexus.

Methods We report a case with an extradural retroperitoneal schwannoma of the L4 nerve root that was treated with a minimally invasive direct lateral transpsoas approach using atraumatic tissue dilators and an expandable tubular retractor. The use of directional and continuous electromyographic monitoring was critical in locating the plexus and positioning the retractor immediately anterior to the tumor.

Results The patient tolerated the procedure well without postoperative complications. The operative approach was direct and intraoperative blood loss was negligible. The patient demonstrated improved left leg strength and ambulation and resolution of paresthesias.

Conclusions A minimally invasive direct lateral transpsoas access approach is an effective technique to safely and adequately resect extradural retroperitoneal lumbar plexus tumors.

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Most cited references 24

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Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion.

Burak Ozgur, Henry Aryan, Luiz Pimenta … (2015)

Minimally disruptive approaches to the anterior lumbar spine continue to evolve in a quest to reduce approach-related morbidity. A lateral retroperitoneal, trans-psoas approach to the anterior disc space allows for complete discectomy, distraction, and interbody fusion without the need for an approach surgeon. To demonstrate the feasibility of a minimally disruptive lateral retroperitoneal approach and the advantages to patient recovery. The extreme lateral approach (Extreme Lateral Interbody Fusion [XLIF]) is described in a step-wise manner. There have been no complications thus far in the author's first 13 patients. The XLIF approach allows for anterior access to the disc space without an approach surgeon or the complications of an anterior intra-abdominal procedure. Longer-term follow-up and data analysis are under way, but initial findings are encouraging.

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Impairment and disability after back surgery is a common diagnostic and therapeutic problem. For the most part the reasons are unclear. Of 178 patients who had undergone laminectomies 2-5 years earlier, 14 patients with good recovery and 21 patients with poor recovery but no evidence of restenosis on computed tomography were selected by the Oswestry index. According to radiologic, neurophysiologic, and muscle biopsy evidence most patients (13 of 15 studied) suffering from the severe postoperative failed back syndrome had dorsal ramus lesions in one or more segments covered by the scar and local paraspinal muscle atrophy at the corresponding segments. Disturbed back muscle innervation and loss of muscular support leads to the disability and increased biomechanical strain and might be one important cause to the failed back syndrome. It may be possible to develop operating techniques that save back muscle innervation better than the usual ones.

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The paraspinal approach was described by our group in 1968. It differs from the approach described by Melvin Watkins in 1953 in that it is a longitudinal separation of the sacrospinalis group between the multifidus and longissimus, and not between the lateral border of the entire sacrospinalis group and quadratus lumborum. Also, Watkins removed a flake of the iliac crest with muscles attached, which he swung cranially and medially. This article also describes several refinements not mentioned in the original article and gives several new uses for the approach. Specifically, its use for removing a far lateral disc, decompressing a far out syndrome, inserting pedicle screws, and for decompressing the opposite side from inside the vertebral canal is described.

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Author and article information

Journal

Journal ID (nlm-ta): Surg J (N Y)

Journal ID (iso-abbrev): Surg J (N Y)

Journal ID (doi): 10.1055/s-00028781

Title: The Surgery Journal

Publisher: Thieme Medical Publishers (333 Seventh Avenue, New York, NY 10001, USA. )

ISSN (Print): 2378-5128

ISSN (Electronic): 2378-5136

Publication date Collection: July 2016

Publication date (Electronic): 06 August 2016

Publication date PMC-release: 1 August 2016

Volume: 2

Issue: 3

Pages: e66-e69

Affiliations

[1 ]Georgetown Medical School, Washington, District of Columbia

[2 ]Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia

Author notes

Address for correspondence Faheem A. Sandhu, MD, PhD Department of Neurosurgery Medstar Georgetown University Hospital Washington, DC 20007 fxsj@ 123456gunet.georgetown.edu

Article

Publisher ID: 1600033cr

DOI: 10.1055/s-0036-1587692

PMC ID: 5553498

PubMed ID: 28824993

SO-VID: b0a6115f-af1c-4ac2-9507-732fd4a7e3da

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.