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Grand Rounds-MIS Lateral Retroperitoneal Approach (Part I): Anatomical and Technical Considerations

Juan Uribe and Bill Taylor

October 16, 2013

Transcript

- Hello, ladies and gentlemen, and thank you for joining us today. We have two special guests, Dr. Forno Ribet from university of south Florida. He's the director of spine surgery there and Dr. William Taylor from UC San Diego, a dear friend, and a mentor who is also the director of spine surgery at UC San Diego. You're going to talk to us about a very important topic and that first session, the first part would include minimally invasive approaches to the lateral spine and would review basic concepts and anatomical correlations. The second part, we'll review more expanded applications of such technique. Gentlemen, Forno and Bill. Thank you for joining us and please take it away.

- My name is Forno Ribet and I have a pleasure today to participate on the serious that have an amazing input in our profession. So today we're going to talk about the minimally invasive blooded out access to the spine. It's a pleasure for me, but Dr. Taylor, that is one of the play on using the technique has been for almost 10 years on the field. Dr. Taylor actually was the first person to perform form a lateral Alexis, basically in America. And I will be so delighted to interact with him type presentation. We will review the technique with all the details and also avoiding complications. And the last part would be including the expanded application through the thoracolumbar and thoracic spine as well. We will do cases on a little detection technique. So that's my disclosures. The lateral spine was initially described in Brasil by Dr. Perfection in America, that's now multiple options on the market is a minimally invasive technique. The access through the retroperitoneum, through the into a spine. So as we see is not at all and is critical, including the access, the use of the intraoperative Eng morning, as we see later on is a critical part of the upper itself and he's out conventional . Using a modernization. This is something that is important because the surgeons can get to easily since you're still using your same pro instruments, you do all their surgeries. So you don't need to have these fast training that include, for example, the laparoscopic techniques, and has been proved that he's safe, reposable ease and to all other procedures. And he has a significant advantages. At this point, I will ask Dr. Taylor, a little bit of introduction through the latter on how this procedure thing to hear how you develop the technique .

- Well, thank you Forno, it's certainly a pleasure to discuss this with you today. Although we did the first 20, are you CSD? It's certainly been Dr. Uribe who has advanced this technique, published it, popularized it, and really expanded the applications into every part of the thoracic and lumbar spine. So we really have wanted to thank for bringing this into the forefront of minimally invasive surgery. I would say that this is one of the techniques which evolved with minimally invasive surgery, as you know, minimally invasive surgery for the spine has been somewhat slower to progress originally slow because of some outcomes, which were not great and endoscopic techniques and thoracoscopic techniques, which were difficult to reproduce and required very, very significant and difficult and complicated technology. I think one of the nicest things about this procedure is that it really follows along the principles of minimally invasive surgery. And those principles really are to use normal tissue planes to use access points, which don't create collateral damage. And then to be able to do surgery in a way that is similar, that people were, were doing open surgery, therefore giving us outcomes that are superior without making it too complicated. And I think that is one of the key things that really though, one of the things we hear about that with minimally invasive surgery, one is how difficult it is for people to learn it. And, for people to translate this into their own patient population, when you started, did you have a hard time learning this? Or how did you get involved in service from the beginning?

- Well, definitely is a learning core, but specifically for the minimally invasive bladder relaxes to me, the lemming core was very smooth. And the reason is because I was not changing too much, my way to flow into cases and is so is that if you follow these six or seven steps, actually the outcomes of the patients are good. So for me personally, these Alexis was ECE as compared, I would say he is more difficult to perform a pristine mini-open Tealeaf than a lateral approach. I don't know you're agreeing with me, but I think as long as you follow, the anatomy, I think the procedure is very visible.

- And what do you think makes this a minimally invasive approach? What about this procedure makes it minimally invasive? And what about this procedure makes it attractive for patients to consider another surgeons to consider?

- I think the alarm much of the procedure are that definite leading sessions are very small. The, a footprint on the multifidus and the posterior muscles are minimal on that one means less post-operative pain. And if you go over the procedure itself, that load loss is minimal. And actually what you see on this slide is actually a real picture of a patient after one or two levels, interbody fusion unfair provide a really good anterior column support and good fusion. So you get all these advanced versus in one single package is what it makes them less invasive approach. When you get through the four or five centimeters incision, no more than that. So we continue. So as we, you see the advantages are not only the minimal soft tissue damage, the blood loss, but also provides a really good decompression. And we'll see later on discussing your words by indeed pressure. I know at our advantage, the pursuit itself, as you see in here, the implant seats from one dialysis to all dialysis. So these one makes not only a new surface for grasping, but also these are various able device in terms of providing a established station. Very soon.

- You talked about indirect decompression as a neurosurgeon and as a spine surgeon, we're sort of taught and we rely on direct decompression. What makes you think indirect decompression works? How do you decide a patient at will on a patient that I won't work on? And how long did it take you to feel comfortable with relying on indirect decompression in doing the surgery?

- So one of the most important parts of these personalities, at least for most of the spine surgeons, is to feel confident with the concept of being the angry compression. And why is because you ain't releasing and doing a foreign monogamous actually by pleasing the east side, that the patient has really lost within the generation of the segment and by regaining and by leaving into touch, he's actually restoring the normal sizes of good for him. And that's the way that they needed to be compression wounds. And sometimes you said concept for the surgeons to assimilate because decompress and be able to answer instrumental for him. And so these points is more what we see also the seniors. So I think this is the way that it works. And once you feel and you believe that actually the patient happens going to show up on the different cases. Now, when these approaches, let's say, for example, you pretty much never have when doing these types of approaches.

- So we're looking at some graphs down here at the bottom, and we're looking at some inner body graphs. What, inner body graphs are we looking at? And what can we say about the size area and the location and the prevention of subsidence and stability and other things that you gained from the lateral approach, as opposed to the other grafting options that we have, because certainly there are other minimally invasive grafting options. What makes this superior to the alternative options?

- So as we see here on this diagram, actually, this is the implant. This is an implant, and this is the me and my invasive lateral implant. So as we're looking here, actually the surface for grafting is actually occupied by the graph itself, giving a really good window for grafting. But that one is not actually the main point. The main point is that if you are relying on indirect decompression, let's say regaining with his height, you don't want to have subsidence. So in order for you to recreate the subsidence, one of the advantages of the lateral procedure, as you see here, that devices, the cages sits on the diaphysis in place, where they are strongly. So avoiding, what can happen is similar procedures in terms of having some societies and then you move your indirect decompression. So this is a very important, and this is part of the concept of the X if approach. But if we're looking here, for example, in terms of how is stable, is this procedure, these not arrow is showing how we approach this from . So if you're looking here, the anterior longitudinal ligament, when we do this procedure is intact and all the posterior elements and posterior tension bonds are intact. So what it means is actually you only make a small window on the analysts. And then the case is going to go through and through the diaphysis providing the index decompression. And by the way, this is one of the few procedures in where you can leave the cages and you don't need to necessarily instrument, but the procedure is less necessary license. For example, a tea leaf. When you have to take the tires, parts out, you have to do entire facetectomy. And by the way, the leaves means that you have to instrument the case. So this is one of the advantages that you actually can do what we are, a stand alone procedure. Are you agreeing with .

