The 1st SOLAS Japan meeting - lateralaccess.org Ryu SOLAS Japan Board members 13:45－14:00 SOLAS...

The 1st SOLAS Japan meeting

Welcome Message

Hiroshi Taneichi, MD, Ph.DSOLAS Japan Regional DirectorProfessor and ChairmanDepartment of Orthopaedic SurgeryDokkyo Medical University School of Medicine

I am greatly honored to cordially invite you to the 1st SOLAS Japan Regional Meeting in Tokyo.

On behalf of the Japan regional committee, I would like to express our sincere gratitude to you

for giving us an opportunity to have this wonderful scientific meeting in Japan.

Since lateral interbody fusion (LIF) was introduced to Japan in 2013, a great paradigm shift

occurred in the area of spinal reconstructive surgery. The numbers of anterior lumbar surgery

have increased two orders of magnitude in the recent 4 years. LIF has brought about significant

improvement of surgical outcomes especially in adult spinal deformity. However, we encountered

mortal complications such as bowel and great vessel injuries. Fine educational programs are

indispensable to share useful knowledge of LIF as a double-edged sword. We planned 1 keynote

lecture, 2 educational lectures, 2 symposia, 1 global forum, 1 case discussion, and 6 scientific

sessions. We invited 2 distinguished international guest speakers from SOLAS. After scientific

programs, we will serve a wonderful reception at nearby restaurant and hope you enjoying the

beautiful capital’s night in Christmas season.

We look forward to meeting you at the 1st SOLAS Japan Regional Meeting in Tokyo.

Finally, I deeply appreciate the support of all the board members of SOLAS and SOLAS Japan,

especially education chair Dr.Kanemura.

Hiroshi Taneichi, MD, Ph.D SOLAS Japan Regional Director

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“Welcome” from the SOLAS BOD

Jim Youssef, MDSOLAS President

Dear Attendees of the 2017 Japan Regional SOLAS meeting-

I would like to thank you for your contribution to this academic program. Clearly, lateral access

surgery is an exciting and evolving field in spine surgery. I am pleased to see such collaboration

and commitment to research and education under the direction of the Japanese SOLAS members.

We hope you will find this program informative and stimulating.

On behalf of the entire Board of Directors of SOLAS, I wish you the best of luck in achieving a

successful Japan Regional SOLAS meeting.

Jim Youssef, MDSOLAS President

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Committee Members

SOLAS Japan Regional Members

Hiroshi Taneichi, MDDirector

Tokumi Kanemura, MDEducation Chair

Jun Mizutani, MDMember Services Chair

Ken Ishii, MDResearch Chair

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Program at a Glance

8:45 － 9:00 Opening Remarks & SOLAS Instruction Hiroshi Taneichi (SOLAS Japan Regional Director)

9:00 － 9:50 Symposium 1Anatomical Consideration for Safe Lateral Access Surgery

Moderator: Tokumi Kanemura

9:50 － 10:20 General Session 1Indirect Decompression: Possible or Impossible?

Moderator: Hogaku Gen

10:30 － 11:30 Educational Lectures 1 *1

・ The Evolution of LIF and the Use of Instrumentation for the Treatment of Spinal Disorders

・ Understanding Retroperitoneal Anatomy for Lateral Approach Spine Surgery

Moderator: Hirotaka HaroStephen Ryu

Tokumi Kanemura

11:30 － 12:00 General Session 2LIF vs. PLIF/TLIF

Moderator: Koji Sato

12:10 － 13:10 Educational Lectures 2 (Luncheon Seminar) *2

・ MIS lateral surgery: Risk Management and complication avoidance

・ How to prevent complications in LIF surgery?

Moderator: Hiroshi TaneichiJuan Uribe

Ken Ishii

13:10 － 13:45 SOLAS Membership & Research in Japan

・The Global Forum for Lateral Surgeons・Membership, Research and ACR registry

Moderators: Jun Mizutani 　　　　　Ken IshiiStephen RyuSOLAS Japan Board members

13:45 － 14:00 SOLAS Japan member group photo14:00 － 14:25 General Session 3

Expand IndicationModerator: Keisuke Nakano

14:25 － 14:50 Keynote LectureThe MIS Anterior Column Release Procedure

Moderator: Yukihiro MatsuyamaJuan Uribe

14:50 － 15:40 Symposium 2 Adult Spinal Deformity

Moderators: Masato Tanaka 　　　　　Kota Watanabe

15:40 － 15:50 Break15:50 － 16:30 General Session 4

ComplicationsModerator: Motoki Iwasaki

16:30 － 17:00 Educational Case Discussion Moderators: Jun Mizutani 　　　　　Mitsuhiro Kamiya

17:10 － 17:40 General Session 5Lateral Access Corpectomy & Reconstruction

Moderator: Akira Matsumura

17:40 － 18:15 General Session 6Innovation Techniques

Moderator: Takashi Tomita

18:15 － 18:20 Closing Remarks Tokumi Kanemura (SOLAS Japan Educational Chair)

18:30 － 20:30 Reception Party for SOLAS members Foyer 3F *1, 2: JOA Educational Credit

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Scientific Program8:45 － 9:00

Opening Remarks & SOLAS Instruction

9:00 － 9:50

Symposium 1：Anatomical Consideration for Safe Lateral Access Surgery

Moderator: Tokumi Kanemura Spine Center, Konan Kosei Hospital

S1-1Integrated anatomy of the neuromuscular, visceral, vascular, and uterine tissues with MRI and CT for a surgical approach to extreme lateral interbody fusion in the presence or absence of spinal deformity○ Shigeto Ebata, Tetsuro Ooba, Hirotaka HaroYamanashi University

S1-2Anatomical consideration in the lateral decubitus position for lateral interbody fusion○ Jun Ouchida, Tokumi Kanemura, Kotaro Satake,

Hiroaki Nakashima, Naoki SegiKonan Kosei Hospital Spine Center

S1-3Risk management for avoidance of major vascular/lumbar segmental artery injury during lateral transpsoas approach○ Toshinori Sakai, Yoichiro Takata,

Fumitake Tezuka, Takashi Chikawa, Koichi Sairyo Tokushima University

S1-4Anatomical study of the lumbar segmental artery and vein to prevent vascular complications during lateral lumbar interbody fusion○ Nobuyuki Suzuki, Muneyoshi Fukuoka,

Jun Mizutani, Seiji Otsuka, Akira KondoDepartment of Orthopaedic Surgery, Graduate School of Medical Sciences, Nagoya City University

S1-5Sonographic observation of the paravertebral anatomy in lateral lumbar spine surgery using transvaginal ultrasound probe in the retroperitoneal space○ Hidetoshi NojiriDepartment of Orthopaedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center

9:50 － 10:20

General session 1：Indirect Decompression: Possible or Impossibe?

Moderator: Hogaku Gen Spine Center, Chiba Central Medical Center

G1-1The effect of indirect decompression in lumbar spinal canal through MIS lateral access surgery○ Seiji Otsuka1）, Muneyoshi Fukuoka1）,

Jun Mizutani2）, Nobuyuki Suzuki1）, Akira Kondo1）, Takanobu Otsuka1）

1) Dept. of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences

2) Dept. of Rehabilitation medicine, Nagoya City University Graduate School of Medical Sciences

G1-2Effect of indirect neural decompression through lateral interbody fusion for severe spinal stenosis○ Shunsuke Fujibayashi, Bungo Otsuki,

Shimei Tanida, Shuichi MatsudaDepartment of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University

G1-3Indirect decompression regarding with the location of cage using XLIF and PPS fixation○ Taku Ogura1）, Taturou Hayashida1）,

Wataru Narita2）, Ryota Takatori3）

1) Spine Surgery and Related Research Center, Kyoto Chubu Medical Center

2) Dept. of Orthop. Surg., Midorigaoka Hospital3) Dept. of Orthop. Graduate School of Medical Science, Kyoto

Prefectual Univ. of Medicine

10:30 － 11:30

Educational Lectures 1

Moderator: Hirotaka Haro Department of Orthopaedic Surgery, University of Yamanashi School of Medicine

The Evolution of LIF and the Use of Instrumentation for the Treatment of Spinal Disorders○ Stephen RyuStanford University Medical Center

Understanding Retroperitoneal Anatomy for Lateral Approach Spine Surgery○ Tokumi KanemuraSOLAS Japan Education Chair

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11:30 － 12:00

General session 2：LIF vs. PLIF/TLIF

Moderator: Koji Sato Department of Orthopedic Surgery, Nagoya Daini Red Cross Hospital

G2-1Outcomes of XLIF vs MIS-TLIF on patients with degenerative lumbar spondylolisthesis ―Minimum 2 years follow up―○ Kazuo Ohmori, Koichiro Ono, Takeshi HoriCenter for Spinal Surgery, Nippon Koukan Hospital

G2-2Radiological comparison of fused segments between XLIF and PLIF○ Yuji Matsubara, Akio Muramoto,

Yoshinori MoritaKariya TOYOTA General Hospital

G2-3The Effects of Sagittal Alignment Correction Using LIF Procedure in Lumbar Degenerative Spondylolisthesis ―A Comparison with TLIF○ Takao NakajimaDept. of Orthop. Surg., Nippon Medical School, Chiba Hokusoh Hospital

