Abstract
Background Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and oblique lumbar interbody fusion (OLIF) are widely used for treating spondylolisthesis patients, but there is no randomized controlled trial study that directly compared OLIF and MIS-TLIF.
Methods Sixty patients who underwent single-level surgery at L4 to L5 were randomly allocated to the MIS-TLIF or OLIF group. Primary clinical outcomes were visual analog scale (VAS) of back and leg pain, Oswestry Disability Index (ODI) scores, and EQ-5D-5L. Secondary outcomes were radiological outcomes including disc height (DH), foraminal height (FH), foraminal area (FA), cross-sectional area of spinal canal, spinal canal diameter, and fusion rates.
Results Both groups showed significant improvements in clinical outcomes from baseline to each subsequent postoperative period. Predicted mean change (95% CI) in VAS back, VAS leg, ODI scores, and EQ-5D-5L were −3.9 (−4.6 to −3.1), −5.6 (−6.2 to −5.1), −15.7 (−19.0 to −12.5), and 25.4 (21.3–29.6), respectively. Clinical differences in both groups over total follow-up were not statistically significant: VAS back −0.38 (−0.87 to 0.11); P = 0.18, VAS leg: −0.40 (−0.81 to 0.02); P = 0.08, ODI: 0.4 (−1.9 to 2.8); P = 0.7 and EQ-5D-5L: 0.1 (−1.9 to 2.2); P = 0.9. Radiological parameters significantly improved from baseline to early postoperation in both groups. Changes in DH, FH, and FA were lower in MIS-TLIF compared with OLIF. The cross-sectional area of spinal canal change was higher in MIS-TLIF compared with OLIF. Spinal canal diameter change was not different between groups. Fusion rates were similar in both groups.
Conclusions Patient-reported outcomes were significantly improved in both MIS-TLIF and OLIF groups without significant differences between both procedures. OLIF demonstrated advantages in restoration of DH, FH, FA, and lower intraoperative blood loss compared with MIS-TLIF.
Clinical Relevance Both MIS-TLIF and OLIF offer comparable clinical benefits for patients with single-level degenerative spondylolisthesis. However, OLIF may be preferred in cases where greater restoration of disc and foraminal dimensions and reduced intraoperative blood loss are desired.
Level of Evidence 1.
Introduction
Lumbar interbody fusion surgery is currently a surgical option for treating patients with spondylolisthesis.1,2 Several posterior open techniques have been used and demonstrated successful outcomes for this degenerative disease. However, a major disadvantage of conventional lumbar spinal fusion surgeries is the extensive soft tissue dissection, which results in increased blood loss, postoperative pain, and length of hospital stays.3 Various minimally invasive (MI) lumbar spinal fusion techniques have recently been developed and gained popularity because they provide promising outcomes and fewer complications compared with conventional procedures.4–6
Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) was initially described by Foley et al.3 This procedure applied a unilateral paramedian approach to directly decompress the neural elements and subsequently implant an interbody cage to support the anterior spinal column and help achieve arthrodesis. Several studies demonstrated that MIS-TLIF provided superior results to conventional open methods in various degenerative lumbar spine diseases.7–9
Oblique lumbar interbody fusion (OLIF) is another MI technique recently introduced by Silvestre et al.10 The OLIF procedure utilizes the oblique retroperitoneal approach that accesses the targeted intervertebral disc between the great vessels and the psoas muscle.11 In contrast to MIS-TLIF, OLIF indirectly decompresses the neural elements by restoring the disc height (DH) and unbuckling the ligamentum flavum via inserting an interbody cage through the retroperitoneal access.12 This helps preserve the integrity and reduce damage to the posterior spinal structures. Several authors also reported good outcomes following the OLIF procedure for degenerative lumbar spine diseases, including spondylolisthesis.5,13,14
Although OLIF and MIS-TLIF are widely used for treating spondylolisthesis patients, there is no randomized controlled trial that directly compared OLIF and MIS-TLIF. This study aimed to compare clinical and radiological outcomes between OLIF and MIS-TLIF procedures in patients who were diagnosed as having low-grade degenerative spondylolisthesis in a randomized controlled setting.