- Yes, I agree with that. Absolutely. I mean, you are in an environment which makes the cage very stable. So not only do you have a decreased rate of subsidence and an increased rate of fusion and an excellent positioning of the cage, the preservation of the ligaments to, in my opinion, AGU and indirect decompression. So the ligament or taxes is a additive factor for indirect decompression, which not only tensions your poster and entered launch and ligament will, will help tension your ligament and play them and allow you to get indirect decompression, not just within the framing, but within the central canal and within the lateral lateral recess. I think that the ligament or taxes and the preservation of the ligaments is not just important for stability, but also will aid in indirect decompression and makes this a very, very stable environment opposed to alternative inner body fusions.

- I totally agree. And then as any other procedure, he has these advantages and the main disadvantages are first because the approach, when you go through the source, you have to deal with the Lumbar plexus elements that is a risk of Lumbar plexus damage. And we would see during the presentation, how you can negotiate and avoid these complications, then definitions are learning core. It's a brand new procedure, and there is a potential for bowel and basketball injuries if their access is truly retroperitoneal. And if there is a variation in terms of losing orientation with your patient in positioning, that also we're going to be a lot of place, a lot of emphasis on this part. And then the last part is the access to L five is one is difficult than this approach. So not only because of the crest is in your way, but also because the anatomy and the nerves are, is more complex. So are you agreeing with disease Taylor or you have any ?

- I have. So I think that this is an excellent group of like a discussion in which we can really get an idea of what the advantage the disadvantage is. All I think in your presentation, you'll certainly go over a Lumbar plexus, maybe some learning curve. And we'll look at identifying L five S one, or you look at bow and vascular injury. That's sort of a scary and in a very, very morbid complication. Is that something which happens routinely? Is that something which you can compare to Elif and the percentage of occurs, or how often would you, should we worry about that? And, what are the things we need to do to sort of avoid that in general?

- Yeah, in general, that is not a big literature report in terms of bowel and vascular injuries, but I can tell you dirty, not recent poll that we did on the us. So salary, which we capture more than 12,000 procedure years, I can give you a pre monitored results. Seems like a, is on the one percent or less chances to have bowel or vascular injury, what we call catastrophic complications. So as you see is very comparable or even better to the leaf approach itself. And I think makes the procedure definitely saved on my own experience. I can tell that in our group, we have in half the first bowel injury, vascular injury so far, and we are close to a thousand cases in the entire group. I don't know what your experience with these, what we call a catastrophic complications. Dr. Taylor.

- We have not had a bow or a vascular injury either. It's something that we certainly consider it, something that I talk to my patients about. However, just as you said, the chance of having this injury with an alternative procedure is certainly higher. So you can't say that it's zero, but it is definitely lower than the alternative procedures. And if the person's going to have surgery, although it's a risk, it's a lower risk. And it's something that I think you certainly can control with your technique and whether you approach and with your identification of what the contraindications for surgery are. And, so therefore I think you eliminated, rather than it being a technical exercise during the surgery, if you look at your technique and do it appropriately, and you eliminate patients with high risk, then you're going to almost completely eliminate that. But it certainly is something that you should consider. It's something that you need to worry about. And it's one of the reasons why, as you know, on what you're going to go into, the specific technique is so important.

- Yeah, I totally agree. So that's why we mentioned us at one of the potential complications can happen any time if you lose control of the case. So a lot of the parts of the presentation is actually trying to show you how to control this part of the procedure. So we go our, the procedure, we, as we mentioned before, the patient has to be in a position now, perfect APN lateral position. And it has to be verified with a set of rates as we see here. So what you really want is the spinus process has to be dead centered. We are equals based ones, both Pakos view. You want to see one M plate at each level and one single EMA, the pay code. So why is so important is because we know that the best is around two years and the canal is posteriorly and the Lexus is running most of the time in the posterior third, when I place my dilator, let's say, in this area, I'm not until Europe studio. Why? Because the patient's using perfect a lateral position. So they avoiding complications start positioning the patient. And on this procedure is critical. You agree with that? Dr. Taylor.

- I agree with you that the risk to the patient is greatly mitigated by your technical expertise on the time that you spend positioning. I think that many of the problems that people have are secondary to the positioning exercise. And if you can do that and you can reproduce it, you can position the patient the same way, and you really work to get that position appropriate. Many of the things that we hear about and concerns that people have in adopting this can be almost completely eliminated the addition of an x-ray tech or an x-ray person. Who's familiar with a lateral approach and has done a refor is very, very helpful in my opinion. And it's something that we stress when we're talking to other people. I do find that when I hear about complications or I visit different institutions, that may the things that happen happen because the patient's not positioned appropriately. It's a different spine surgery. In my mind, the surgery begins where the positioning, rather than the incision. And that's when you save the patient, those complications and the complications that we can avoid are really not just placing the incision in the wrong spot or making more difficult it's vascular and the Lumbar plexus injuries and other things. So positioning is absolutely critical to my mind in this procedure as is obtaining x-rays. Do you ever do this with navigation or you as alternative approaches? Or what do you say about someone who's concerned about radiation exposure? I know that one of the limitations and one of the reasons people are concerned about minimally invasive surgery is radiation. Is it something that you can avoid and how much radiation do you think that you use with this procedure?

- Definitely the first part of your learning core, you expect to have some exposure to radiation, I would say more than a conventional open procedures, but once you get through the learning course, absolutely you can decrease a lot of the amount of radiation. I personally prefer to do it on their fluoroscopy image. And the big reason is because you start real time information on the navigation, you can lose control of the position, especially when the patient is on ladder. And as you know, one or two or three millimeters are critical this procedure. So you really want to have a feedback real-time information. And the only way to have it up today is probably using a fluoroscopy. So, and then as we know, the most common complication during this approach is actually injury of the Lumbar plexus. So a lot of effort has to be placed in avoiding this type of complication. So because of that, that is important. The next two or three slides, I'm going to revise a little bit about the lateral approach on the lumbar Flexos with relation to this approach. So, as we know, the Lumber plexus go from B12 to L4 most of the plexus is situated on this. So as mayor, but you need to be careful because there is some branches that actually are part of the Lumbar plexus that they don't live inside the source itself, and they can be injured with the procedure. And then most of the plexus, as we see here is not about you, is in fraud of the Tempus processes and the coordinator of approach. See, for example, in here, if you are approaching at four and five, you have to negotiate five or six different narratives. And when you compare to, for example, the Tealeaf, if you access in 11 on leave, you only have to deal with the exit in roots and the colors include, and not only that, but when you doing the Lumbar plexus, if you injure one of these nerves, actually you are injured in a different narrative. So let's say this is the femoral nerve on this case. If I the femoral nerve at this level and fallen five injury to a 300, 400 roots. So in the audio side, if I do I injured the exiting group, I told you I'm doing a injury to Proxima. So that's why it has to be so much attention in avoiding and manipulating the Lumbar plexus, because the clinical portions are significant and yards because you're dealing with peripheral injuries. So it doesn't mean that they are not feasible or safe or reversible. It means that you really have to know where you, where are those structures located and how you negotiate them, anything Dr. Taylor to add.