12:10 － 13:10

Educational Lectures 2 (Luncheon Seminar)

Moderator: Hiroshi Taneichi Department of Orthopaedic Surgery, Dokkyo Medical University School of Medicine

MIS lateral surgery: Risk Management and complication avoidance○ Juan UribeBarrow Neurological Institute

How to prevent complications in LIF surgery?○ Ken IshiiSOLAS Japan Research Chair

13:10 － 13:45

SOLAS Membership & Research in Japan

Moderators: Jun Mizutani SOLAS Japan Regional Member Services Chair

Ken Ishii SOLAS Japan Regional Research Chair

The Global Forum for Lateral SurgeonsStephen RyuSOLAS Global Membership Director

Membership, Research and ACR registryJun MizutaniSOLAS Japan Regional Member Services ChairKen IshiiSOLAS Japan Regional Research ChairHiroshi TaneichiSOLAS Japan Regional Director

14:00 － 14:25

General session 3：Expand Indication

Moderator: Keisuke Nakano Department of Orthopaedic Surgery, Takaoka Seishikai Hospital

G3-1LLIF for revision spine surgery after decompression surgery○ Yukihiro Nakagawa, Hiroshi Yamada,

Hiroshi Hashizume, Yasutsugu Yukawa, Akihito Minamide, Hiroshi Iwasaki, Shunji Tsutsui, Masanari Takami

Department of Orthopaedic Surgery, Wakayama Medical University

G3-2Lateral Interbody Fusion Surgery for Thoracolumbar Junction○ Hiroaki Nakashima1）, Tokumi Kanemura1）,

Kotaro Satake1）, Yoshimoto Ishikawa1）, Naoki Segi1）, Jun Ouchida1）, Shiro Imagama2）

1) Department of Orthopedic Surgery and Spine Center, Konan Kosei Hospital

2) Orthopedic Surgery, Nagoya University Graduate School of Medicine

G3-3Salvage operation of adjacent segment disorders after lumbarfusion by Lateral lumbar interbody fusion○ Masahiro YoshidaDept. of Orthopaedic Surgery, Seirei Mikatahara General Hospital

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14:25 － 14:50

Keynote Lecture

Moderator: Yukihiro Matsuyama Department of Orthopedic Surgery, Hamamatsu University School of Medicine

The MIS Anterior Column Release Procedure○ Juan UribeBarrow Neurological Institute

14:50 － 15:40

Symposium 2：Adult Spinal Deformity

Moderators: Masato Tanaka Department of Orthopaedic Surgery, Okayama University Medical School

Kota Watanabe Department of Orthopaedic Surgery, Keio University

S2-1Minimally invasive approach to adult spine deformity using XLIF and PPS technique○ Takanori Saito1,2）, Shinitirou Taniguchi1）,

Taketoshi Kusida1）, Takashi Adachi1）, Masayuki Ishihara2）, Youichi Tani2）, Jonun Paku1）

1) Dept. of Orthopedic Surgery, Kansai Medical University2) Kansai Medical University Medical Center

S2-2Advantages and limitations of extreme lateral interbody fusion in adult spinal deformity surgery○ Hiroshi Moridaira, Satoshi Inami,

Daisaku Takeuchi, Haruki Ueda, You Shiba, Futoshi Asano, Hiroshi Taneichi

Dept. of Orthop. Surg., Dokkyo Medical Univ. Sch. of Med.

S2-3Radiographic and clinical evaluation of anterior-posterior spinal fusion with LLIF for adult spinal deformity, minimum 2-year follow up○ Tsuyoshi Sakuma1）, Toshiaki Kotani1）,

Tsutomu Akazawa2）, Keita Nakayama1）, Shohei Minami1）

1) Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital

2) Department of Orthopaedic Surgery, St. Marianna University School of Medicine

S2-4Efficacy of lateral interbody fusion in adult spinal deformity surgery: Comparison with posterior-only surgery○ Shunji Tsutsui, Hiroshi Yamada,

Hiroshi Hashizume, Yasutsugu Yukawa, Akihito Minamide, Yukihiro Nakagawa, Hiroshi Iwasaki, Masanari Takami

Department of Orthopedic Surgery, Wakayama Medical University

S2-5A Hybrid Method of Lateral Lumbar Interbody Fusion and Open Posterior Corrective Fusion for Adult Spinal Deformity ―Less Invasive in Blood Loss and Complications―○ Yu Yamato, Tomohiko Hasegawa,

Daisuke Togawa, Go Yoshida, Tomohiro Banno, Hideyuki Arima, Shin Oe, Yukihiro Matsuyama

Department of Orthopedic Surgery, Hamamatsu University School of Medicine

15:50 － 16:30

General session 4：Complications

Moderator: Motoki Iwasaki Department of Orthopedic Surgery, Osaka Rosai Hospital

G4-1Complications Associated with Lateral Interbody Fusion: Nationwide Survey of 2998 Cases During the First Two Years of Its Use in Japan○ Shunsuke Fujibayashi1）, Noriaki Kawakami2）,

Takashi Asazuma3）, Manabu Ito4）, Jun Mizutani5）, Hideki Nagashima6）, Masaya Nakamura7）, Koichi Sairyo8）, Ryuichi Takemasa9）, Motoki Iwasaki10）

1) Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University

2) Department of Orthopedics and Spine Surgery, Meijo Hospital

3) Department of Orthopedics, Murayama Medical Center4) Department of Orthopedic Surgery, National Hospital

Organization Hokkaido Medical Center5) Department of Orhopaedic Surgery, Nagoya City University

Medical School6) Department of Orthopedic Surgery, Faculty of Medicine,

Tottori University7) Department of Orthopaedic Surgery, Keio University School

of Medicine8) Department of Orthopedics, Institute of Biomedical Sciences,

Tokushima University Graduate School9) Department of Orthopaedic Surgery / Spine Center, Kochi

Medical School10) Department of Orthopaedic Surgery, Osaka Rosai Hospital

G4-2A case report of bowel injury in extreme lateral interbody fusion (XLIF)○ Yohei Yuzawa1）, Yuichi Takano2）,

Hirohiko Inanami1）

1) Inanami Spine and Joint Hospital2) Iwai Orthopaedic Medical Hospital

G4-3Lymphoduct injury during LIF : Case report○ Hisatake YoshiharaDepartment of Spine Surgery , Toyohashi Municipal Hospital

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G4-4A Case of DSSI after XLIF: One Stage Cure with Cage in situ○ Nakayuki Kato1）, Hiroshi Taneichi2）

1) Zama General Hospital2) Dokkyo Medical University

16:30 － 17:00

Educational Case Discussion

Moderators: Jun Mizutani Department of Rehabilitation Medicine, Nagoya

City University Graduate School of Medical Sciences

Mitsuhiro Kamiya Department of Orthopaedic Surgery, Spine

Center, Aichi Medical University

Debators:　　Masatsune Yamagata　　 Orthopaedic Surgery, Spine and Low Back Pain Center,

Chiba Rosai Hospital　　Ken Ishii　　 Department of Orthopaedic Surgery, School of Medicine,

International University of Health and Welfare (IUHW)　　Tomoaki Toyone　　Department of Orthopaedic Surgery, Showa University　　Masahiro Hoshino　　Sonoda Medical Institute Tokyo Spine Center　　Shigeo Ueda　　Shin-aikai Spine Center, Katano Hospital

17:10 － 17:40

General session 5：Lateral Access Corpectomy & Reconstruction

Moderator: Akira Matsumura Department of Orthopaedic Surgery, Osaka City General Hospital

G5-1Lateral access corpectomy combined with short-segment posterior fixation for osteoporotic vertebral collapse in the elderly○ Masatoshi Hoshino, Hidetomi Terai,

Akinobu Suzuki, Hiromitsu Toyoda, Kentaro Yamada, Shinji Takahashi, Hiroaki Nakamura

Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine

G5-2lateral access corpectomy for patients with kyphotic deformity following osteoporotic vertebral collapse○ Masayuki Ishihara1）, Takanori Saito2）,

Shinichiro Taniguchi2）, Yoichi Tani2）, Masaaki Paku2）

1) Kansai Medical University Medcal Center2) Kansai Medical University Hospital

G5-3Treatment of kyphotic deformity due to osteoporotic vertebral fracture through posterior spinal fusion combined with anterior vertebral body replacement○ Keita Omori, Masahiro Hoshino,

Hiromi Matsuzaki, Hidetoshi Igarashi, Koji Yamasaki

Sonoda Medical Institute Tokyo Spine Center

17:40 － 18:15

General session 6：Innovation Techniques

Moderator: Takashi Tomita Department of Orthopaedic Surgery, Aomori Prefectural Central Hospital

G6-1Anterior Column Realignment (ACR) Using a Lateral Transpsoas Approach○ Satoshi Inami, Hiroshi Moridaira,

Daisaku Takeuchi, Haruki Ueda, Yo Shiba, Futoshi Asano, Hiromichi Aoki, Hiroshi Taneichi

