Lateral Options for

Deformities Management
• Assistant Professor, Department of
Orthopedics, Boston University
• Chief of Spine, Boston University
• Founding President, Society for
Progress & Innovations for the Near East
• Interest:
• MIS, Deformity, Tumors
• Designs: Viper, Lateral Cougar cage
• Medical education exchange: national and
international
Tony Tannoury, MD • Enjoys Tennis, Ski, Travel, Social
Networking
• Contact: www.neareastspine.org
 Lateral Options for
Deformity’s management

Tony Y Tannoury, MD
Assistant professor,
Department of Orthopedics
Boston University
tannoury@bu.edu www.neareastspine.org
Which patient is most likely to have
chronic pain?
 Adult Degenerative Deformity
 Always involves the Lumbar spine
 Painful
 Patients:
 Elderly
 Co-morbidities

 Fusion harder to achieve vs pediatric

 Must have
 Solid fusion
 Good sagittal balance
 Decompression
 Fusion options
 Posterior
 anterior
 Challenging questions regarding
MIS
 How to achieve sagittal X
osteotomy
balance Interbody reconstruction

 How to achieve fusion X

Posterior

interbody

 Decompression: direct vs laminectomy

indirect X
facetectomy

Spinal reduction
Foraminal distraction
LET ME MAKE MY CASE
 Why inter-body fusion?
 Better Mechanics
 Better Biology
 Better physiology
 May be The best option to Address the pain
generators
MECHANICS
 Why Interbody

 Biology: under
compression.
 Better pysoelectric
charges
 Better Physiology:
 The only compartment in
the spine void of
functional muscles
 Potentially Eliminates
Pain generators
 Promising techniques
MIS Lateral/Anterolateral Techniques
 Straight lateral surgery
(XLIF, DLIF, Lat concord etc…)
 Indicated for lateral
pathology
 Lateral decubitus position
 Incision at lateral border
of erector spinae
 Dilates through iliopsoas
 “Finger assisted”
 Risks
 Lumbar plexus (in psoas)
 Requires monitoring
 WHY LATERAL!!
 Viscera are out of the way
 No need for vascular mobilization
 Preserves the ALL:
 Containment
 Anterior tension band
 Protects against over-distraction
 Can be done with the posterior work simultaneously
without repositioning
 No iatrogenic stenosis
 Less risk for retrograde ejaculation
 No traumatic sympathectomy
Traditional Anterior Approach
Anatomy
Analysis of Vascular Anatomy

 High Lateral
Configuration
Analysis of Vascular Anatomy

 Very Low Medial

Configuration
 Anatomy
 Psoas gets wider in lower lumbar spine (males>females)
 Lumbar plexus posterior 2/5 of psoas
LLIF
Anterior Posterior
Favorable Anatomy
Unfavorable Anatomy
Antero-lateral interbody fusion

 L1-2, L2-3, L3-4, L4-5

 Split fibers of oblique and
transversus muscles
 Retract anterior 20%
psoas
 be Very careful of the
misleading Quadratus
Lumborum muscle
approach
 2 inch incision

legs

Head of
patient

abdomen
External oblique fascia and muscle
split
Internal oblique and transversus
fascia split
discectomy
Cage and buttress screw
Skin closure
2 level A/P fusion
Concave vs convex side
Concave side
Concave approach:
54 yo, multiple spinal surgeries
severe pain
Before and after
Before and after
72 YO lady. Severe back and leg
pain. Failed conservative Rx.
MRI
 conservative
 Lost 90 pounds
 8 ESIs
 Yoga
 Psychiatric eval.
 Not better
BEFORE AND AFTER
BEFORE AND AFTER
58 y0 male. Still disease. Severe back
and hip/thigh pain
Sagittal balance
Axial cut at L3-4
 Failed conservative Rx
CONSERVATIVE RX OPTIONS:
 PT  Don nothing

 TIME  Laminectomy

 PAIN MEDS  Laminectomy fusion

 Approach:
 Posterior
 Anterior posterior
 Fusion levels:
T11-L4
Before and after
Before and after
12 months postop
 Both are happy:
his pain is gone & I feel good/look tall
preop
Full Spine Films
Post op
55 yo, 325 lbs
MRI
Intraoperative pictures
Post op
 Conclusion.
 MIS is very promising:
 Approach
 Anterior vs posterior
 Concave vs convex
 Indirect decompression
 More studies need to be done
 Conclusion
 Fusion surgery is quite Morbid.
 MIS is very promising option and might be the
best option
 We have to rethink anterior fusion
 Go concave
 Be careful,
bad stuff can happen through small
holes
IT WILL THROW YOU UP IN
THE AIR