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Year : 2021  |  Volume : 16  |  Issue : 3  |  Page : 665-666

Letter to the editor regarding “lumbar interbody fusion: Techniques, pearls and pitfalls”

Department of Neurological Surgery, Christian Doppler Klinik Paracelsus Medical University; Laboratory for Microsurgical Neuroanatomy, Christian Doppler Klinik, Salzburg, Austria

Date of Submission26-Feb-2021
Date of Decision10-Apr-2021
Date of Acceptance10-Apr-2021
Date of Web Publication14-Sep-2021

Correspondence Address:
Dr. Santino Ottavio Tomasi
Department of Neurological Surgery, Christian Doppler Klinik Paracelsus Medical University, Ignaz-Harrer-Strasse 79A, Salzburg 5020
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajns.AJNS_82_21

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How to cite this article:
Tomasi SO, Winkler PA. Letter to the editor regarding “lumbar interbody fusion: Techniques, pearls and pitfalls”. Asian J Neurosurg 2021;16:665-6

How to cite this URL:
Tomasi SO, Winkler PA. Letter to the editor regarding “lumbar interbody fusion: Techniques, pearls and pitfalls”. Asian J Neurosurg [serial online] 2021 [cited 2021 Dec 4];16:665-6. Available from:

We appreciated and read with great interest the manuscript by Kim et al.[1] entitled “Lumbar Interbody Fusion (LIF): Techniques, Pearls and Pitfalls” published in October 2020 in Asian Spine Journal.

In their review, the authors analyzed literature reports about LIF pearls and pitfalls, providing useful indications and contraindications according to the recent literature evidence.

The authors summarize the approaches through which LIF can be performed in posterior, transforaminal, anterior, and lateral approaches by open surgery or minimally invasive surgery (MIS). Of course, each technique shows advantages and disadvantages. Posterior LIF is the most familiar procedure, which offers good fusion rates and low complication rates. Iatrogenic injuries to the neural structures and paraspinal muscles are its most important disadvantages. MIS transforaminal LIF reduces these iatrogenic injuries. Anterior LIF (ALIF) can restore the disk height and sagittal alignment but with risks of visceral and vascular complications. Lateral LIF and oblique LIF are performed using the MIS technique and have shown postoperative outcomes like ALIF; however, these approaches carry a risk of injury to psoas, lumbar plexus, and vascular structures.