Dokkyo Medical University

G6-2Virtual reality simulator for pedicle screw insertion in the lateral position○ Wataru Narita Midorigaoka Hospital

G6-3Assessment of cage subsidence at 1-year follow-up after stand-alone XLIF○ Toshinori Sakai, Yoichiro Takata,

Fumitake Tezuka, Takashi Chikawa, Koichi Sairyo

Department of Orthopaedic Surgery, Tokushima University

G6-4Single-approach LLIF with lateral vertebral plate system for degenerative lumbar spinal disorders○ Mitsuru Yagi1）, Yuichiro Mima1）,

Nobuyuki Fujita1）, Eijiro Okada1）, Osahiko Tsuji1）, Narihito Nagoshi1）, Ken Ishii2）, Masaya Nakamura1）, Morio Matsumoto1）, Kota Watanabe1）

1) Department of Orthopedic Surgery, Keio University School of Medicine

2) Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare

18:15 － 18:20

Closing Remarks

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Symposium 1 9:00-9:50

Anatomical Consideration for Safe Lateral Access Surgery

S1-1

Integrated anatomy of the neuromuscular, visceral, vascular, and uterine tissues with MRI and CT for a surgical approach to extreme lateral interbody fusion in the presence or absence of spinal deformity○ Shigeto Ebata, Tetsuro Ooba, Hirotaka Haro

Yamanashi University

Extreme Lateral Interbody Fusion (XLIF) is an increasingly popular interbody fusion technique. These techniques utilizes a fast and minimally i n v a s i v e a p p r o a c h , a l l o w i n g s u f f i c i e n t visualization of the intervertebral discs and bodies to radical ly debride the vertebral body and intervertebral disc , and place a large cage. However, potential complications due to the specificity of the technique might arise. They include neural, vascular, lymph vessel and visceral injuries and approach-related psoas muscle damage. The purpose of the current study is to investigate anatomical characters of lumbar spinal stenosis (LSS) or adult spinal deformity (ASD) patients with respect to XLIF approach. This study showed 1) the ASD group was at the position that was nearer to the nerve plexus from the disc than the LSS group 2) the ASD group had a run position of the inferior vena cava that was nearer than the LSS group from the center of the disc 3) the ASD group had a run position of the inferior vena cava that was nearer than the LSS group from the center of the disc. It is important for surgeons to pay attention to anatomies of the psoas major, the bifurcation, the inferior vena cava, and kidneys using the diagnostic imaging system to avoid intraoperative complications.

S1-2

Anatomical consideration in the lateral decubitus position for lateral interbody fusion○ Jun Ouchida, Tokumi Kanemura, Kotaro Satake,

Hiroaki Nakashima, Naoki Segi

Konan Kosei Hospital Spine Center

Purpose：Though many reported that retroperitoneal organs show considerable anatomical variation, little mention has been made of these variations in the lateral decubitus position. The purpose of this study is to investigate the distribution of retroperitoneal organs with the retroperitoneal approach in this position.Material and Methods：A total of 100 consecutive patients scheduled to undergo lateral approach surgery were enrolled. We performed computed tomography with supine (S-CT) and lateral decubitus positioning (L-CT). The anteroposterior position of the organs were divided into four zones (zone A: anterior to the anterior border of the vertebral body, AL: from the anterior edge to the middle line of the vertebral body, PL: from the middle line to the posterior edge of the vertebral body, P: posterior to the posterior edge of the vertebral body).Results：The deviation in S-CT and L-CT (A: AL: PL: L, %) was 0: 1: 5: 94 and 1: 17: 38: 44 for the kidney, 18 : 27 : 32 : 23 and 64 : 20 : 12 : 3 fo r the descending colon, 35: 57: 8: 1 and 86: 14: 0: 0 for the ureter, and 66: 31: 2: 1 and 96: 4: 0: 0 for the gonadal artery. In multivariate analysis, cases with the descending colon in zone P under S-CT tend to remain in the approach zone even under L-CT. (odds ratio, 4.21; 95% confidence interval [CI], 1.36 to 13.0; P=0.01)Conclusion：W h i l e a n t e r i o r m i g r a t i o n i n L - C T i n a l l retroperitoneal organs was found, a certain percentage of the descending colon still remain in the way while performing LIF. We emphasize the importance of preoperative imaging evaluation and meticulous attention during surgery in cases where the descending colon extends outside zone P in S-CT.

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S1-3

Risk management for avoidance of major vascular/lumbar segmental artery injury during lateral transpsoas approach○ Toshinori Sakai, Yoichiro Takata,


Tokushima University

Purpose of this study：The purpose of this study was (1) to identify risk factors for injury to the major vessels in the lateral transpsoas approach, and (2) lumbar segmental arter ies in pat ients with lumbar scoliosis.Materials and Methods：(1) The abdominal contrast-enhanced mult i-p lanner 3D-CT scans of 323 subjects were retrospectively reviewed. According to the Moro system, the true axial view was divided into 6 zones from the front side (A, I II, III, IV, P) and the locations of the dorsal tangential line of the major vessels at L3–4 and L4–5 were evaluated. (2) Among them, 27 subjects with lumbar scoliosis with over 15° of Cobb angle were retrospectively reviewed. The cranio-caudal intervals of the adjacent segmental arteries were measured. The cutoff value for an intersegmental Cobb angle that would estimate a cranio-caudal interval of less than 24mm was determined.Results：(1) At the L3–4 level, the dorsal tangential line of the major vein located in zone I in 74%, and in zone II in 8%. The line of the major artery was located in zone I in 7.1%. At the L4–5 level, the line of the major vein was located in zone I in 75%, in zone II in 20%. The line of the major artery was identified in zone I in 12%, and in zone II in 1%. (2) The cutoff value for the best prediction of an interval less than 24mm was 14.5° of Cobb angle.

S1-4

Anatomical study of the lumbar segmental artery and vein to prevent vascular complications during lateral lumbar interbody fusion○ Nobuyuki Suzuki, Muneyoshi Fukuoka,

Jun Mizutani, Seiji Otsuka, Akira Kondo

Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Nagoya City University

In recent years , Latera l Lumbar Interbody Fusion(LLIF) is getting popular to acquire strong correction power and reduce operation time and bleeding. However, potential complications due to the specificity of this technique have been arising. One of the common complication of this technique is the segmental artery or vein injury. In Japan, the segmental artery injury has been reported in 2.4% of 155 LLIF cases. Once the segmental artery or vein is damaged, it is difficult to stop bleeding in a small field of view, so it is important to unders tand i t s runn ing and anatomica l charac te r i s t i c s be fore surgery to preven t complication. The purpose of this study is to inves t iga te anatomica l fea tures o f lumbar segmental artery and vein by using cadaver and CT angiography to prevent segmental artery or vein injury.Segmental artery and vein was running highly variable with individual . When divided into several running patterns, the parallel type was common in L2,L5, the descending type was common in L3,L4.5, but the running pattern was not determined at the vertebral level or left side and right side. The closest segmental artery to the intervertebral disc in the anterior site of the vertebral body was 2 mm, the closest one to the intervertebral disc in the center of the vertebral body was 4 mm.So, it is important to evaluate the running of the s e g m e n t a l a r t e r y a n d v e i n b y u s i n g C T angiography before the operation to perform LLIF safely.

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S1-5

Sonographic observation of the paravertebral anatomy in lateral lumbar spine surgery using transvaginal ultrasound probe in the retroperitoneal space○ Hidetoshi Nojiri

Department of Orthopaedic Surgery, Juntendo Tokyo Koto Geriatric Medical Center

The lateral lumbar spine surgery has been s p r e a d i n g w o r l d w i d e b e c a u s e o f i t s l e s s invasiveness and better effectiveness compared to the conventional methods, however, the incidence of serious complications including vascular injury and bowel injury has sometimes been reported. Furthermore, this surgery has unsolved problem about much radiation exposure to surgeons due to frequent use of fluoroscopes. Therefore, it must have innovative developments of machines and techniques to reduce the complication rate and surgeon’s radiation exposure.We thought that sonographic observation using transvaginal ultrasound probe in the retroperitoneal space in the process of the lateral approach might help surgeons to understand the paravertebral anatomy and make lateral surgery safer. Surgical site sonography could non-invasively show the real-time position of organs around the vertebral body, such as psoas muscle, major vessels, lumbar arteries, colons, and kidneys even in cases with severe spinal deformity or anatomical anomaly. It could also describe bony surfaces of the vertebral body detecting the intervertebral space, meaning a possibility that we reach to the intervertebral discs from lateral side without fluoroscopes. We have already used sonography in over 70 cases with degenerative lumbar diseases without any specific perioperative complications and had a better understanding of the anatomy around the lumbar spine. In this presentation, I’d like to show some movies showing how to use the machines, how the sonography displays organs, and how much advantage reg ard ing sa fe ty and rad ia t ion exposure it will have. We also discuss some problems and limitations of this method.

General session 1 9:50-10:20

Indirect Decompression: Possible or Impossibe?