- So then you talked about, we started thinking spine surgery more in the way of root injury. So we think of root injury as being, L three root or L four, or we're doing a T lift at L four five. We might retract the nerve root injury, but in this case, we're talking about a nerve injury. What are the symptoms, or what are the problems you get from the femoral or the arbitrator nerve, and why are those more easily injured than the roots or the other nerves? Is there any particular anatomical variant we need to worry about with those? And then why do you feel that those are more likely to be injured?

- So, I observed looking here, this is the way that the Lumbar plexus looks from the lateral view. So the femoral is particular vulnerable to get injured on this approach, especially when you're accessing the lower level, that is in four and five. And the reason is because it's the dominant Nair root of the plexus. And not only that also ruins on the posterior third, most of the time of this space from anterior to posterior. And because he's thrills to the area is particularly susceptible to injury. And your job during the approach is to make sure that you localize the femoral injury. You know, what is Jord relation there? So when you place a retractor, the retraction is minimal, or the retraction is more from idea to posterior. So the nerve action, as we see are laid it on. But if you look in here in the next slide we see of the adios representation or the Lumbar plexus itself, you see this green area is actually representation since sodium representation of the femoral nerve. So you see here is, takes a list half of the sensory innervation of the type. So that's why when you put one on, there is so much significance clinically, and then as you see here, they have also a significant clinical pollution on the upper Sr. And another important point is most of the nerves, believe it or not, they have a mix participation on innovation. Most of them, they have sensory representation. And this is important is because you can actually identify it for some reason when you have a urea, one of them by sensory information, what nervous were on, the more operational, but definitely it's a very important point. That's why you have to know exactly where is the territory of each year and where are located into the retroperitonium places. Any, other comments about this Dr. Taloy?

- No, I think that the nerve, is very important to identify and also to get an idea of exactly what we're talking about when we're talking about an injury that the sensory root gives us an idea of the nerve, which is injured. And also the weakness in the quadriceps muscle is the femoral nerve motor output. And that the femoral nerve is also injured because it's the largest nerve in the vascular supply. It can often become a schemic and this goes in and leads into why the monitoring for the femoral nerve is so important and along with, and it also lets us know what the EMG and what our neuromonitoring Canon can monitor. So if you look back at the genital femoral nerve, that's really a sensory nerve, which is difficult to get any feedback from our EMG, which it won't really give us any feedback at all. Whereas the motor function of the femoral nerve is easily. We easily get feedback from that on the approach. And I think you're going to look at a video now, which goes into positioning of the patient and then stretch of the nerve, which is one of the times it can be injured.

- Yeah. So, and this is actually, this video is important is because for the surgeon, when you have the patient on lateral position, you break the table, give or levels, and four is fine because you're moving the crest away from the surgical field. But the problem is when you break the table too much, a lot of tension on the psoas muscle that we see on this video to orientate the audience a little bit is actually posterior where my arrow is, this is anterior, this is superior, and this is inferior. So and this is the femoral nerve has been dissected, and this is specimen through SOS and whatever, what we're going to do is we're going to break the table. And I want you to keep an eye on these shiny line and you see how much tension you put on the mirror as you break this table. So if we go in the video, we brought the table to see how much now is relaxed in there. I mean, we bring the table again. You see how much they wouldn't get married. So the theory behind these is that if you retract a nerve, like in this case, there isn't a lot of tension. It would tolerate less retraction that if you retract a hair that is actually relaxing. Any .

- So why . We need to gate the table in this patient as a page to the patient, when did the advantages of the break-in and how much is too much . Can you get an idea of hamlets that isn't and you ever see Eng changes when you're breaking the table? That may give you an indication that .

- Actually a really good question. And I have you see here on the screen, this is a patient with an extreme of breakage of the table. You see here is almost jackknife. And while you're trying to who you're trying to take the Lia crest away from the surgical field, so you can access the spine easily. And the crest of the ribs don't get in the sergeant's way. The problem is that by doing that, you put a lot of tension on this issue. I personally see changes on the EMG. In my cases, this is just a high, I would say frame. I'm not sure what your own experience around when you break too much the table.

- It's. When I first started, I was very, very concerned about getting the iliac crest out of the way. And I more aggressively wrote the terrible as you go on. It seems as though that less and less brake will give you the same opportunity. And certainly, as you know, there are alternative methods for getting down to L four or five, which don't include an aggressive break of the table. I don't know that you've gained that much more by aggressively breaking the table. You certainly put the femoral nerve at a higher risk and with angled instruments and a careful approach. And even occasional, I will resect some bone or moving the retractor. I think that that's better alternative than aggressive break of the table, which also gets in the way of the fluoro. It makes it positioning more difficult. The patient tends to move. So I see a lot of advantages in a less of a break of the table as time time goes on. And I think you can also identify the person that might need a more aggressive break in the beginning of the surgery. So a highly I crest or something, and you really need to not just break the table the same way every time, but consider what level are we operating? How high is the iliac crest? How prominent is the Lumbar plexus and exactly what are we trying to do for this patient beforehand? So consider those options before you decide how much you're going to break the table. And I do think, as I hope we're going to look at now is although all four or five is a concern for everyone, there certainly is no problem accessing that. And I think if you get to start to look at these slides, you really need to consider yourself general surgeon when you do an excellent, what do you look for on the MRI scan preoperatively, as opposed to just the spinal anatomy. Now that you've done with thousands .

- This is a really good observation and a part of your complication avoidance is start in your clinic. I've you seen here on this MRI, you follow the best cells as we go with the cots down to L four and five. We can move the video game. If, you see here, you follow the basis, or you see, as you go to the four or five is space in this case, particularly the vessels is way too loud it out. So it's almost on the way of your approach. Actually, this is a case that we decide not to do, let it up. So let's you see of your complication avoidance in this case, vascular injury started actually in bikini. So you have to be careful that the patients, they don't have an early bifurcation of the a ILLiad vessels or in most of the cases, what can happen either. Actually the patient has a better breath. So actually you're not working at 45. You're working on L five and six, and you are getting a little bit gain by the normal. So you have to be careful on these findings because on that cases, actually, you can create a vascular injury just because you didn't pay attention to your preop MRIs. Are you agree with these Dr. Taylor?

- Yes. And I think that that's one of the biggest issues that I hear is that the transitional anatomy, because often you'll get an MRI report or you'll get a patient and we'll come in and we'll say L four or five, and even the x-ray or the MRI report, we'll say all four or five, and you can quite easily tell the difference between a transitional anatomy, L five, six or an S one S two and a specifically L four or five, not just based on the patient's symptoms, but based on the shape of the psoas muscle, which begins to elongate as time goes on and you get lower down. And then also the location of a Lumbar plexus and the shape of the arterial body. And I am not concerned at all about saying this is not an appropriate patient for lateral approach based on what I see being the vascular anatomy, the shape of a body and the location of the Lumbar plexus. And, this is the time where you're going to avoid your complications is preoperatively rather than thinking, well, I'll do something and positioning that to help myself out. So look at the films beforehand and remember that you're doing the general surgery approach or retroperitoneal approach, and you're going to have to get used to looking at the vascular anatomy and the retroperitoneal space.

