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Minimally Invasive Lateral Spine Surgery

Innovative surgical approach offers major advantages to spine surgeons and their patients

UH Department of Orthopaedics - Winter 2018

Zachary Gordon, MD


Orthopaedic Spine Surgeon, UH Cleveland Medical Center; Assistant Professor of Orthopaedics, Case Western Reserve University School of Medicine

Many traditional approaches to spine surgery require a large incision, significant blood loss and long recoveries for the patient. However, advances in minimally invasive surgery (MIS) have led to new approaches, such as MIS lateral spine surgery.

This contemporary approach enables spine surgeons to access the spine through a small incision in the psoas muscle, rather than peeling back the muscles – as would be done in an open surgery such as the anterior lumbar interbody fusion (ALIF).

“You can get to the spine through a number of different techniques, including direct anterior, oblique or direct lateral approaches,” says Zachary Gordon, MD, an orthopaedic spine surgeon at University Hospitals Cleveland Medical Center and Assistant Professor of Orthopaedics at Case Western Reserve University. “The MIS lateral approach is actually a modified version of ALIF procedure performed through a direct lateral approach. This allows for smaller incisions with less disruption of the muscles.”

Doctors can use the technique to address and correct numerous spinal conditions, including degenerative lumbar spinal stenosis and spondylolisthesis. “It can help give these patients stability, height and more room for their nerves,” Dr. Gordon explains.

Additionally, doctors are increasingly using the MIS lateral approach to help patients with degenerative scoliosis and flat back syndrome, he says. “The minimally invasive technique may limit the number of levels that need to be involved in the fusion.”



Neural monitoring was the first major advance that made MIS lateral spine surgery possible. Real-time nerve monitoring allows spine surgeons to know exactly where the nerves are.

“This allows for the surgery to be done through small incisions,” Dr. Gordon says. “Smaller incisions mean less pain, less blood loss and a quicker recovery.”

Surgeons are constantly refining minimally invasive techniques to further reduce the trauma to a patient’s surrounding muscle and soft tissue.

Dr. Gordon is seeing the latest advances in the technique’s ability to address adult deformity, particularly scoliosis and flat back syndrome. Patients with this condition suffer back pain and neurologic symptoms associated with spinal stenosis.

“In the past, this condition would require a posterior approach and the removal of a lot of bone,” he says. “These were very lengthy and bloody procedures. Patients can lose up to 1.5 to 2 liters of blood during a procedure of that magnitude.”

Using the MIS lateral approach, surgeons can forgo osteotomy and place wedge-shaped implants, which create more angulation of the spine.

“Rather than breaking the spine, we can give patients 20 to 30 degrees of segmental correction with approximately 50 ccs of blood loss instead of 1.5 liters,” Dr. Gordon says. Patients have less need for blood transfusions and can be back on their feet with more mobility quicker.

While the MIS lateral approach can address a spectrum of spine conditions, Dr. Gordon stresses that it is not the answer for every patient. “There are limitations,” he says. “We have to be highly selective about who we choose for this technique.”

For example, patients with conditions that affect the spine at the L5 and S1 levels are not candidates for MIS lateral spine surgery because too much of their neurovascular anatomy is in the way.

Just because the MIS lateral approach won’t work for these patients does not mean that a minimally invasive approach is off the table. “Even if patients aren’t candidates for lateral surgery, there are still a lot of other minimally invasive options,” Dr. Gordon says.


If you have a patient who has been diagnosed with flat back syndrome, degenerative lumbar spinal stenosis or spondylolisthesis, call 216-844-7200 to schedule an appointment with Dr. Gordon.