G1-1

The effect of indirect decompression in lumbar spinal canal through MIS lateral access surgery○ Seiji Otsuka1）, Muneyoshi Fukuoka1）,

Jun Mizutani2）, Nobuyuki Suzuki1）, Akira Kondo1）, Takanobu Otsuka1）

1） Dept. of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences

2） Dept. of Rehabilitation Medicine, Nagoya City University Graduate School of Medical Sciences

Minimally invasive lateral transpsoas interbody fusion including extreme lateral interbody fusion (XLIF) procedure is changing the generally ‐a c c e p t e d i d e a t h a t t h e d i r e c t p o s t e r i o r decompression (removal of ligamentum flavum, laminectomy, facetectomy) and/or fusion which is used for the treatment of spondylolisthesis and lumbar spinal canal stenosis as a traditional method. The purpose of this study is to examine the indirect spinal canal decompression with XLIF and to demonstrate if those effects gradually change with time after surgery. A retrospective review of 20 consecutive patient’s pre ‐ operative and 1 ‐ week, 1, 3, 6 and 12 ‐ month follow ‐ up radiographic measurement were checked from plain sagittal CT image and sagittal, axial magnetic resonance imag ing (MRI ) v iews . XLIF procedure was performed in all patients for 8 spondylolisthesis, 12 spinal canal stenosis with low back pain without any decompression procedure. The measurements were done by an independent spine surgeon using medical imaging software and those are included disc height , foraminal hight , degree of disc protrusion, flavum thickness and dural sac area. The clinical symptom was improved in all patients. Substantial dimensional improvement was revealed in radiographic parameters. These changes have a tendency to stay constant after 12 months passed. By limiting the discussion to the spondylolisthesis and spinal canal stenosis, the effect of indirect decompression for not only central canal but also foramen was gradually increased with time at least for twelve months after surgery with improvement of clinical symptoms. And thickness reduction of l igamentum f lavum and decreas ing of d isk protrusion contributed to the effect of indirect neural decompression.

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G1-2

Effect of indirect neural decompression through lateral interbody fusion for severe spinal stenosis○ Shunsuke Fujibayashi, Bungo Otsuki,

Shimei Tanida, Shuichi Matsuda

Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University

Introduction：We reported the effect of indirect neural decompression through LIF and inverse correlat ion between extension rate of cross sect iona l area (CSA) of the theca l sac and preoperative CSA (Fujibayashi S. Spine 2015). However, the operative indication for severe spinal stenosis is still controversial. In the current study, both clinical and radiological results of indirect neural decompression for severe spinal stenosis were evaluated. Materials and Methods：71 levels in 46 cases were enrolled in this study. Schizas classification was used for the assessment of stenosis severity on preoperative and 2 weeks postoperative MRI. B o t h g r a d e C a n d D w e r e c o n s i d e r e d t o myelographic bloc. The correlat ion between preoperative CSA and extension rate of CSA, change of disc height (dDH), change of fused segment disc angle (dSDA), and clinical results (JOA score) were analyzed statistically.Results：The average improvement of Schizas grading was 1.32. The average extension rate of CSA was 114% and recovery rate of JOA score was 74.5%. The correlation between preoperative CSA and extension rate of CSA, and preoperative CSA and dSDA were significant. The correlation b e t w e e n t h e e x t e n s i o n r a t e o f C S A o r postoperative CSA, and recovery rate of JOA score and dDH were not significant. Although 6 levels (17.6%) were still remained in grade C and D after LIF, the clinical results were favorable.Discussion and Conclusion：In all cases of severe spinal stenosis, clinical results were improved and no additional direct decompression was required. Those results indicated the severe spinal stenosis might be an operative indication of indirect decompression.

G1-3

Indirect decompression regarding with the location of cage using XLIF and PPS fixation○ Taku Ogura1）, Taturou Hayashida1）,

Wataru Narita2）, Ryota Takatori3）

1） Spine Surgery and Related Research Center, Kyoto Chubu Medical Center

2） Dept. of Orthop. Surg., Midorigaoka Hospital3） Dept. of Orthop. Graduate School of Medical

Science, Kyoto Prefectual Univ. of Medicine

Objective：The purpose of this study was to investigate indirect decompression regarding with the location of cage for lumbar degenerative kyphoscoliosis by XLIF and PPS fixation using th ree d imens iona l images dur ing surgery quantitatively. Subjects ＆ Methods：Subjects were 17 kyphoscoliosis patients (2 males and 15 females, a mean age 72.1 years). The affected inter vertebral regions were 45 cases. Three dimensional images were taken three times during surgery (before surgery, after XLIF, after PPS fixation) using SIEMENS ARCADIS Orbic 3DR . Evaluation of the deformities are lateral bending, lordosis, axial rotation, disc height index, area of vertebral foramen and anterior area of cage using OsirixR. Rotation angle of upper vertebra of each fixed segment was measured. Statistical analysis was used Friedman test and probabilit ies of less than 0.05 were considered significant. Results：Lateral bending has improved at 3.0 degrees (after XLIF) and 2.4 degrees (after PPS) from 6.5 degrees (before surgery). Lordosis has improved at 10.7 degrees (after XLIF) and 12.2 degrees (after PPS) from 6.3 degrees (before surgery). Axial rotation has improved at 2.2 degrees (after XLIF) and 1.4 degrees (after PPS) from 5.5 degrees (before surgery). Although the disc height index increased from 0.38 (before surgery) to 0.62 (after XLIF), it decreased at 0.55 (after PPS). Area of vertebral foramen increased from 1.38 (before surgery) to 1.72 (after XLIF), it decreased at 1.54 (after PPS). The disc height index and anterior area of cage showed the negative correlation (R=-0.5, P=0.009). Conclusions：Lateral bending, lordosis and axial rotational deformity were mainly corrected by XLIF. The degree of the indirect decompression is influenced by the location of cage in sagittal plane.

12



LIF vs. PLIF/TLIF

G2-1

Outcomes of XLIF vs MIS-TLIF on patients with degenerative lumbar spondylolisthesis ―Minimum 2 years follow up―○ Kazuo Ohmori, Koichiro Ono, Takeshi Hori

Center for Spinal Surgery, Nippon Koukan Hospital

Aim：The purpose of this study was to compare the surgical outcomes of XLIF vs MIS-TLIF on p a t i e n t s w i t h d e g e n e r a t i v e l u m b a r spondylolisthesis (DS). Methods：We retrospect ive ly assessed 43 consecutive patients with a mean age of 68 year who had undergone XLIF or MIS-TLIF. Of the 43 patients, 22 had undergone XLIF (X group), and 21 done MIS-TLIF (M group). The mean follows up period was 979 days, which of each case was more than 2 years after surgery. The variables assessed and compared between the X and M groups included operat ive t ime, amount of bleeding, complications, radiographic parameters, union rate of the grafted bone, recovery rate of JOA score and VAS of post-operative low back pain and leg pain. Results：The operative time in the X group (141 min) was significantly shorter than that of the M group (167 min). The amount of bleeding in the X group (41 ml) was also significantly less than that of M group (119 ml). Post-operative thigh pain was observed in 5 cases of the X group. Bone fusion rate at the 1 year after surgery and the final follow up in the X group were 59/73%, and that of M group were 76/91%. There were no significant differences of the clinical parameters between both groups at the final follow up.Discussion：In this study, the bone fusion rate in the X group was found to be significantly lower than that in the M group, however it was not related to clinical outcomes. Therefore, XLIF becomes a good option for surgical treatment in patients with DS.

G2-2

Radiological comparison of fused segments between XLIF and PLIF○ Yuji Matsubara, Akio Muramoto,

Yoshinori Morita

Kariya TOYOTA General Hospital

Objective：This study compares the radiological features of the fixed segment of lumber interbody fusion using XLIF plus pedicle screw fixation and PLIF.Methods：Patients who received one or two level of lumber interbody fusion for spondylolisthesis in September 2012 or later were included in the study. Patients who received XLIF were grouped as group X. Those who received open PLIF were grouped as group P. Group X consists of 47 segments in 29 pat ients (11 males and 18 females). Average age was 69.5 y.o. and mean follow up period was 18.3 months. Group P consists of 51 segments in 48 patients (16 males and 32 females). Average age was 67.7 y.o. and mean follow up period was 26.8 months. Coronal segmenta l ang le , l a te ra l segmenta l ang le , subsidence rate (1.5 mm or more), fusion rate were compered between the groups.Results：Correction rate of coronal segmental angle were significantly larger (p <0.001) in group X (72%) compared to group P (44%). Lateral segmental was significantly larger in group X compared to group P (p <0.001) . Incidence of cage subsidence of 1.5 mm or more were significantly higher (p <0.01) in group P (22%) compared to group X (4%). Fusion rate was 93% in group X and 86% in group P with no significant differences.Conclusions：In group X, correction of coronal segmental angle was better, gain of the lateral segmental angle was larger, incidence of cage subsidence were lower compared to Group P. There were no significant differences in fusion rate between two groups.

