The Prone-Angled Transpsoas Approach: Utilizing Position, Approach, Navigation, and Neuromonitoring in Prone Lateral...

Lateral lumbar interbody fusion techniques have advanced toward minimally invasive, anatomy-preserving approaches that enhance sagittal alignment and reduce perioperative morbidity. The most common existing approaches-the prone transpsoas and oblique lumbar interbody fusion-offer distinct advantages with opposing limitations. This manuscript describes a novel prone angled transpsoas (PAT) technique that combines the ergonomic and sagittal benefits of prone positioning with a navigated oblique/angled approach and direct lateral working corridor. This technique aims to simplify lateral surgery and minimize plexus and vascular risk, while enabling single-position surgery with the help of image-guidance navigation and neuromonitoring.

The operative technique for a PAT approach is described. The rationale for this approach and a representative case example are reviewed.

A 73-year-old woman with grade 1 L4-L5 anterior spondylolisthesis and bilateral radiculopathy underwent PAT lateral lumbar interbody fusion with concurrent percutaneous posterior fixation. With the use of neuromonitoring and navigation, PAT approach combined the advantages of prone transpsoas surgery (increased lordosis, more posterior lumbar plexus, single-position surgery, minimized risk of bowel and vascular injury) with the navigated anterior angled approach (oblique lumbar interbody fusion/anterior-to-psoas) that may minimize risk of plexus injury.

The authors' early experience with the described PAT technique suggests that it is not only feasible but also offers advantages. This technique leverages prone techniques with an oblique angled approach while making use of navigation and neuromonitoring when creating a lateral corridor, which removes the need to work obliquely. The use of navigation and neuromonitoring improves the ability to safely work laterally. Further follow-up studies of this technique are ongoing.