The Minimally Invasive Intercostal Subdiaphragmatic Access without Rib Resection for Lateral Lumbar Interbody Fusion at L1/2: Surgical Techniques and Cases Illustration

Objective: The minimally invasive (MI) lateral approach to the thoracolumbar junction for treating various spinal pathologies is quite challenging for spine surgeons due to this region's unfamiliar and complex anatomical structures. In addition, controversy still exists regarding approach selection, the need for rib resection, and diaphragm manipulation.

Methods: We present the senior author (N. A.) technique of an intercostal subdiaphragmatic retroperitoneal approach without rib resection for the lateral lumbar interbody fusion (LLIF) procedure at L1/2 in patients who underwent multilevel LLIF from L1/2 to L5/S1. Also, we demonstrate a similar subdiaphragmatic retroperitoneal access technique, using a single skin incision with 2 fascial approaches for performing the single-level LLIF L1/2 in a cadaver.

Results: The staged procedures for multilevel LLIF L1-S1 were completed without any complications. The patient's symptoms significantly improved after the operations. Improvements to the radiographic parameters were also noted.

Conclusions: Intercostal subdiaphragmatic retroperitoneal access without rib resection is an alternative MI lateral approach to the upper lumbar spine. These reproducible techniques could help surgeons access the L1/2 disc level without unnecessary rib resection. Surgeons can use this technique for performing a single-level lateral approach at L1/2 or incorporate this MI technique with a standard lateral approach to the lower lumbar spine for performing sequential multilevel lateral fusion for patients diagnosed with adult spinal deformity.