13


G2-3

The Effects of Sagittal Alignment Correction Using LIF Procedure in Lumbar Degenerative Spondylolisthesis― A Comparison with TLIF○ Takao Nakajima

Dept. of Orthop. Surg., Nippon Medical School, Chiba Hokusoh Hospital

Purpose：To compare a combined posterior and anterior fusion approach using the LIF and p e r c u t a n e o u s p e d i c l e s c r e w s ( P P S ) w i t h conventional approaches (TLIF/PLIF) with respect to sagittal alignment correction in patients with lumbar degenerative spondylolisthesis. Methods：26 patients underwent LIF with PPS i n s t r u m e n t a t i o n f o r l u m b a r d e g e n e r a t i ve spondylolisthesis since (9males, 17females, mean age 67.7years) (hereafter, Xgroup). Disc height (mm), slip (mm), and disc angle (°) were measured for these patients on pre- and postoperative lateral plain radiographs and compared with 26 patients who recently underwent TLIF/PLIF (14males, 12females, mean age 63.7years) (hereafter, Tgroup). Both in the X and Tgroups, patients consecutively underwent surgery performed by a single surgeon. A 10°-lordotic cage was used for LIF.Results：The mean preoperative disc height, slip, and disc angle in the Xgroup were 6.98mm, 6.73mm, and 5.68°, respectively, while those in the T group were 7.48mm, 6.73mm, and 2.88 °. The mean postoperative disc height, slip, and disc angle in the Xgroup were 11.7mm, 2.47mm, and 10.8 °, respectively, while those in the Tgroup were 10.2mm, 4.33mm, and 5.85°. For the correction of sagittal alignment, the mean disc height, slip, and disc angle, were +4.74mm, -4.27mm, and +5.16 °, respectively, in the Xgroup compared to +2.69mm, -2.69mm, and +2.96° in the Tgroup, indicating that the correction effect was significantly greater in the Xgroup than the Tgroup.Discussion：This study suggested that LIF allows a wider range of patients to be a candidate for surgery including elderly patients and patients with more severe deformity, and that LIF is less invasive as compared to conventional procedures.


Expand Indication

G3-1

LLIF for revision spine surgery after decompression surgery○ Yukihiro Nakagawa, Hiroshi Yamada,

Hiroshi Hashizume, Yasutsugu Yukawa, Akihito Minamide, Hiroshi Iwasaki, Shunji Tsutsui, Masanari Takami

Department of Orthopaedic Surgery, Wakayama Medical University

Introduction：Lateral lumbar interbody fusion (LLIF) bring a new strategy for complex spine surgery. Use of LLIF and percutaneous pedicle screw (PPS) e n a b l e s t o a v o i d d i r e c t s p i n a l c a n a l decompression. Therefore, this technique is expec ted fo r rev i s ion sp ine surgery a f t e r decompression surgery.Objectives：To report the clinical results and utility of LLIF for revision spine surgery after decompression only surgery.Patients and Methods：From 2013, 28 patients (15 males, 13 females, m e a n a g e 7 1 . 2 y r s ) u n d e r w e n t L L I F w e r e candidate for this study. Minimum follow up was two years. Clinical status were evaluated by visual analogue scale (VAS) for low back pain, Oswestry disability index (ODI), Roland-Morris disability quest ionnaire(RDQ) , JOA score and pat ient satisfaction score. Prior surgery, duration from prior surgery, pathologies, blood loss, operative time, perioperative complications were evaluated.Results：Prior surgeries includes 13 tradit ional open surgeries, 12 microendoscopic and 3 both of them. Mean duration from prior surgery was 6.9 year. Mean blood loss was 81ml per level. Pre and postoperative clinical evaluations were as follows; ODI: 25.5 to 13.7, RDQ: 12.2 to 8.3, VAS for low back pain and leg pain: 60.1 to 28.7, 57.2 to 34.8, JOA score: 13 to 18.9. Patient satisfaction was 76.8%. One nonunion was recognized.Discussion and Conclusion：Revision surgery has a potential risk of a long operative time, blood loss and complications for direct decompression. LLIF and PPS enables to do minimally invasive interbody fusion and avoid direct decompression. This procedure is also expected for revision surgery in high risk patient and obese pa t i en t . Rev i s ion surgery a f te r decompression surgery is a good indication for XLIF and PPS.

14


G3-2

Lateral Interbody Fusion Surgery for Thoracolumbar Junction○ Hiroaki Nakashima1）, Tokumi Kanemura1）,

Kotaro Satake1）, Yoshimoto Ishikawa1）, Naoki Segi1）, Jun Ouchida1）, Shiro Imagama2）

1） Department of Orthopedic Surgery and Spine Center, Konan Kosei Hospital

2） Orthopedic Surgery, Nagoya University Graduate School of Medicine

Lateral interbody fusion (LIF) surgery has become popular technique for anterior fixation of the lumbar surgery. However, LIF for thoracolumbar junction is technically demanding: diaphragm and pleura complicate surgical exposure from a true lateral of an affected vertebra. Extrapleural and transdiaphragmatic approach have been used for thoracic and upper lumbar spine surgery using LIF respectively for thoracolumbar junction in our hospita l . The purpose of the current study was to invest igate anatomical characters of thoracolumbar junction and clarify the advantage of LIF technique compared with conventional anterior surgery in thoracolumbar junction (from T11 to L2). Consecutive 67 cases with conventional anterior surgery or LIF surgery in thoracolumbar junct ion were retrospect ively assessed. The patients were divided into 3 groups: extrapleural, transdiaphragmatic and diaphragm ring-shaped incision. Surgical time was 232.2 ± 41.9 min, 275.7 ± 82.0 min, 220.2 ± 44.4 min in extrapleural, d i a p h r a g m r i n g - s h a p e d i n c i s i o n , a n d transdiaphragmatic approach, respectively. Estimated blood loss was 521.9±635.0 ml, 806.3±797.3 ml, 275.5 ± 221.7 ml in extrapleural, diaphragm ring-shaped incision and transdiaphragmatic approach respectively, and the blood loss in transdiaphragmatic approach was significantly smaller compared with diaphragm ring-shaped incision. Perioperative respiratory compl icat ions were as fo l lows : hemothorax in ex t rap leura l ; a te lec tas i s in t ransd iaphragmat ic approach ; lung in jury, atelectasis and pleural effusion in diaphragm ring-shaped incision. In this presentation, I would show some movies showing how to perform extrapleural and transdiaphragmat ic approach in L IF in t h o r a c o l u m b a r j u n c t i o n a n d d i s c u s s t h e advantage , sa fe ty and l imi ta t ions in these approaches.

G3-3

Salvage operation of adjacent segment disorders after lumbarfusion by Lateral lumbar interbody fusion○ Masahiro Yoshida

Dept. of Orthopaedic Surgery, Seirei Mikatahara General Hospital

Introduction：In our hospital TLIF and pedicle screw fixaion was indicated for adjacent segment disorders after lumbarfusion befor 2013.After2014 we indicate Latral lumbar interbody fusion（LLIF）for ASD.Material and Method：We examined 28cases LLIF for the adjacent segment disorders after lumbarfusion.operation time,blood loss during operation,complication are checked retrospectively.Conclusion：extreme lateral intrebody fusion（XLIF）with lateral plate fixation was 5cases,mean operation t ime;154min, b lood loss ; 93g. LLIF and PS posteriorfusion was 4cases,ope time; 307min, blood loss; 285g. LLIF and extirpation of rod and extension of posterior fusion was 14cases, ope time; 342min, blood loss; 323g. LLIF and TLIF and extension of posterior fusion was 2cases, ope t ime ; 419min , b lood loss ; 700g . LL IF and p o s t e r i o r o s t e o t o m y a n d e x t e n t i o n o f posteriorfusion was 3cases, ope time; 723min, bloob loss ; 1953g. Complicat ion was 1case additional decompression and 1case delayed wund healing.Discussion：For 1 or 2level ASD above L2/3 we indicate XLIF and lateral plate fixation,ope time was 154min, blood loss was 93g, so this method was minimaly invas ive surgery w i thout poster ior musc le damage.We indicate LLIF and posterior fusion below L3/4 or over 3level ASD, ope time was 300min, blood loss was 300g, so this method was satisfactory low invasive surgery. For the cases include L5/S we add TLIF. Ope time was 419min and blood loss was 700g, this method was still high invasive surgery. For corrective cases we add, posterior osteotomy, and TLIF, ope time was 723min and blood loss was 1953g, this method was still, high invasive surgery.

