{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T03:18:05Z","timestamp":1792034285297,"version":"4.4.0"},"reference-count":28,"publisher":"SAGE Publications","issue":"7","license":[{"start":{"date-parts":[[2025,3,15]],"date-time":"2025-03-15T00:00:00Z","timestamp":1741996800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"},{"start":{"date-parts":[[2025,3,15]],"date-time":"2025-03-15T00:00:00Z","timestamp":1741996800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Global Spine Journal"],"published-print":{"date-parts":[[2025,9]]},"abstract":"<jats:sec>\n                    <jats:title>Study Design<\/jats:title>\n                    <jats:p>Retrospective Cohort Study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Lateral lumbar interbody fusion (LLIF) is a treatment option for correcting lumbar degenerative pathologies that uses a retroperitoneal, transpsoas corridor to the disc space. Conventional teaching of the LLIF technique has been to perform the procedure \u2018as efficiently as possible', with a goal of keeping the total retractor time to less than 20 minutes to prevent injuries. This study aims to examine the sensitivity of the \u201c20-minute\u201d rule for predicting postoperative femoral nerve palsy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A multicenter, retrospective cohort of patients who underwent an LLIF was established. Retractor time was recorded and compared to postoperative motor exams for its relationship to motor injury.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      658 total patients were included in the study. The most frequently operated level was L4-5 (71.7%). The average retractor time was 17.5 \u00b1 8.0 minutes. The injury rate of the cohort was 1.8% (12\/658). There was no difference in average retractor time for non-injured vs injured patients (17.5 \u00b1 8.0 min vs 19.6 \u00b1 11.2 min,\n                      <jats:italic>P<\/jats:italic>\n                      = 0.367). Analysis of the \u201c20-minute\u201d rule for LLIF revealed a sensitivity of 50%, a specificity of 73.8%, and a positive predictive value of 3.4%. There were 174 patients with retractor times &gt;20 minutes and six injuries, yielding a false positive rate of 96.6%.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Post-operative quadriceps motor palsy after lateral lumbar interbody fusion does not appear to be caused by prolonged retractor time greater than 20 minutes. The authors recommend surgical efficiency without the need to rush through the procedure because the \u201c20-Minute\u201d threshold is approaching. Limiting retractor time to under 20 minutes was a poor predictor of post-operative quadriceps injury.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/21925682251321490","type":"journal-article","created":{"date-parts":[[2025,3,15]],"date-time":"2025-03-15T09:25:21Z","timestamp":1742030721000},"page":"3189-3198","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":6,"title":["The \u201c20-minute Rule\u201d in Lateral Lumbar Interbody Fusion. Fact or Fiction? A Multi-Center Analysis of 658 Patients"],"prefix":"10.1177","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2722-9676","authenticated-orcid":false,"given":"Ashish","family":"Patel","sequence":"first","affiliation":[{"name":"Duly Health and Care, Naperville, IL, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3488-2614","authenticated-orcid":false,"given":"Michael R.","family":"McDermott","sequence":"additional","affiliation":[{"name":"Duly Health and Care, Naperville, IL, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"suffix":"Jr","given":"Gregory M.","family":"Mundis","sequence":"additional","affiliation":[{"name":"Scripps Clinic, La Jolla, CA, USA"},{"name":"San Diego Spine Foundation, San Diego, CA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2359-1707","authenticated-orcid":false,"given":"Robert K.","family":"Eastlack","sequence":"additional","affiliation":[{"name":"Scripps Clinic, La Jolla, CA, USA"},{"name":"San Diego Spine Foundation, San Diego, CA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0275-5020","authenticated-orcid":false,"given":"Aaron J.","family":"Buckland","sequence":"additional","affiliation":[{"name":"Melbourne Orthopaedic Group, Melbourne, VIC, Australia"},{"name":"Spine and Scoliosis Research Associates Australia, Melbourne, VIC, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cristiano M.","family":"Menezes","sequence":"additional","affiliation":[{"name":"Federal University of Minas Gerais (UFMG), Columna Institute, Belo Horizonte, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew L.","family":"Miller","sequence":"additional","affiliation":[{"name":"OrthoNebraska, Omaha, NE, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chester J.","family":"Tyson","sequence":"additional","affiliation":[{"name":"Atlantic Brain and Spine, Wilmington, NC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alfred-John","family":"Bayaton","sequence":"additional","affiliation":[{"name":"Duly Health and Care, Naperville, IL, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6706-6539","authenticated-orcid":false,"given":"J. Alex","family":"Thomas","sequence":"additional","affiliation":[{"name":"Atlantic Brain and Spine, Wilmington, NC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2025,3,15]]},"reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.otsr.2016.06.022"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.21037\/jss.2018.07.11"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.3171\/2018.9.SPINE18800"},{"key":"e_1_3_3_5_2","doi-asserted-by":"publisher","DOI":"10.14444\/8573"},{"key":"e_1_3_3_6_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00586-012-2426-5"},{"key":"e_1_3_3_7_2","doi-asserted-by":"publisher","DOI":"10.1097\/BRS.0b013e318278417c"},{"key":"e_1_3_3_8_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.wneu.2019.05.144"},{"key":"e_1_3_3_9_2","doi-asserted-by":"publisher","DOI":"10.3171\/2012.5.SPINE1288"},{"key":"e_1_3_3_10_2","doi-asserted-by":"publisher","DOI":"10.14444\/2062"},{"key":"e_1_3_3_11_2","doi-asserted-by":"publisher","DOI":"10.1093\/neuros\/nyaa064"},{"key":"e_1_3_3_12_2","doi-asserted-by":"publisher","DOI":"10.1055\/s-0035-1569055"},{"key":"e_1_3_3_13_2","doi-asserted-by":"publisher","DOI":"10.3171\/2010.3.SPINE09766"},{"key":"e_1_3_3_14_2","doi-asserted-by":"publisher","DOI":"10.1177\/21925682211049170"},{"key":"e_1_3_3_15_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00586-015-3871-8"},{"key":"e_1_3_3_16_2","doi-asserted-by":"publisher","DOI":"10.1097\/BRS.0000000000000357"},{"key":"e_1_3_3_17_2","doi-asserted-by":"publisher","DOI":"10.1177\/2192568220922979"},{"key":"e_1_3_3_18_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00586-022-07224-9"},{"key":"e_1_3_3_19_2","doi-asserted-by":"publisher","DOI":"10.3171\/2021.11.SPINE211289"},{"key":"e_1_3_3_20_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00586-015-3801-9"},{"key":"e_1_3_3_21_2","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.ST.22.00022"},{"key":"e_1_3_3_22_2","volume-title":"Society for Minimally Invasive Spine Surgery Annual Meeting","author":"Louie P","year":"2023","unstructured":"Louie P. Lateral access complication management: quadriceps palsy - the evidence and management strategies [podium presentation]. In: Society for Minimally Invasive Spine Surgery Annual Meeting. Las Vegas; 2023."},{"key":"e_1_3_3_23_2","volume-title":"Society for Minimally Invasive Spine Surgery Annual Meeting","author":"Nunley P","year":"2023","unstructured":"Nunley P. Size matters for implant and tubular retractors in LLIF but is retraction time impactful when using a smaller portal system? In: Society for Minimally Invasive Spine Surgery Annual Meeting. Las Vegas; 2023. [podium presentation]."},{"key":"e_1_3_3_24_2","volume-title":"Aids to the Investigation of the Peripheral Nervous System","author":"Medical Research Council","year":"1943","unstructured":"Medical Research Council. Aids to the Investigation of the Peripheral Nervous System. 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