- Yeah .

- We say the move to health for a five. I think it's a, probably a bigger problem. Maybe you could touch briefly on what you see at the upper levels when you get into the diaphragm and what are you doing when you see the kidney? And can you actually go from the right-hand side with the liver on, on that side? And that may be a more advanced technique, but any particular tips and things that you see for that anatomy.

- In general, we access the lateral is five from the left. And probably this is just a tradition taking from the anterior approaches to the spine, to the AA list. But if we, on the retroperitonium structures, if there's structure that actually live on the retroperitoneum beside the Lumbar plexus on the source itself, you have the kidneys for the easy structures are a way the mobile structure. So they move freely into a retroperitonium. And as long as your dissection always is on the posterior part of the retroperitonium close to the equator, lumbar muscle is very easy to negotiate. The kidneys are in the opera lyrics. And also at the levels, if you are working in between 10 or 11 rooms, you can get actually . So when you're doing this access at this level, you always has to be aware that if you dissect inferiorly, actually you can get into the retroperitoneum and more upward the AE from the retroperitoneum only structure. So you don't necessarily have to be into it every time you do it. And then the last part of your question is about the liver. Fortunately, the liver is interpreting the structure, so that's why on the right side, actually, you can access all the spine from as four all the way up to a direct lumbar area without having to leave it itself. So right or left, I would say, defending, what is the Leah crest in relation to? What crest' side, let me have better access to four or five 11. So now the recap, the axis in terms of the spine. So the first part of the procedure access the retroperitonium, it means cutting your incisions. There is two sets of different ways to do the approach single incision or two incisions. And the video that we're going to see first is the three incision shows a style, which one incision is directed by thoracoscopy. That is exactly at the level of the index Brolin. And the second incision is, was dearly close to the, a process areas on that incision helps the Sergeant to dissect the retroperitonium. So each it's technically valid, and I will show you both techniques. And then once you read to prepare access, then you just need to dissect the retroperitonium. And the last part of the Sr access is the saw as muscle massage. And then it's just my yours. So now we're going to each of these steps, as we see here, this is the incision technique. I'd you see here? What incision is here? The patient is left side up. This is an ear posterior. You see the surgeon dilated through the abdominal muscles. And this hand with the second incision is guiding. As we see on these diagram, the dissection of the dilator retroperitonium until the top of the psoas muscle. And then you go to a second stage of the technique, any commentaries in here, Dr. Taylor?

- I was going to ask you is, do you prefer the two incision or a one incision technique? And what do you think is a good idea for someone who's just beginning? Is there an advantage to one, as opposed as opposed to the other and how easy is it to access the retroperitoneal space with a finger in the second incision?

- I believed a safer technique. If you are not familiar with the retroperitoneum like most of us, we not general surgeons, but I would say early on once you get confident with the anatomy of the retroperitonium, you can migrate over single incision. I personally do single incision, but I believe that two incisions should be part of your learning curve. On the first cases, we give you a very confidence hope to ask the director, predict Tonia. Do you two or one incision Dr. Taylor.

- I almost always still do two incisions. I absolutely agree with your comment is that when you're starting, the second incision allows you to dissect bluntly through the lateral aspect, which is an advantage. And it also allows you to make sure that you know exactly where you're at. And that also allows you to, if you're moving farther up in the spine, I often will use two incisions. And when I want to move something out of the way. So in other words, if I'm at L two, three, or I'm farther up in the spine, and I want to know where the diaphragm is, I can put my finger in there to make sure that I'm not in the thoracic cavity, or I can make sure that I palpate the kidney to move it out of the way. And I feel much more comfortable doing that. You certainly, once you've done it a few times, the advantages are less. When you have more experience, when I'm doing multiple levels, I often will use a single incision because I'll make my incision a little bigger and I will still access my finger in the retroperitoneal space and then through the same incision. So I think that the most important thing to remember is safe access and confirmation that you're in the retro peritoneal space before you begin your surgery. And that can be safely done with either incision technique, but certainly when you're starting out, or if there's any question easier with the two incision technique.

- So as we see here, so you localize your level on their APR, lotta for oscopy. Then once you open the incisions you access the retroperitonium, they did I later. So in this video, on we showing the single incision technique. So in this case is a patient on the left side up, as we see here, the yellow arrow, and you see here, once you open be a fascia of the abdominal muscles, you will see how you zone dissect with the hemostat, the abdominal muscles, first, the statement of need. Then, tell me all of li I tell you, see, again, fat, that means retinal breaks on me and fat. I know sometimes you can find your Nazis, like in this case, one of the nerves and you have to be careful, and this is another complication avoidance, Steve, that we do into the presentation. Once you find these nerves, you don't want them to burn, or you don't want to cut them with the Bobby. That's why we're doing indeed dissection, Blondie, where your finger, or with this pair of hemostats these nerves easily be, or the genitofemoral or the inguinal nerves, and then, or the, your hypogastric. And actually you can injure E domino wall. Then the patient can have, so you've seen this shirt and these extra amount of leg and the fascia. So one of you get into a recovery for me is the dissection of the recovery. So these are the two nerves that can get your through the approach, depending on what level you are, but in the lower lumbar area, you can eat hypogastric. And even if you're higher, the suppose to nerves and the complication is this. So is this abdominal wall Perez or also for hernias on it cannot be avoided with a sequential dilation, any comments on this complication that the Taylor.

- Absolutely the way to avoid that is with blunt dissection and not to use the Bovie or to use heat or to use a knife. I see too many people who feel as though that they don't have any risk to any structures until they get to the retro peritoneal space. And they're overly concerned about either a vascular or a Lumbar plexus injury, as opposed to what is a pretty significant cosmetic injury and a cosmetic problem for the patient. And, that is dissecting through the abdominal wall. So not just a, not using the monopolar or heat or knife, but I think you can probably prevent that by using it to incision blunt, dissection technique. And I think those two things are critical that you avoid those because it really is. It's not, it's an unsightly and it's not a complication that you want, although it's certainly not a life-threatening complication.