15


Symposium 2 14:50-15:40

Adult Spinal Deformity

S2-1

Minimally invasive approach to adult spine deformity using XLIF and PPS technique○ Takanori Saito1,2）, Shinitirou Taniguchi1）,

Taketoshi Kusida1）, Takashi Adachi1）, Masayuki Ishihara2）, Youichi Tani2）, Jonun Paku1）

1） Dept. of Orthopedic Surgery, Kansai Medical University

2） Kansai Medical University Medical Center

Minimally invasive spine surgery (MIS) was not applicable to the adult pat ients with spinal deformity having a worsened global balance on the sagittal plane. Recently, XLIF has enabled a frontal approach to dissociate intervertebral disc and minimally invasive insertion of cage with a frontal angle of 10 degrees in all cases except for L5/S. In this study, we present our minimally invasive approaches for the treatment of spinal deformity in adult pat ients admitted to our hospital. Subjects and Methods：Fifty-eight patients (26 men and 32 women, average age 72.6 years) with spine deformity due to kyphosis or scoliosis who underwent MIS using XLIF were studied. Results：X-ray evaluations before and after operation revealed that 1) LL was improved from 12.5 ° to 43.8° in bilateral PPS group, from 12.8° to 49.7° in unilateral PPS group, and -9.2° to 58.5° in open group; 2) PT was improved from 39.7° to 24.5° in bilateral PPS group, from 32.1° to 20.4° in unilateral PPS group, and from 41.0° to 19.2° in open group;Discussion：Minimally invasive approach is very important in corrective spinal fusion surgery for the treatment of spine deformity because most patients are old. Clinical outcomes, however, are not satisfactory even though minimal invasiveness is achieved using PPS if adequate correct ion cannot be obtained. We divided the patients in 3 groups and applied PPS in different ways to achieve similar clinical outcomes to open surgery. We could attain satisfactory correction in every group.

S2-2

Advantages and limitations of extreme lateral interbody fusion in adult spinal deformity surgery○ Hiroshi Moridaira, Satoshi Inami,

Daisaku Takeuchi, Haruki Ueda, You Shiba, Futoshi Asano, Hiroshi Taneichi

Dept. of Orthop. Surg., Dokkyo Medical Univ. Sch. of Med.

ELIF is a powerful tool for adult spinal deformity surgery, has been gaining popularity in Japan. We have conducted hybr id procedures of ELIF combined with Ponte osteotomy and pedicle screw instrumentation in sagittal imbalance cases from 2013 to the present.In our propensity matched study between hybrid procedures (40 pts . ) and more aggress ive convent iona l procedures (40 pts . ) such as 3-column osteotomy, hybrid procedures reduced blood loss (1154 vs. 2051 ml, p < 0.001) and perioperative complications rate (17.5 vs. 27.5%) without affecting deformity collection.The length of construct can potentially influence perioperative risks in elderly patients. We have also conducted relatively short posterior fusion combined ELIF for de novo degenerative lumbar s c o l i o s i s w i t h o u t s e v e r e d e f o r m i t i e s i n thoracolumbar junction. In our 16 cases fused a mean of 3.5 levels, well-balanced cases (mean final SVA: 2.5cm) showed low PI (42 vs.57.4°, p < 0.05) when compared to imbalance cases (mean final SVA: 15cm). For the cases with high PI, the short posterior fusion combined ELIF may have still limitations.In addit ion, to perform ELIF in adult spinal d e f o r m i t y s u r g e r y , b o n e h a r v e s t e d f r o m autologous i l iac crest is not enough of the required amount. In Japan, substitutes such as hydroxyapatite or allografts were mixed with autologous bone and grafted. In our assessment of bone un ion o f EL IF cage us ing computed tomography at 1 year postoperatively, the rate of levels of complete fusion, whereby any slices in the cage region were fused with remodeling, was only 25%.

16


S2-3

Radiographic and clinical evaluation of anterior-posterior spinal fusion with LLIF for adult spinal deformity, minimum 2-year follow up○ Tsuyoshi Sakuma1）, Toshiaki Kotani1）,

Tsutomu Akazawa2）, Keita Nakayama1）, Shohei Minami1）

1） Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital

2） Department of Orthopaedic Surgery, St. Marianna University School of Medicine

The objective of this study was to evaluate the radiographic and surgical outcomes of patients with adult spinal deformity (ASD) undergoing anterior–posterior spinal fusion (APSF) using the lateral lumbar interbody fusion (LLIF). All cases were observed follow-up for at least 2 years. A total of 25 patients (mean age 69.9 years; 3 men and 22 women) with ASD and global sagittal malalignment who underwent APSF since 2012 was enrolled. Cobb angle, lumbar lordosis (LL), pelvic incidence minus LL (PI-LL), pelvic tilt (PT), sagittal vertical axis (SVA), interbody disc angle, interbody bone bridging, and HRQOL (SRS-22) were evaluated. Significant improvement was seen in all radiographic dates, and the correction observed at 2-year follow-up. At the t ime of 2-year follow-up, 80% of levels treated by LLIF had sol id consolidat ion. There was no level described as a pseudarthrosis. Function, pain, self-image, and total component scores at SRS-22 were significantly improved at 2 years. No rod breakage case was seen, but proximal junctional fai lure was reported 6 pat ients . Of those 6 patients, 3 had re-operation. Result of this study, APSF with LLIF was s ignif icant ly improved postoperative sagittal alignment 2 years after surgery. But cases of revision surgery because of proximal junctional failure were increased.

S2-4

Efficacy of lateral interbody fusion in adult spinal deformity surgery: Comparison with posterior-only surgery○ Shunji Tsutsui, Hiroshi Yamada,

Hiroshi Hashizume, Yasutsugu Yukawa, Akihito Minamide, Yukihiro Nakagawa, Hiroshi Iwasaki, Masanari Takami

Department of Orthopedic Surgery, Wakayama Medical University

Introduction：Adult spinal deformity (ASD) has been becoming one o f the most preva lent disorders in the super-aged society, which often needs surg ica l t reatment . Recent ly, la tera l interbody fusion (LIF) has been introduced and widespread in the field of deformity correction. The purpose of this study was to investigate the e f f i cacy o f L IF compared to conven t iona l posterior-only surgery.Methods：Fi f teen pat ients undergoing LIF followed by posterior instrumented fusion (L+P) and 12 pat ients having posterior-only (PO) instrumentation/fusion were retrospectively reviewed. All patients underwent spinal fusion from T9 or T10 to pelvis and were followed-up for more than two years post-operatively. Pelvic incidence (PI) - lumbar lordosis (LL) mismatch (PI-LL ) , and sag i t t a l ve r t i ca l ax i s ( SVA) were invest igated on radiographs before surgery, immediately after surgery and at 2-year post-operative visit. The operative time (OT), intra-operative estimated blood loss (EBL), and pre-operative and 2-year post-operative Oswestry Disability Index (ODI) were also assessed in the charts.Results：There was no statistical difference in PI-LL and SVA at any time of visits as well as in age, gender, OT and ODI between the groups. EBL in the PO group (2075 ± 686 ml) were statistically significantly greater than in the L+P group (1061± 706 ml, p=0.010).Conclusion：ASD has been treated traditionally via poster ior-only procedure including pedic le subtraction osteotomy and/ or vertebral column resection, which might cause significant morbidity a n d / o r m o r t a l i t y i n t h e e l d e r l y . E B L w a s demonstrated to be significantly reduced when using LIF in this study, suggesting that surgical indication for ASD can be widen with LIF.

17


S2-5

A Hybrid Method of Lateral Lumbar Interbody Fusion and Open Posterior Corrective Fusion for Adult Spinal Deformity ―Less Invasive in Blood Loss and Complications―○ Yu Yamato, Tomohiko Hasegawa,

Daisuke Togawa, Go Yoshida, Tomohiro Banno, Hideyuki Arima, Shin Oe, Yukihiro Matsuyama

Department of Orthopedic Surgery, Hamamatsu University School of Medicine

I n t r o d u c t i o n ：LL IF i s ava i l ab l e f o r adu l t degenerative disease as a minimally invasive alternative. We performed a two stage surgery (Hy br id g roup ) t o r e s to re s ag i t t a l g l o b a l alignment: first, LLIF to lumbar spine, and second, open PCF from thoracic spine to ilium.Methods：Eighteen patients (mean age, 69) with SRS-Schwab type L deformity and minimum one year follow up were included in this study (Hybrid group). We also investigated 21 patients (mean age, 70) with the same inclusion criteria who underwent posterior corrective fusion using mult i- level posterior column osteotomy as a comparison case series (PCO group). Radiological p a r a m e t e r s , s u r g i c a l i n v a s i o n i n c l u d i n g complications were analyzed in both groups.Results：Average operative time was total of 436 min (406 min in PCO). Average blood loss was total of 979 g, which was significantly less than that of the PCO group (average 1778 g). Average values for preoperative radiographic parameters for the Hybrid and PCO group were Cobb angle (CA), 48° and 46; lumbar lordosis (LL), 17° and 10° ; SVA, 113 mm and 106 mm, respectively, which improved CA, 12°and 14°; LL, 55°and 48°; SVA, 17 mm and 24 mm, after surgery respectively. All parameters significantly improved after surgery; hence, no significant difference was observed b e t w e e n t h e t w o g r o u p s . P e r i o p e r a t i v e complications were observed, including transient neurological deficit, Hybrid 2 cases and PCO 4 cases; hematoma, 0 and 2; and surgical site infection, 1 and 1.Conclusion：By using a hybrid technique with LLIF and PCF, sagittal alignment was restored, with less bleeding and complication than other methods.


