What is the lateral transpsoas approach

The approach is performed from the left side with the patient positioned in the right lateral decubitus position. Fluoroscopy is used to mark a small skin incision over the anterior third of the target disc space at the posterior border of the paraspinous muscles. The layers of the lateral abdominal wall are bluntly dissected to enter the retroperitoneal space. The peritoneum is mobilized anteriorly and the psoas muscle is identified. The psoas is dissected, mobilized, and retracted to expose the disc space. Palpation, direct visualization, and neurophysiologic monitoring are used to facilitate safe placement of a specialized expandable tubular retractor. While working through the retractor, the disc space is prepared for fusion and a transversely oriented structural interbody spacer containing graft material is inserted.

The lateral transpsoas approach was developed as a less invasive option for achieving anterior fusion from L1 to L5. This approach avoids the need to mobilize the iliac vessels or sympathetic plexus. However, the genitofemoral nerve, lateral femoral cutaneous nerve, and femoral nerve are placed at risk due to their intimate relationship with the psoas muscle. The approach is not feasible at L5-S1 due to the location of the iliac vessels. The approach is challenging at L4-L5 and may not be possible due to obstruction by the iliac crest or due to the relationship of the lumbosacral plexus to the lateral aspect of the disc space. See Figure 70-4.

Figure 70-4. Lateral transpsoas approach. (From Kim DK, Henn JS, Vaccaro AR, et al. Surgical Anatomy and Techniques to the Spine. Philadelphia: Saunders; 2006.)
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