- Unfortunately, most of the times it can be resolved spontaneously after nine to 10 months to a year. So, and then the next step is dissecting the retroperitonium. So when you're dissecting the retroperitonium, there is also a point that you need to be careful. So once you praise your dilator and your target point, then you keep winning separation dilation. And in these color, vertical specimen, we just trying to demonstrate the anatomy inside the retroperitonium. So if you're looking here in this, a specimen that is no abdominal wall, this is the crest. This is the left side, and these are get close to your wall of the retroperitonium Mosul is here. That is your posterior aspect of the retroperitoneum. So as most of us you see here. So actually the approach is exactly like this. So when you're dissecting, you have to be careful not to in your, these nerves, there are climbing from to trying to reach the abdominal muscles to be doing ratio. So as you see here, they can go very close to . So that's why you can injure anyone on ed to their roots and their sorry, nerve nerves when you are accessing actually lower limits, but you have to be careful in doing these dissection. So, the next step is the, actually the negotiation of the source Mosul itself. So on this point is the EMG. They eat important road, and we're going to be having a lot of details because if you have a system that actually has directionality in terms that you can localize, where is the specifically the feminine there, and the main narrative of the flexors with relation to the dilator is a very important part of the procedure. And as we see here, let's see, we can see in these video, in the patient, we want to make the dilation sauce is a case using a directional EMG money. You see, as usual Tate, the dilators, the numbers, which you had response of the same are lower when you , and then when you go anterior, you see how these numbers go on here. So you find going on, it will be in one of the tales of this point, ease. So I am a standing you're part of the patient. This arrow is actually the area that I missed in deep into a sauce. So in this case, it was a stimulator here. And as you saw in the video, I was rotating the stimulation. I was getting very old numbers of . It means very little energy, have a response of the feminine nerve. And when I wasn't inferior, I need more energy to have the same amount, the stimulation of the nerves. So in that case, we can go to a next screen. That's like in that case, we were located right here in front of the product, the feminine nurse. And this is specimen. This is . This is posterior. This is the L four or men with the going down the femoral mirror, coming from entry. I'm the displays of four, five. So we'll recap what we saw on that video. That's when we went stimulating posterior, we were hiding no numbers to the same response that if we were stimulated until you were, the stimuli has to go around and cut the gained. So that's why I needed more energy to have the same responses. So that's when he said good position, your return, because on that eight better retraction from anterior to posterior. If I put my right here or right here, any comments Dr. Taylor?

- I'm going to ask you, what do you do when someone tells you, oh, you don't need neuromonitoring because I'm dissecting directly down through, or I don't need any directional integrated neuromonitoring, or I have somebody that fits that I'm using who is going to help me out. Do you, is it something you think you can do? Can we do this case without no monitoring? Or is it absolutely essential to do it?

- Well, to me, the thing that you can do is suppose you weed out monitoring, but I would say the procedure, you will be very hard first to do a minimally invasive, because you are relying on a big incision, be able to see the lumber places through. So as muscle, and as you know, the distance between the skin on the lumber flex or the femoral on is at least four inches a list. And there is a currently that by nature is full of fat. So it's really hard to dissect. It becomes cumbersome, but if your skills you're able to do it in an efficient manner and be able to identify this, and when I'm married and I'm pleasured with direction, you might avoid that the monitoring, but I would say it's easier if you have a good understanding of the neural monitoring, they are not to me on a, you have a good relation between the first Copic vision on the EMG. I totally, you can do a persevere. You can flow better, and you can, during this procedure in a very simple operation, instead of bringing Microsoft's dissect the muscles, move people dissections, and to me is easier to do it using the EMG, as long as you have a good system. And you understand exactly how this system works. And any comments on this Dr. Taylor

- I feel pretty strongly that both the directional capability of the neuromonitoring is critical rather than just viewing this as neuromonitoring, I thought of sort of view it as a navigation system. So if you think about it, a electrical navigation system and say, this is how I'm going to identify the nerve, rather than just considering it's there for monitoring of the nerves, because it's there for more than just monitoring it. It's there to give us directional and distance and to really navigate between them and know where our safe areas. So, I try to consider this and I try to consider nerve monitoring, not just monitoring to protect safety of the nerves, but to make, as you said, make the operation easier and make it safer. And to use it as a monitoring device and a navigation device. And I personally have never done one without monitoring, but I do agree with you. There certainly are situations where you could get by with it. You're going to have to do a bigger, more complicated dissection. And there are certainly a lot of limitations to the neuromonitoring. I mean, this is EMG monitoring. It's triggered EMG, which, and also free running mg, not SSEP and not, not MEP. So there are limitations, but it certainly makes the operation faster, easier and safer.

- Yeah. And this video, for example, you just to show him the importance of having a directionality on your EMD monitoring directionality means like able to stimulate posterior anterior. And I know when I'm stimulating in what that action, second, how important is a system that give you immediate feedback of how much Millie arms you need to get the response of the muscle? So in this video, this is a specimen. This is undue fear. This is posted here again. This is the femoral nerve. And this marker is actually the five level in the ideal position to place the retractor. So what I'm going to do is assimilate. If I go with that, I will go generic EMG monitoring. If I stimulate right here, the ignition is going to tell me there is an error in your way, and I want to ask him, what is the mirror? He, because he has no directionality. He's not going to be able to tell me if I am behind on the front of the neck. So what they tell me is golden period. So I go more empty here. I have only muscle around it, and there is a stay away from the fence. But in this point, I'm too much, I'm on the space to place my implant. So the numbers are good, but once I moved my dilator posterior, to get access to the nice areas, to open that door, actually this piece of muscle, you will become actually a big offender, and he's going to put more, we can action on the knee itself. So as you see here, when I'm high on that case, it was a false sense of security that actually I was safe. I was surrounded by muscle, but the problem is since I was too much anterior on the this space, once I put the regional location, then there's most of the coma. So that's why it's so important to have the externality, because if I know that I'm exactly in front of the mirror, very close to it, I kept they've made retractor right there and open the retractor anteriorly instead of trying to find from a posterior to anterior the localization. So this is a, I would say nationwide, there is some reports which say that the EMG monitoring was perfect and the patient wakes up with, so this could be one of the ways to explain that incidence. Any comment Dr. Taylor?

- Well, I just think that you can protect. I mean, when you move nerves all the time in spine surgery. So this idea that we have to find a adequate safe zone, which is existing before retraction and distraction. And before we do anything, I don't think is, is an adequate explanation for how we do surgery on a regular basis. I do feel as you do that, we need to, to protect that nerve and adding some cushion. And it is certainly an excellent idea. Splitting the psoas muscle allows you to do that. And then dial was, remember that your safe area is anterior. We liked to get the cage as far back as we can. And we like to have as much space as we possibly can to work, but the safe cell is anterior. And if you run into trouble, move anterior, keep your nerves behind you use an integrated neuromonitoring system that has directional and distance capabilities. And I think you're going to be much happier with your surgery. It's absolutely more critical to do this at L four five. I know people are more concerned about L four five, but the majority of surgeries are done at L four five. And the majority of surgeries are done safely. There's some discussion in the literature about what the risk is to the femoral nerve. If you're using all the techniques and all the safety things you talk about, what do you tell your patients? The risk is to the femoral nerve and the recovery time using a, selecting the patients appropriately and doing the surgery in a standard and using the monitoring techniques.

- Yeah. So I think that the femoral nerve is more vulnerable to injure at the L four five level. No question about it. However, I think I view respect that technique. The ACS is not as high as you think in our group. Our, we consent the patients with approximately 20 to 25% chances of a transitory numbness on the anterior cutaneous branch or the femoral mirror on almost unexisting risk of full blown. What we call full blown femoral nerve injury, the oldest, because we are in the laboratory, but I will say on injury, as long as you are able to identify with during the procedure that you are in front of the fender on there, you don't see it when your reflectors on you are efficient time, in terms of time, amount of retraction and dissection, they the incidence of significant injuries, very low. What are your experience Dr. Taylor and your numbers?