Complications

G4-1

Complications Associated with Lateral Interbody Fusion: Nationwide Survey of 2998 Cases During the First Two Years of Its Use in Japan○ Shunsuke Fujibayashi1）, Noriaki Kawakami2）,

Takashi Asazuma3）, Manabu Ito4）, Jun Mizutani5）, Hideki Nagashima6）, Masaya Nakamura7）, Koichi Sairyo8）, Ryuichi Takemasa9）, Motoki Iwasaki10）

1） Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University

2） Department of Orthopedics and Spine Surgery, Meijo Hospital

3） Department of Orthopedics, Murayama Medical Center4） Department of Orthopedic Surgery, National Hospital

Organization Hokkaido Medical Center5） Department of Orhopaedic Surgery, Nagoya City University

Medical School6） Department of Orthopedic Surgery, Faculty of Medicine,

Tottori University7） Department of Orthopaedic Surgery, Keio University

School of Medicine8） Department of Orthopedics, Institute of Biomedical

Sciences, Tokushima University Graduate School9） Department of Orthopaedic Surgery / Spine Center, Kochi

Medical School10） Department of Orthopaedic Surgery, Osaka Rosai Hospital

Introduction：LIF has the potential risk of several complications unique to the procedure. Although there are many reports of complications, no nationwide survey has been conducted. The purpose of this study was to elucidate the incidence of complications and risk factors.Materials and Methods：Questionnaires were sent to all Japanese Society for Spine Surgery and Related Research members. Questionnaires requested information about surgical procedures, patient characteristics, preoperative diagnosis, complications, salvage procedures, final outcomes, and the surgeon’s experience of LIF. The data from replies received between March 2013 and April 2015 were recorded and the details of complications were analyzed.Results：Seventy-one institutions (12.3%) answered “yes” to LIF experience and 2998 cases (1995 XLIF and 1003 OLIF) were enrolled in this study. The response rate was 86.1%. A total of 540 complications were reported, of which 474 could be further analyzed. The overall complication rate was 18.0%. The most frequent complications were sensory nerve injury (5.1%) and psoas weakness (4.3%), and the majority resolved spontaneously. The rates of major vascular injury, bowel injury and surgical site infection were 0.03%, 0.03% and 0.7%, respectively. Higher rates of sensory nerve injury and psoas weakness were reported for XLIF and higher rates of peroneal laceration and ureteral injury were reported for OLIF.Conclusions：A nationwide survey of complications associated with LIF was conducted. Although the majority of complications were minor, a relatively high rate of complications was reported. Approach-related specific features of the two procedures were identified.

18


G4-2

A case report of bowel injury in extreme lateral interbody fusion (XLIF)○ Yohei Yuzawa1）, Yuichi Takano2）,

Hirohiko Inanami1）

1） Inanami Spine and Joint Hospital2） Iwai Orthopaedic Medical Hospital

Introduction：We report a bowel injury case of XLIF and analyze the cause and course of treatment of the accident. Case report：T h e p a t i e n t w a s a 6 6 y e a r o l d f e m a l e o f degenerative scoliosis. We did XLIF of her L3/4 and L4/5. On the third postoperative day she had fever of 39.7 degrees and we started another antibiotic treatment considering surgical site infection. The CT scan of her trunk at the fifth postoperative day showed the surgical site and subphrenic free air. A gastroenterologist excluded the possibility of a bowel perforation because she had no peritoneal irritation signs. On the seventh p o s t o p e r a t i ve d a y h e r c o n d i t i o n w a s n o t deteriorated but we decided to treat her as she had bowel perforations. She had a laparotomy and a perforat ion of the descending colon was detected. She had proctostomy for three months and it also took three months to control surgical site infection. Discussion：The patient was very slim and there was little retroperitoneal fat. Therefore the descending colon was adjacent to the psoas muscle. In such case there is a possibility of damaging the colon. As a sharp colonial incision may not induce typical peritoneal irritation sign, a surgeon should be aware of it. After this accident we conducted a preoperative CT scan of the operative position (right lateral of left lateral) and checked the bowels, vessels, urinary duct and so on. The surgical incision was also enlarged and soft tissues expansion and psoas split are done under the direct visual checking.

G4-3

Lymphoduct injury during LIF : Case report○ Hisatake Yoshihara

Department of Spine Surgery , Toyohashi Municipal Hospital

A 62-year-old man with severe low back pain and bilateral leg pain failed nonoperative treatment. Preoperative imaging showed multiple LSCS in L1-L5 and local kyphosis in L1-L3. Surgical planning was one stage operation with L1-L5 XLIF in the left lateral decubitus position, followed by same-day multi-level percutaneous pedicle screws. We continued the procedure without a problem unt i l we passed a tr ial implant through the interspace at L1/2, but just after placement of the L1/2 cage, colorless and transparent serous liquid sprung out from the other side of the cage. At first we cou ld no t unders tand wha t happened , comprehensively we concluded this event was lymphoduct injury after some examinat ions including intravenous injection of indigo carmine solution and biochemical inspection of the liquid. We cou ld no t r epa i r the l ympho duc t , the remainder of the procedure was performed, operation was finished after the drainage tube was placed. Postoperat ively drainage of a large quantity of lymph which was slightly turbid yellow was confirmed and CT imaging showed a large amount of fluid in extrapleural space and retroperitoneal space. The patient suffered from prerenal failure by the decrease of intravascular volume and needed medical treatment, but finally completely recovered. Lymphorrhea was treated with closed tube drainage and diet therapy which was non per oral for one week and followed by restriction of oral fat intake for one week. We inferred this complication was caused by inserting the cage which did not fit the shape of L1-2 vertebra in anterior portion.

19


G4-4

A Case of DSSI after XLIF: One Stage Cure with Cage in situ○ Nakayuki Kato1）, Hiroshi Taneichi2）

1） Zama General Hospital2） Dokkyo Medical University

Introduction：We treated DSSI after XLIF whose prevalence is much lower than those conventional posterior or anterior methods in databases.Case：A 74- year-old female had been received XLIF (L3/4, L4/5). One year and seven months after the surgery, she complaed of severe low back pain, buttock pain, and fever up (38.4 degrees).CT scan study indicated osteolytic lesion around the cage and CRP value was 7.75mg/dl just after t h e h o s p i t a l i z a t i o n . A f t e r a t h r e e - w e e k conservative treatment by means of antibiotics, CRP value well decreased to 1.07. However CRP value aggravated to 7.11 after then and we con t inued the an t ib io t i c s admin i s t r a t i on . Therefore we planned the removal of the cage and debridement with enough irrigation. The re-operation was performed through the same left side approach as the previous surgery with an enlarged 12 cm incision along the pelvic crest. The approach was easily and successful to the p o s t e r i o r p a r a r e n a l s p a c e . T h o u g h t h e postoperative adhesion was less than expected, the identification of the intervertebral disc was so difficult that a fluoroscopic aid was necessary. We had tried to remove the cages after a deliberately peeling off around the intervertebral discs and succeeded in grasping the cages us ing the inserter, however the bony fusion around the cages was so firm that the cages had broken at the junction with the inserter. Despite the failure to the removal of cages, the inflammatory reaction gradually improved and the lesion finally cured.Conclusion：The removal of cages was quite diff icult as expected and the adhesion was much less than expected.


Lateral Access Corpectomy & Reconstruction

G5-1

Lateral access corpectomy combined with short-segment posterior fixation for osteoporotic vertebral collapse in the elderly○ Masatoshi Hoshino, Hidetomi Terai,

Akinobu Suzuki, Hiromitsu Toyoda, Kentaro Yamada, Shinji Takahashi, Hiroaki Nakamura

Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine

O s t e o p o r o t i c v e r t e b r a l c o l l a p s e s a r e a n increasingly common cause of pain and severe functional disability in the elderly. Although spinal fusion and vertebral column reconstruction using various surgical techniques, such as anterior instrumentation surgery, posterior three-column osteotomy and posterior spinal fusion, offers an efficacious and durable treatment, the associated high blood loss, long durations of surgery, and prolonged hospitalization are often not tolerable for elderly patients, who are most often medically frail with multiple comorbidities. Also, there are concerns about postoperative correction loss following cage subsidence and screw loosening due to their poor bone strength. X-CORE system is expandab le w ide - foo tpr in t t i t an ium cage , therefore theoret ica l ly, th is system can be considered in the setting where implants have a load-bearing role in fragile vertebral endplates of elderly patients. We adopted this system for o s t e o p o r o t i c ve r t e b r a l c o l l a p s e s w i t h o u t intravertebral instability. The purpose of this presentat ion is to evaluate the eff icacy and limitation of lateral access corpectomy using X-CORE system combined with short-segment posterior fixation for osteoporotic vertebral collapse in the elderly patients (9 men and 15 woman, average age, 74.4 years (56-84)).

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G5-2

lateral access corpectomy for patients with kyphotic deformity following osteoporotic vertebral collapse○ Masayuki Ishihara1）, Takanori Saito2）,

Shinichiro Taniguchi2）, Yoichi Tani2）, Masaaki Paku2）

1） Kansai Medical University Medcal Center2） Kansai Medical University Hospital

In 2015, X-core 2 system using expandable cage with wide footprint was innovated, we have been a b l e t o m in ima l l y i nvas i ve l a t e ra l a c ces s corpectomy. The objective of this study is to report mid-term clinical results of this surgical technique.

