Prone Single Position Approach to Lateral Lumbar Interbody Fusion: Systematic Review and Meta Analysis 1 2 2 Matthew Rohde, BS, Robert Carrier, MD, Alexandra Echevarria, 2 2 Alex Ngan, MD, Rohit Verma, MD
1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell 2Northwell Health Department of Orthopedic Surgery
Background
Methods
Lateral lumbar interbody fusion (LLIF) with Posterior Screw Fusion (PSF) is a safe and effective treatment for patients suffering from degenerative spine disorders. LLIF with PSF previously required repositioning patients from lateral to prone position for posterior pedicle fusion, often requiring two separate surgeries. The evolution of surgical techniques, navigation, and robotics has allowed for a single position approach to LLIF with the patient in the prone position (Figure 1). The purpose of this study was to perform a systematic review and meta-analysis comparing the prone single position LLIF approach to the dual position LLIF approach.
The literature was reviewed per Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) 2020 guidelines. Patient demographic, surgical, patient reported, and radiographic outcomes were extracted from selected studies. A meta-analysis was performed using an unstandardized mean difference (UMD) or log odds ratio with a confidence level of 95%.
Results Fifteen studies with outcomes for single position LLIF were included in the systematic review (Table 1). We performed a meta-analysis on five studies comparing single to dual position LLIF: • Single position LLIF had a reduced operative time and LOS, (Figure 2), although there was no significant reduction in EBL. • Single position LLIF improved lumbar lordosis more effectively than dual position LLIF (p=0.05). • There was no difference in other radiographic measures, complications or reoperations. Table1: Demographic data for each study
Figure 1: Procedural setup for single position LLIF surgery with patient in the prone position.
Hypothesis We hypothesized that single position LLIF will have a reduced operative time, complication rate, and blood loss compared to the dual LLIF procedure.
Study Name
Age (years)
BMI (kg/m2)
PSP LLIF (N)
LLIF (N)
% Female
Amaral 2023 Buckland 2023 Diaz Aguilar 2023 Farber 2022 Godzik 2020
57.2 60.7
30.1
18 43
53 58
64.8 52.5
Levels of Fusion 1 2.3
64.5
31.9
363
-
57
-
67.9 61
28.9 26.5
28 11
-
75 54.5
1.39 1.42
10
70.6
1
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Patel 2023 Pimenta 2021 Pimenta 2021 Smith 2021 Soliman 2022 Soliman 2023 Walker 2021 Wang 2022 Wellington 2023
64.3 65 61.6 60.1 62 60.4
30.4 27 33 30.3 32.3 28.5 31.6
155 32 34 120 10 15 15 24
10 15 -
60 56.3 55 53.3 60 58.3
1.61 1.62 1.48 1.2 1.07 1 1.21
63
-
82
-
56.1
1.62
Figure 2: Forest plots of unstandardized mean difference (UMD) of operative time (top, p<0.001) and LOS (bottom, p=0.03)
Conclusions Prone single position LLIF reduced operative time and LOS, with no relative increase in complications or reoperations compared to the dual position approach. Surgeons may experience the added benefit of improved postoperative lumbar lordosis relative to LLIF in lateral decubitus position.
Future Direction
Future randomized control trials comparing single position prone to dual position LLIF should be performed to confirm trends reported in the preliminary research.
Resources 1. Reisener MJ, Pumberger M, Shue J, Girardi FP, Hughes AP. Trends in lumbar spinal fusion—a literature review. J Spine Surg. 2020;6(4):752-761. doi:10.21037/jss-20-492 2. Passias PG, Williamson TK, Krol O, et al. Patient-Centered Outcomes Following Prone Lateral Single-Position Approach to Same-Day Circumferential Spine Surgery.