- Yeah, I absolutely agree with you. I think that the incidents of a significant femoral nerve injury, if indeed, you're using the technique and described, and you understand the anatomy is less than one percent, it may be higher in your initial cases because of the length of time it takes, there is some advantage in this procedure to working quickly, but there's a bigger advantage to not just working expeditiously, but using appropriate retractors and using appropriate monitoring and performing the technique. And if you do all those things, it's going to be less than one percent. Those will recover, but they certainly are a possibility. And that I'm not sure that I consider the sort of the dysesthesia, or some weakness in the soleus muscle post-op as a comp as a nerve complication, because these are the things that we see with lots of other procedures we have. And I think that's where people feel their pain, rather than there being a complication. It's certainly something which is going to recover quickly. So using those things, your real risk to the nerve is in my mind one percent or less.

- Yeah, totally agree. And then are we going with a technique once you identify the femoral or you find a dilation, you play your retractor. In this case, we see here, these retractor is a duct on the posterior blade. He has a shim, as we see on the, a AP view. And this shame is very important. The fact that it's and the reason is because once you put your feelings inside of this space, then the plexus is behind. It will stay behind all the case. What you don't want is to be able to negotiate with Femara mirror, be able to play defense with a mirror behind your retractor, but at some point lose control during the Hills and the nerve people go below the . So that's why it's so important to Doug, the retractor and that level April's to your shims. And then do that. What we call the carpentry is basically perforation or the end plates you use coughs Cary soons. You can use a any instrument, you have preference. In this case, you see a call, we'll see a box cutter, and then you go with the implant. And in this case, a lot of plates screws, any comments on this part of the, of the procedure, Dr. Taylor.

- I think that, again, the other nice thing about this procedure is that it's not it's standard surgery that you're doing. So what, in other words, if you prefer to use a pituitary rather than a box cutter, or you prefer to use a Kerrison rather than a pituitary, or there's some instrument that you like you should use what works best for you. There are death, many, many ways to do that. And the critical thing is to place your attractor appropriately work expeditiously, and prepare the disc space for fusion in the way that you normally do it. There are many options, and there are many tools to do that. And, it should be what you feel comfortable doing rather than a specific set of steps, which someone else dictates to you when you release the contract. I am, unless I saw both on your pictures there, how far across have you ever run into problems or releasing the contralateral annulus, and you release it with a box cutter in addition to the cob that you're doing.

- So, as you'll see here, once you go with the call on the controller, I don't lose. I think it's very important to release it because he's allows you to do a better indirect decompression and regain this height, but you have to be careful and how a good control on the system. And you don't want to injure Capella really structures, and you have to be exactly enough, perfect perpendicular line and not to lose your orientation. And you see here, I'm releasing with the co-op, but, and then with the books cut, and I want to make sure that I have a lead the size of the implant release on the contralateral analysts. That way they are going to have memory and get out of the DC space during postoperative period. And give me a good intranet, the compression, and I can use the dialysis side to sit them here. Who are boys who cited? So as you see is two or three advantages, why you should do a release. You have to be careful not to applaud because there is a story the other side.

- Yes a greed.

- So now once you have they, for example, in this case, as you see here in this case, the retractor didn't have a sheet Encore yearly, as you see how the retractor migrate and what you don't want to like in this case is ended up in the middle of the bed area, where the segment or the Arthur is wrong when you don't have nothing to do with that. So it's very easy to lose control the taste. So that's why you have to be metallic and following a standard set of movement during the procedure. Any comments Dr. Taylor.

- Yeah. I sort of look at this picture, like, the cartoons that they have in magazines, where you compare two pictures and you try to find, the what's wrong with one picture compared to the next. So when I look at those things, and I think about that, I try to look at that picture and I say, well, how many things can I find wrong with it as compared to what would be inappropriate picture? And then I want to picture, starting the patient wasn't positioned properly. If we can go back to the last slide, because the they're rotated in the spinus processes are not lined up and the pedicles are not lined up. The retractors not placed in, at the appropriate angle. The retractors not locked in place. It's lifted up off of the spine. It's angled in appropriately, and you're heading for exactly the wrong spot. So from the very beginning, this has somebody that's going to run into trouble when I run into this situation, because I certainly have had times where the retractor has been lifted off or it's moved or something happens. I honestly start back from scratch. I take everything out and I go back to my initial dilator so I can get back to exactly where I want to do, and I don't know what you do. If you run into trouble, if you get in the wrong spot, I just find you can't save it and you can't work quickly. You just have to go back and start over again.

- Yeah. And that's a really good point. And when you are not, when things doesn't make sense and you are not in a good position is better to go back on his star from scratch instead of totally lose control of the case, because this is when the complications happened. So that's why is so standardized that once you get over one stage and you think you did not fulfill the objective of that stage, you have to go back and re position and restart on. This is actually a really good point from you, Dr. Taylor, and you don't want to keep with the mistake. What you get is even a bigger complication. So now, while we come in here is actually a video of a patient with degenerative scoliosis, as we see here on this image without significant sagittal balance problems, and you see here, the patient has a good sagittal balance. He has a good espionage parameters. This patient, a interestingly, he has a significant co-morbidity, especially in how a previews, a heart surgery that we see here. They're going to Chronicle bag. This patient is on a anticoagulant that is very likely to take him out of them. And when we go to surgery, we take a lot of blood, those applications to correct his deficits. So that's why in this case, we are selected to do a minimal Alexis to access the eyes scoliotic curve, but not only that, but also a standalone fashion. We were thinking that the patients can be only out of the anticoagulation for no more than 24 hours. So as we see here, we're going to go through a procedure. We marked incision at every level, open the skin. And then as we're using here, we dilated . Is that extend none of live. Then, as you see dissection on on this case, we found one of the nerves and then you dissect it. You keep going with your dissection to the standard, started muscles. And finally you get into the retroperitonium. And then in this case, actually, you can see the deep into a retrofit . This scale we place in a microscope for teaching purposes. Usually the procedure is done with your loops, but in this case, we can show these anatomical details. So once you get through the more social you see here with dissecting the retroperitonium placing the first dilator or the helper psoas muscle. And then we very fun. They look in-session of the dilator followed by the EMG monitoring. How do we see here? We never seen their psoas muscle with real-time monitoring. And as we see here, as we rotate it, we have a significant throne of numbers. As we stimulate posterior and anterior, I just see here, anterior, we have in high numbers, then we place a guy wire or a different eye later. And then we do a continue dilation of the source Mosul itself all the time with everyday later aspecting to how the same trends on the EMG rates followed by placement of the expandable tubular retractor. In this case, a three blaze retractor, as you see here carefully into a retroperitoneum followed by the retractor with these handle, then one, the retractor is in place. Then first thing that we do is to verify that your Eng monitoring and your location of the retractor is not in conflict with their injury or with the lumbar flexors, as you've seen here. Your first thing that you should do is slays the lungs and then the nerve is not in your field. As you seen here, the guy wire, this is the beauty of the retractor.

- So you made idea of how many levels you think you can do through each incision. Can you reach here , two incisions with two levels, each working your way up. If you're doing three levels, do you make one incision or how do you decide how many incisions to make and when you might make an incision up and down rather than front to back.

