Complication avoidance in prone single-position lateral spine surgery: Strategies and best practice

Prone transpsoas lateral lumbar interbody fusion (LLIF) is an emerging minimally invasive technique, that combines the advantages of lateral access with the efficiency of a single-position approach. This approach enhances segmental and global alignment correction with large-footprint lordotic interbody devicess, facilitates spondylolisthesis reduction, and can reduce operative and anesthetic time. However, prone transpsoas LLIF presents unique challenges, necessitating meticulous preoperative planning and intraoperative execution. Neurological complications, primarily transient radiculopathy or sensory symptoms, occur in approximately 8.2% of cases, with most resolving within three months. Notably, hip flexor weakness and pain - likely secondary to psoas muscle dissection and retraction - are most common, but typically resolved within several months. Preoperative planning focuses on optimal patient selection, considering key anatomical factors such as iliac crest height, vasculature location, and psoas anatomy to minimize complications. Intraoperative risk mitigation relies on precise patient positioning, strategic incision planning, and careful retroperitoneal dissection guided via real-time fluoroscopy and neuromonitoring. Effective postoperative management necessitates vigilant monitoring, proactive pain management, and early mobilization. With proper technique and patient selection, prone transpsoas LLIF offers improved surgical efficiency, favorable clinical outcomes, and low complication rates, reinforcing its utility in minimally invasive spine surgery.