G5-3

Treatment of kyphotic deformity due to osteoporotic vertebral fracture through posterior spinal fusion combined with anterior vertebral body replacement○ Keita Omori, Masahiro Hoshino,

Hiromi Matsuzaki, Hidetoshi Igarashi, Koji Yamasaki

Sonoda Medical Institute Tokyo Spine Center

Purpose：Spinal deformity caused by osteoporotic vertebral fracture has commonly been treated by anterior strut reconstruction. However, loss of correction and a l ignment have been observed due to subsidence of the graft bone. We report adult spinal deformity correct ion cases achieved through anterior procedure.Methods：6 patients (1 male / 5 female) with adult spinal deformity caused by osteoporot ic vertebral fracture corrected from thoracic to pelvis were evaluated. Sagittal alignment correction and postoperative complications were observed in these patients.Results：Average opera t ion t ime was 166 .2min for anterior, and 220.2min for posterior procedure. The est imated b lood loss was 316.5ml for anterior, and 976.2ml for posterior. PI-LL: 67.8 ° → 4.7°, SVA: 214.2mm → 54.8mm, PT: 31.8° → 23.5 °, local kyphotic angle: -15.3 ° → 8.2 ° and achieved 24° correction. There was 1 case of PJF and 1 case of rod breakage, and revision surgeries were performed.Discussion：With the introduction of LLIF, anterior-posterior surgery in the treatment of adult spinal deformity has become widespread. Anterior release at the intervertebral disc level and fixation through posterior procedure st i l l remains to be the standard of care, but this technique is limited in its ability to restore alignment, making PSO and VCR necessary. With the use of expandable cage with LLIF, a more physiological alignment may be achieved.Conclusion：Selection of implants to prevent complications such as vertebral fracture at UIV is still debatable, but our short term observation in achieving alignment correction showed favorable results.

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Innovation Techniques

G6-1

Anterior Column Realignment (ACR) Using a Lateral Transpsoas Approach○ Satoshi Inami, Hiroshi Moridaira,

Daisaku Takeuchi, Haruki Ueda, Yo Shiba, Futoshi Asano, Hiromichi Aoki, Hiroshi Taneichi

Dokkyo Medical University

The lateral interbody fusion to the anterior spinal columns rely on the condition of the anterior longitudinal ligament (ALL) for graft tensioning and a barrier to prevent anterior interbody graft dislodgement. However, when considering the correction of a sagittal plane deformity, the ALL is t h e p r i m a r y o b s t a c l e t o a n t e r i o r c o l u m n lengthening and deformity correction. Anterior co lumn rea l ignment (ACR) technique is an advanced application of extreme lateral interbody fusion (XLIF) to make larger lordosis in an inter-vertebral space, involving complete anterior longitudinal ligament and annulus release and the use of hyper-lordotic intervertebral cages. Some previous studies reported that ACR is less invasive than posterior column osteotomy (PSO or VCR) which are associated with significant complication late. The identification and separation of the plane between the ALL and anterior structures are mandatory in ACR. Discectomy and contralateral a n n u l u s r e l e a s e a r e e s s e n t i a l t o e n s u r e symmetrical distraction. Then, patients with a b n o r m a l v a s c u l a r a n a t o m y , e x t e n s i v e calcification of the aorta, previous retroperitoneal i n f e c t i o n , o r p r e v i o u s a n t e r i o r s p i n a l o r retroperitoneal surgery are likely not candidates for ACR.To introduce ACR, both of institute and surgeon should conform to the safety regulation, and to attend a workshop is mandatory for the surgeon. Registration for all cases during 2 years after introduction is obligation.

G6-2

Virtual reality simulator for pedicle screw insertion in the lateral position○ Wataru Narita

Midorigaoka Hospital

Introduction：Lateral lumbar interbody fusion (LLIF) is a minimally invasive procedure performed in the lateral position. It is advantageous as an effective reduction procedure that ensures satisfactory alignment. If the safety of inserting the PPS while the pat ient is in the lateral posit ion can be beneficial. But without a standardized program, training can be difficult.Objective：We developed a VR simulator for use in training PPS insertion when the patient is in a lateral posi t ion . To a l low the user to pract ice the insertion of pedicle screws into a 3-dimensional model of a patient-specific spine, and have both visual and immersive feedback provided to the user. The goal is to better prepare surgeons to perform pedicle screw insertion surgery and help reduce the risk of pedicle screw misplacement. Results：Pedicle screw insertion can be practiced using pedicle screws of various sizes and analyzed in both 2-dimension and 3-dimension. Quantitative feedback is provided to the user in the form of anatomic lengths and angles, relative purchase of inserted screws, and a screw placement grading system. The software allows the user to adjust the translucency of a patient's spine to develop a better sense of the tra jectories and depths involved with performing pedicle screw insertion on a patient.Conclusions：The simulator offers many helpful features to the surgeon with respect to complex cases and to the surgical trainee learning the technique of pedicle screw insertion.

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G6-3

Assessment of cage subsidence at 1-year follow-up after stand-alone XLIF○ Toshinori Sakai, Yoichiro Takata,


Department of Orthopaedic Surgery, Tokushima University

Purpose of this study：The purpose of this study was to assess the radiological findings at 1-year follow-up after stand-alone XLIF.Materials and Methods：A total of 35 intervertebral spaces (L2/3: 8, L3/4: 14, L4/5: 13) in consecutive 18 patients (7 men and 11 women) who underwent the stand-alone X L I F w e r e e n r o l l e d i n t h i s s t u d y . P l a i n radiographs and multi-detector CT scans at 1-year follow-up were assessed. We defined Fusion, Stabilized, and Non-fusion as follows (Fusion: c o m p l e t e o s s e o u s c o n t i n u i t y , S t a b i l i z e d : incomplete osseous continuity and intervertebral motion<5°, Non-fusion: no osseous continuity, or radiolucent line on surface of the cage ≧ 50%). Case subsidence was classified using both of sagittal and coronal views as follows (grade 0: <25%，grade I: 25-50%，grade II: 50-75%，grade III: 75%<).Results：Among the 35 intervertebral spaces, bony fusion were found in 21 (60.0%)，fusion were in 10 (28.6%), and non-fusion were in 4 (11.4%). Among the 18 patients, non-fusion was seen in 2 patients (11.1%). Regarding the cage subsidence, 33 of 35 were ident if ied as grade 0 (94.3%), Grade I subsidence was seen in 2 spaces (5.7%) in 2 patients. Both cases of the Grade I subsidence were identified at the anterior side of the caudal endplate against the inserted cage.

G6-4

Single-approach LLIF with lateral vertebral plate system for degenerative lumbar spinal disorders○ Mitsuru Yagi1）, Yuichiro Mima1）,

Nobuyuki Fujita1）, Eijiro Okada1）, Osahiko Tsuji1）, Narihito Nagoshi1）, Ken Ishii2）, Masaya Nakamura1）, Morio Matsumoto1）, Kota Watanabe1）

1） Department of Orthopedic Surgery, Keio University School of Medicine

2） Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare

Background：Lumbar interbody fusion is indicated in the treatment of lumbar stenosis, spondylolisthesis, and adjacent segmental disease. Successful outcomes depend on fusion. The best opportunity for fusion may be anterior interbody fusion owing to improved loading of the graft and the largest surface area for fusion compared with other techniques. Several operative approaches are commonly used to access the anterior column for fusion, including PLIF, TLIF, ALIF, and more recently, LLIF. Methods：We described the advantage and disadvantages of single-approach LLIF with lateral vertebral plate system (LPS) by our experience and literatures review.Results：The LLIF with LPS is specifically designed to integrate seamlessly with the LLIF. Performing LLIF with LPS allows a large interbody implant and highly effective fixation to be delivered through a single approach. By eliminating the need for an additional posterior surgery, the LPS delivers meaningful benefits to both patient and surgeon. Single-approach LLIF with LPS decreased patient morbidity, shortened hospital stays, reduced blood loss, allowed quicker recovery, and improved cosmesis with less scarring. Additionally, no patient need repositioning and therefore reduced operative time. Contrarily, due to the design of the LPS system, the flexion-extension rigidity is weaker than bilateral pedicle screws and therefore special attention is needed for geriatric patients due to the potential risk for the endplate fracture and cage subsidence.Conclusion：LLIF with LPS provides an attractive alternative with reduced blood loss and complications in the surg ica l t reatment of lumbar degenerat ive disorders, as there is no need to re-explore a previous laminectomy site.

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持田製薬株式会社 2017 年 10 月 31 日現在　　 50 音順　敬称略　　

本学術集会開催にあたり、上記の皆様より協賛を賜りました。ここに深く感謝の意を表します。

SOLAS Japan Regional Director 種市　洋 Education Chair 金村徳相 Member Services Chair 水谷　潤 Research Chair 石井　賢

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The 1st SOLAS Japan meeting - lateralaccess.org Ryu SOLAS Japan Board members 13:45－14:00 SOLAS...

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Transcript of The 1st SOLAS Japan meeting - lateralaccess.org Ryu SOLAS Japan Board members 13:45－14:00 SOLAS...