- That's a really good question. In general, the skin incision is not the main problem. What I do is if I measured it, the transparency shows are longer than one longitudinal incision on the skin. Then I opt for one single incision. But the important thing is that on the fascia, you always do separate incisions and entry points on the fascia. The point is because you don't want first to keep the stable. So there's two, there's more opportunity to a fascia. And second, you don't want to communicate and create a big difference on the fascia because you don't normally has more chances to injure the nurse, but also you can create more leaders for no reason. And in this case, for example, on the scoliotic patients, we are typically the patient from the content side of the Corp. And the reason is because most of the time, the call came side, give you access to and 45 lyric. Also because of the concave side, one is issue as well. We can access two or three levels. And the third reason that we like to go from the concave side is also the concave side is the side that is contracted. So you release that side first. And as you see here, once you get the access, you place the retractor, and.

- This is a scoliosis case, is this something you should start with? And as neurosurgeons, what do we need to know about adult degenerative scoliosis? Certainly in a brief, a few minutes before we really start to tackle this, you drew some numbers and other things. I mean, are we getting standing films now on everybody? And, how do you start looking at a scoliosis patient rather than just a degenerative patient?

- Yeah. And this is a really important point. And I will say today, every patient that has curiosities should have three full standing fields, scholarly films. And the reason is because, the fullest penal pelvic parameters should be taken into account because as we know, one of the biggest complications in the past 3d patients with deformity or unknown deformity is missing the sagittal balance. And the only way to ask balance is having a three fluid standing films and measuring these parameters. But since the focus is not to talk about the, but I think is really important, your point is that you need to recognize what kind of scoliosis you have and what type of scoliosis are you on for what three days a week, and the only ways to having a good EMA, if you have a patient we don't fix , that is by no means a reversible. This patient is probably entailed entirely a significant procedure. It will still autonomies and all what is required to get restarted balance in this case, as we saw this, especially has absolutely no issues. That's why we can access the problem without doing a manipulation of the anterior column of the posterior elements to provide more lordosis. But we do in this case is a, trying to establish a nice or dental before owner, before me, and provide a release of the homepage side, where the patient is hiring. They're like no party. And then we need to start this phenomenon of the 4 million and Dustin, the main goal on this case, I think does the main points on this one. And then the other thing is the thing that'd be the first case and landed on, shouldn't be other form of the case because most of the time, this component. And if you don't recognize this early on, you can get into a big complication. And the point is that every level has to address each time that we access that particular level. If I explain better, so in front of five, you have to position the patient perfectly for that one. And then you move to a three and four. You probably need to reposition the move the table until you put the patient in a perfect AP and lateral position. So as you see, he has more exited to exploration on my recommendation is you will explore your sustains. It should be when you get at least affordable standard living for seniors. Any comments Dr. Taylor?

- I agree with you. I think especially as neurosurgeons, we need to hold ourselves to a level of the scoliosis surgeons. We can't assume just because we know how to do a lateral approach, that all of a sudden we can begin to treat scoliosis. And it's amazing, everybody in my practice that's had previous surgery or has had a problem, has any deforming at all, gets standing scoliosis films now. And I would like to do it on almost every patient because it's amazing how many people you find that have, really the biggest overlying problem is that is a sagittal balance problem, not just a spondylolisthesis and a stenosis, an a lateral approach, a minimally invasive lateral approach is a tool to help us treat scoliosis. And if you are not checking spinal pelvic parameters, which, includes your pelvic tilt and your pelvic incidence and your sacral slope, and you're not getting standing films to calculate your coronal offsets and your SVA, you really shouldn't be taking care of scoliosis patients. And you shouldn't do this as a first case. It's an excellent, wonderful, fantastic tool to help treat those patients. And, as I'm sure you would agree, my scoliosis patients are some of the most grateful patients that I have. They do very well because their disability. So it's so severe, but on the same side, there are also a group of patients in which you can cause problems very, very easily. If you're not careful, and you don't respect the standards that have been set for taking care of adults, scoliosis over the years and the guidelines.

- Yeah. I'm telling her like, really. And so that's why it's so important that you have a really good idea what kind of the former you facing. So we get them there. So in terms of the technique, as we see it through the microscope viewing here, once you upload your retractor, you're shamed. If it's posterior, this is anterior, the annulus is located right there. So you do your unload on me. As you see here, and you have to be careful just to open the retractor minimum, and then you start doing your diskectomy. And as you see, you're using the same tool that you use for pituitary steps, then it's the cops and you see how you want to be on the empathy without violating the end plates. As you see here, you navigate it through the, this space until you release the contralateral analysts. Then in this case, I use these above Scotter to a take the rules of the, this, once you have this totally prepared, then you proceeded place, the implant pleasure case, or you see the markers, then you have your interbody fuchsia. And as you've seen here, as you remove the retractor, you need to refer for that. You're not leaving any leader behind it, and that you've seen here, you work through it. So I see how the psoas muscle, and then you migrate to the next level. And then you're able to get this correction in this case, as you've seen here, you decrease the cost significantly, and you get that on release. The, this is a testimonial, the patient six months after the surgery actually set the function itself. So in this case for a station with a high morbidity, we say, actually, it was prohibited you a bigger approach with more than 300 CCS of logos, or more than five days this procedure and actually .

- I just, as you said, I mean, the, we could discuss for a long time, use of instrumentation and lateral plates and when and where. And I think that might be Beth's best left for, or another time, but your selection of the inner body cages and the location of the interbody cages are critical. And your ability to have a wide selection of interbody cages available so that if you run into problems or if there's something you need to do you have that have that option. And I think that obviously that low SBA, the large cages and location just allow you to treat this patient in a manner that maybe if someone had a more significant sagittal correction or needed to do something else would be much, much more difficult. The score was, his patients are very happy. If indeed we can bounce them appropriately, maintain their sagittal correction and continue to give them a minimally invasive procedure, as opposed to a large open procedure, which quite frankly, the complication rate is two, three, four or five times higher than it would be in the minimally invasive lateral approach. But you have to do effective surgery. Can't just be a minimally invasive approach with less complications, because then you're just creating more problems later on, which are going to require a bigger surgery to fix.

- Yeah, there's a library. So, we put together the complication avoidance lose eight points that you have to consider in order to have a good outcomes. So first you have to have a really good understanding of the regional anatomy. You have to know where the Lumber plexus is, how it runs, what is the relation with these spaces through the entire lumbar spine, not only on the psoas level, but also at the abdominal musculature level where you can injure us with third a second. You have to make sure that the patient is in a perfect AP and lateral position. As you're seeing here, when you read the table, instead of breaking the table, this much, you can do a procedure just with a minimal breakage is probably better tolerated that having extreme breakers. Third, when you resecting the dominant muscles, they showed that he's a blown dissection. You don't want to use bobbies or sharp instruments. So you avoid these complications forth, you had to be gentle when they secting with your fingers, the retrofit, these nerves, as you've seen here, they can get injured. We don't have aggressive dissection. So five, you have to understand how the EMG monitoring works. And you have to rely on a system that has actual and real time information for these are your eyes during the approach. The EMV is the best way to let you know that you already brought in these cases. But then when I'm there that instead of the front behind, when you don't want to place your retractor six, you have to be very gentle with the manipulation of the tool. You have to open the retractor, the minimum you can do. We able to place a, and that's it. You don't want to open the retractor too much because you don't only can injure a neighborhood structure like a segment, very vessels, but you will put more retraction on the Lumbar plexus nerves. You will have more chances of a narrative that disease. So even if you have perfect understanding of the monitoring and location of your retractor, if you open the retractor for too much, or you stay for too long, then you can, so you have to flow and be very efficient in this part of the procedure. Seven, don't forget this, these procedure, realize you are to address it with the plate. This is the complication that you have to silence. Then you will be facing a second surgery with a jazz, because you'll be well not diligent with this input preparation. And the last one, we really careful when you size in the implants, it's very easy to place a big implants. When the patient is on the lateral position, on their anesthesia, all the tissues are relaxed, but then you put such a big implant. The pressure is going to be too high as the, they will be facing a subsidence. So over this, a points Dr. Taylor something to add has you think is important?

