Name:
FOCUS25824video9
Description:
FOCUS25824video9
Thumbnail URL:
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Duration:
T00H05M31S
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https://stream.cadmore.media/player/ee527e8b-5ac6-479e-83fb-9a0bc6c26b44
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Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: How to prevent the most common complication
SPEAKER: of lateral lumbar spine surgery: lumbar plexus injuries. This case highlights the prevention of lumbar plexus injuries, which are a frequent complication of lateral lumbar interbody fusion procedures. We focus on a patient in their early 60s presenting with chronic lumbar back pain and bilateral lower extremity radiculopathy.
SPEAKER: Physical examination revealed bilateral lower extremity weakness, decreased sensation along the L4–5 dermatomes, and diminished reflexes. Imaging identified degenerative lumbar spondylolisthesis, L4–5, severe foraminal stenosis, and significant neural compression. Following the failure of conservative treatments, including physical therapy, pain medications, and epidural steroid injections, a minimally invasive LLIF with percutaneous fixation was recommended to restore spinal alignment and decompress the neural elements.
SPEAKER: MRI and CT confirmed severe foraminal stenosis with narrowing of the disc space, lateral recess impingement, and significant spondylolisthesis at L4–5. This imaging confirmed the severity of the condition and validated the LLIF approach as a suitable treatment. Preoperative imaging confirmed the severity of the patient's condition and the suitability of the surgical approach. No additional comorbidities or anatomical anomalies were noted.
SPEAKER: The treatment plan aimed to achieve indirect decompression in spinal alignment using a minimally invasive LLIF procedure with a lordotic cage. However, potential risks included nerve injury, prolonged retraction effects, and challenges posed by the narrow surgical corridor at the L4–5 level. The standard LLIF procedure was performed starting with positioning the patient in a right lateral decubitus position with hip and knee flexion.
SPEAKER: An EMG-monitored dilator was used, followed by gradual retractor expansion. Meticulous discectomy was performed before cage insertion. Despite proper placement of the cage, postoperative numbness and weakness in the ipsilateral thigh were observed, indicative of lumbar plexus injury. There was no gross anatomical variant observed. Postoperatively, the patient experienced significant ipsilateral thigh numbness and quadricep weakness consistent with a femoral nerve injury.
SPEAKER: Recovery was anticipated with close follow-up and targeted rehabilitation. By 9 months, full resolution of symptoms was achieved and radiographic imaging confirmed correct placement of the interbody cage without neural compression. The following example shows a patient with a similar femoral nerve injury on the contralateral side.
SPEAKER: Final imaging, including fluoroscopy, MRI, and CT, demonstrated proper placement of the interbody cage. Postoperative imaging also showed spinal stability and absence of neural compression, confirming technical success with the procedure. The complication was attributed to prolonged retraction and excessive anterior blade expansion, compounded by the neurosurgical corridor at the L4–5 level.
SPEAKER: These factors increase the risk of nerve stretch injuries. This case highlights that even with meticulous planning and monitoring, complications may still occur due to intraoperative dynamics and patient-specific variations. Thus, these measures are necessary but not always sufficient. Continuous intraoperative reassessment, evolving monitoring strategies, and surgical adaptability are essential.
SPEAKER: Opportunities for improvement include enhanced imaging analysis and anatomical review during the preoperative planning, conservative retractor blade expansion and optimal dilator positioning intraoperatively, and earlier initiation of targeted rehabilitation protocols postoperatively. This case emphasizes the importance of meticulous surgical technique, thorough anatomical assessments, and continuous intraoperative monitoring.
SPEAKER: By addressing gaps in EMG signal interpretation and enhancing our understanding of femoral nerve positioning, we can advance surgical precision and improve patient outcomes. Preoperative risk mitigation, minimal retraction, and technical excellence are critical to achieving optimal safety and efficacy in LLIF procedures. There was no misinterpretation of EMG but an overreliance on it.
SPEAKER: Although preoperative imaging was normal, the femoral nerve's anterior course at L4–5 placed it at inherent risk. This case exemplifies that even thorough planning and monitoring may not fully prevent complications, reinforcing the importance of ongoing evaluation and surgical adaptability.
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