We found this manuscript of great value, we agree with the authors' suggestions, and we are glad to share with the international scientific community our concept and vision of minimally invasive neurosurgery, in spine and brain surgery, as a unitary concept. The development of new tools, materials, and technologies promoted minimally invasive techniques work wide, like the application of neuronavigation in spine surgery.[2],[3],[4] Intraoperative imaging devices such intraoperative computed tomography, O-ARM, Ziehm rfd, and Loop-X allow to verify the accuracy during the entire time of the procedure making misplacement impossible since the trajectory can be modified until getting the desired result, thus avoiding redo surgery with its high medicolegal risks.[5],[6],[7],[8],[9],[10],[11] Moving toward the cranial direction, also approaches to the craniovertebral junction are performed reducing of surgical damage to soft tissues; the use of endonasal approaches to C1–C2 has decreased morbidity and the odontoid screw fixation has been reported to be performed percutaneously.[12],[13],[14] Furthermore, vertebral corpectomy, invasive as well all know, can be accomplished with MIS technique for both traumatic and tumoral diseases, reducing surgical blood loss, patient's morbidity, and hospital stay saving costs.[5],[15] In brain surgery, endoscopic assisted brain surgery is a well-established technique and with proved efficacy. While if we look back in the past, transsphenoidal approaches aimed to reduce brain manipulation with direct access to the pathology, reducing morbidity and mortality.[16],[17],[18],[19] In the end, the most common pathology of modern times of neurosurgery, the surgical evacuation of chronic subdural hematomas, experienced a progressive reduction of invasively shifting from craniotomy to burr hole or to the twist drill craniostomy.[20],[21],[22] In consideration of the present study and based on our institutional experience, we think that the MIS technique must be advocated and powered by technological innovations. Experienced surgeons should support younger colleagues in using approaches with reduced invasiveness. The association of senior surgeons and ingenious, innovative, tech-friendly junior colleagues is a powerful alliance to boost MIS with special benefit for patients, reducing direct (hospital stay, redo surgery) and indirect (medico-legal issues) costs.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kim YH, Ha KY, Rhyu KW, Park HY, Cho CH, Kim HC, et al. Lumbar interbody fusion: Techniques, pearls and pitfalls. Asian Spine J 2020;14:730-41.  Back to cited text no. 1
Umana GE, Passanisi M, Fricia M, Chiriatti S, Fagone S, Cicero S, et al. Letter to the editor regarding accuracy of pedicle screw insertion among 3 image-guided navigation systems: A systematic review and meta-analysis. World Neurosurg. 2020;138:595-7.  Back to cited text no. 2
Du JP, Fan Y, Wu QN, Wang DH, Zhang J, Hao DJ. Accuracy of pedicle screw insertion among 3 image-guided navigation systems: Systematic review and meta-analysis. World Neurosurg 2018;109:24-30.  Back to cited text no. 3
Umana GE, Scalia G, Perrone C, Garaci F, Pagano A, De Luna A, et al. Safety and efficacy of navigated trocarless pedicle screw placement: Technical note. Interdiscipl Neurosurg 2020;21:100771.  Back to cited text no. 4
Yu JY, Fridley J, Gokaslan Z, Telfeian A, Oyelese AA. Minimally invasive thoracolumbar corpectomy and stabilization for unstable burst fractures using intraoperative computed tomography and computer-assisted spinal navigation. World Neurosurg 2019;122:e1266-274.  Back to cited text no. 5
Umana GE, Passanisi M, Fricia M, Cicero S, Narducci A, Nicoletti GF, et al. Letter to the editor regarding minimally invasive thoracolumbar corpectomy and stabilization for unstable burst fractures using intraoperative computed tomography and computer-assisted spinal navigation. World Neurosurg 2020;139:692-3.  Back to cited text no. 6
Kim TT, Drazin D, Shweikeh F, Pashman R, Johnson JP. Clinical and radiographic outcomes of minimally invasive percutaneous pedicle screw placement with intraoperative CT (O-arm) image guidance navigation. Neurosurg Focus 2014;36:E1.  Back to cited text no. 7
Nicoletti GF, Umana GE, Chaurasia B, Ponzo G, Giuffrida M, Vasta G, et al. G. Navigation-assisted extraforaminal lumbar disc microdiscectomy: Technical note. J Craniovert Spine 2020;11:316-20.  Back to cited text no. 8
Scalia G, Umana GE, Graziano F, Tomasi SO, Furnari M, Giuffrida M, et al. Letter: Image-guided navigation and robotics in spine surgery. Neurosurgery 2020;nyaa404. doi: 10.1093/neuros/nyaa404.  Back to cited text no. 9
Nicoletti G, Furnari M, Giuffrida M, Ponzo G, Iacopino DG, Cammarata G, et al. A new tool to improve pedicle screw placement accuracy in navigated spine surgery: A monocentric study. J Neurosurg Sci 2020. doi: 10.23736/S0390-5616.20.04957-7.  Back to cited text no. 10
Umana GE, Passanisi M, Fricia M, Distefano G, Cicero S, Nicoletti GF, et al. Letter to the editor regarding radiolucent carbon fiber-reinforced pedicle screws for the treatment of spinal tumors: Advantages for radiation planning and follow-up imaging. World Neurosurg 2020;139:674-5.  Back to cited text no. 11
Umana GE, Visocchi M, Scalia G, Passanisi M, Fricia M, Fagone S, et al. Minimally invasive percutaneous anterior odontoid screw fixation: Institutional experience with a simple and effective technique. J Neurosurg Sci 2020. doi: 10.23736/S0390-5616.20.04886-9.  Back to cited text no. 12
Wu AM, Wang XY, Xia DD, Luo P, Xu HZ, Chi YL. A novel technique of two-hole guide tube for percutaneous anterior odontoid screw fixation. Spine J 2015;15:1141-5.  Back to cited text no. 13
Aldea S, Brauge D, Gaillard S. How I do it: Endoscopic endonasal approach for odontoid resection. Neurochir 2018;64:194-7.  Back to cited text no. 14
Visocchi M, Germano' A, Umana G, Richiello A, Raudino G, Eldella AM, et al. Direct and oblique approaches to the craniovertebral junction: Nuances of microsurgical and endoscope-assisted techniques along with a review of the literature. Acta Neurochir Suppl 2017;124:107-16.  Back to cited text no. 15
Fraioli MF, Marciani MG, Umana GE, Fraioli B. Anterior microsurgical approach to ventral lower cervical spine meningiomas: Indications, surgical technique and long term outcome. Technol Cancer Res Treat 2015;14:505-10.  Back to cited text no. 16
Rigante L, Borghei-Razavi H, Recinos PF, Roser F. An overview of endoscopy in neurologic surgery. Cleve Clin J Med 2019;86:16ME-24ME.  Back to cited text no. 17
Fraioli MF, Umana GE, Fiorucci G, Fraioli C. Ethmoidal encephalocele associated with cerebrospinal fluid fistula: indications and results of mini-invasive transnasal approach. J Craniofac Surg 2014;25:551-3.  Back to cited text no. 18
Fraioli MF, Umana G, Pagano A, Fraioli B, Lunardi P. Prolactin secreting pituitary microadenoma: Results of transsphenoidal surgery after medical therapy with dopamine agonist. J Craniofac Surg 2017;28:992-4.  Back to cited text no. 19
Jablawi F, Kweider H, Nikoubashman O, Clusmann H, Schubert GA. Twist drill procedure for chronic subdural hematoma evacuation: An analysis of predictors for treatment success. World Neurosurg 2017;100:480-6.  Back to cited text no. 20
Umana GE, Chiriatti S, Fricia M, Alberio N, Cicero S, Nicoletti GF, et al. Letter to the editor regarding twist drill procedure for chronic subdural hematoma evacuation-an analysis of predictors for treatment success. World Neurosurg 2020;139:698.  Back to cited text no. 21
Umana GE, Chiriatti S, Roca E, Scalia G, Fricia M, Alberio N, et al. A New tools in percutaneous minimally invasive chronic subdural hematomas evacuation. Interdisciplinary Neurosurg 2020100771:100736. [ 2020.100736].  Back to cited text no. 22


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