- I just think that rather than worrying so much about the technique, if you're viewing this video, is Tara. Remember this top list of things to try to avoid, because this is a surgery that people do very well from, and the complications are avoidable, and they're avoidable by following, along with the steps after you've done 100s of them, you can change around and do different steps, but in the beginning, follow the steps. The, that Dr. Uribe has outlined here and think about the ways that you can avoid complication even before you get into the operating room. And I think you'll be very, very happy. I mean, as you're going to see the lengths and the direction that Dr has taken, the lateral approach is really going to not just change the way that your patients do. It's going to change the way you practice spine surgery. The idea that all of these things we can do without, post your decompressions and infections and spinal fluid leaks and complications and other things. And the corrections that we can get in scoliosis are going to mean that you're going to look at patients and you're going to be able to treat patients differently. This will change what you're going to do with it, change the way you think about it, but you have to follow along the steps, steps beforehand.

- I totally a greed. And the other thing is this video today, more than for the viewer to get out of the video and try to do a surgery is more to give an idea what is the potential of this procedure, and some key points on how to avoid complications, but this procedure requires a minimal car verdict training before doing it a, an amount or a skilled to get through the procedure itself. So please do not intend to do a case after you see this video, why do you need to have proper training? And if you keep and you follow what we discussed today, I'm sure that the outcomes would be good. So I just finished the sowing summary, the minimally invasive approach, the most common complication is nerve injuries, specifically Lumbar plexus injury, but definitely, I'm a surgical technique and a good knowledge of the anatomy we understanding of the energy monitoring. You will have a low insidence of complication It just mattered to put them on. So when to our board keys, and this is very important when you're doing these cases and there is no safe choreo, there is, they don't make sense. They are not to just not what you expected to have. That is a normal variations on the anatomy at every level of the body. If the, you see normal elements in your way on the monitor, it just doesn't make sense. Don't forget that there is oil options. You always can do a eat. You all. We can do an elite. You always can do a clique. So I, in that cases is better, or I'm a golfer. I annoyed options. Any commentary Dr. Taylor?

- I think the last thing is really important is that I don't consent my patients beforehand for an alternative approach. And, the chance of that you're going to have to do an alternative approach is, is very, very low, but I liken this to endoscopic surgery. So if you're looking in the ventricles with an endoscope and you can't see what you're looking at, you're not going to try to do a third ventriculostomy. You're just going to put a shunt in and there absolutely are alternatives. So if you're not sure, and something happens, just stop, do something else, because you're going to get into trouble without doing that. It's never, it's much better to stop and try something else than it is to move forward when you're not sure.

- So this is not a list with the case of a patient with a significant loss of lordosis and degeneration of the disc spaces. As we see on the CT on the MRI, and this case is just, we almost raid the power of the internet, the compression, and this is a really good use case. As you see here on, on two, there is a significant central stenosis. As you see here, the compression of the neuro elements and all these are degeneration of the order limits. And as you'll see the space, the wind and mini money, basically Larry, Alexis, and as you see the MRI . You'll see how by restoring that this is correct in this case, these responded earlier, this is I sort of, you get a decent, the compression of the canal. We now manipulate in the posterior elements. So that was the situation. And then as you see here, you provide lordosis at the same time by the approach itself. So there is a learning curve, and the only way to get through it is actually walking through that. Any comments Dr. Taylor?

- I think the learning curve is really critical to think about and not just the beginning of the learning curve. So when we learn how to do an X lift, that might be at L four or five stenosis and spawn roll his thesis that you get comfortable doing, or maybe an adjacent level disease at L three four. So the learning curve doesn't stop or change just because you learn how to do something. The other end of the learning curve, where you moved from being, competent to being an expert or being a master, or being able to do some of the things that Dr. Ribet can do, continuing to think about that learning curve as you go along, and that's going to allow you to treat, to treat different patients.

- And then this is just showing the power of the procedure. Once you get to a lemon core, this is a patient with a significant degenerative scoliosis, as we see here in the Corona plate and on the sagittal plane. But as you see here with group planning on, in this case, making extended applications of the lateral Alexis, which include section of the ALL, anterior longitudinal ligament using, also mini-open and leaf in this course, particularly we were able to obtain a significant resource during lateral technique. They call the screws and a mini open, a live as comparing to the standard techniques. So a is a powerful technique when you use it correctly and right, actually gives really good outcomes. As you've seen here post you can correct severe deformities when you use them as a combined technique, any comments Dr. Taylor.

- I just, again, looking at that that's the person that's done many, many lateral approach surgeries. If you're not sure where to draw those lines, and you're not sure what the pelvic incidence is, you really need to start looking at that. It's there, they're simple concepts to learn. And there are certainly people that you can take care of. You cannot avoid a L five S one just because you can't do it with an X lift. If you need to, you have to know how you're meeting Alf approaches or a Tila approach. And then once you start talking about percutaneous iliac screws, and when not to use them, you've advanced up to the point where you can really start taking your scoliosis patients. And it's going to expand your practice, expand the way you look at it. And, that's a person most likely who really had had a procedure, which would be much less complicated and much safer, much faster, and a quicker return to work with less complications than if that would have been done open at another location. So I just think that these, this is where you want to go. And this is the promise of minimally invasive surgery. Minimally invasive surgery started out as endoscopic disc surgery as the original thing. And, really the promise and the payoff for minimally invasive surgery has come from people like Dr. Rebate, expanding the indications, using the technique to treat more and more complex patients. And that's where you get the advantages for a minimally invasive surgery. Don't abandon it just because it didn't work for, your one level diskectomy is, or you found that the patients did the same. Or we look at the studies and show that the outcomes for a one-level Lammy or a disc are similar. I mean, the advantage to minimally invasive surgery and learning this techniques comes when you can take care of a complex adult degenerative scoliosis patient, or a osteomyelitis, or a corpectomy or a trauma patient that that's when you really get the advantage of minimally invasive surgery for the future. I think we might look at some of those cases now at the moment to try and get an idea of where you can go once you've reached that expert level.

- Taylor and Bill 10 can for very thoughtful comments. And we'll go here to port two, to discuss expanded approaches using the lateral minimally invasive techniques. Again, thank you.

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