Methods
Study Design and Patient Populations
This single-center randomized clinical trial was conducted from April 2021 to September 2023 in Thailand. All included patients gave their informed consent before proceeding with the trial. All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board (IRB number 663/63). The trial was registered with the Thai Clinical Trial Registry (TCTR ID: TCTR20200830001).
Patients aged 40 to 80 years who had grades 1 to 2 degenerative spondylolisthesis at the L4 to L5 spinal level, had failed conservative treatment for more than 6 months, and were willing to participate in the trial were eligible for enrollment. Patients with a history of previous lumbar spine surgery, infection, or tumors at the lumbar spine; patients who had profound motor weakness; pregnant or breastfeeding patients; patients with bleeding disorders; and patients who were unlikely to adhere to the follow-up visits were excluded. In addition, patients who needed the operation for more than 1 spinal level were also excluded. Participants’ baseline characteristics, including age, gender, body weight, height, comorbidities, and radiographic results before surgery, were recorded.
The single-level OLIF and MIS-TLIF procedures were performed under general anesthesia by an experienced spine surgeon who had more than 5 years of experience in doing these procedures. The procedures were performed by using the O-arm navigation (Medtronic, Minneapolis, MN, USA) as the main intraoperative method for placing pedicle screws. Regarding MIS-TLIF, patients were placed in a prone position. A mini-paramedian incision was made at the targeted spinal level, followed by insertion of the sequential soft tissue dilators and table-mount tubular retractor to expose the ipsilateral posterior bony elements. Spinal canal decompression was done by ipsilateral laminotomy, facetectomy, and thorough discectomy. The proper size interbody spacer filled with local autologous graft and demineralized bone matrix (GRAFTON, Medtronic, Minneapolis, MN, USA) was inserted into the operated disc space following endplate preparation and sequential trialing. Finally, percutaneous pedicular screws and rods were inserted in a standard fashion.15,16
For the OLIF procedure, patients were placed in a right lateral decubitus position. The incision was made in the anterolateral part of the left-sided abdominal region, centered at the targeted disc level. The retroperitoneal oblique corridor was accessed by blunt dissection and sequential soft tissue dilation. Then, a thorough discectomy and endplate preparation were performed after applying self-retaining retractors. The sequential trialing was done, and an appropriately sized cage filled with demineralized bone matrix was implanted in the disc space. Finally, percutaneous pedicle screws and rods were placed in the same lateral decubitus position.15
The postoperative protocol for these 2 procedures was similar. Patients received adequate postoperative pain control and were encouraged to ambulate early after the surgery. The follow-up visit was scheduled at 1, 3, 6, and 12 months after the surgery, with the assessment of clinical outcomes and plain radiographs at each visit. Postoperative magnetic resonance imaging was performed at 3 months, and a computed tomographic image was obtained at 12 months following surgery.
Outcome Measurements
The primary outcomes were patient-reported outcomes, including the visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI) scores, and EQ-5D-5L scores. These outcomes were assessed by the same blinded research assistant preoperatively and at 1, 3, 6, and 12 months postoperatively.
The secondary outcomes were radiological outcomes, including DH, foraminal height (FH), foraminal area (FA), cross-sectional area (CSA) of spinal canal, spinal canal diameter (SCD), and fusion status. DH was defined as the mean of the anterior and posterior height between the upper and lower endplates of the L4 to L5 level. FH was defined as the distance between the lower edge of the pedicle of L4 to the upper edge of the pedicle of L5. The DH and FH were measured on the preoperative and immediate postoperative lateral radiographs. A T2-weighted image of magnetic resonance imaging was used to evaluate FA, CSA, and SCD at 3 months after the operation. FA was the CSA of the neural foramen at the mid-pedicle on parasagittal cuts. CSA was an area of the spinal canal measured at the facet joint level on an axial cut. The SCD was measured as the length between the annulus’s posterior surface and the ligamentum flavum’s anterior surface (Figure 1). The successful fusion was defined as the presence of bridging bone between the implant and the superior and inferior vertebral endplates of the operated vertebral segment on computed tomography images at 12 months postoperation.
Radiographic measurement: anterior disc height (ADH), posterior disc height (PDH) (A), foraminal height (FH) (B), foraminal area (FA) (C), spinal canal area (SCA) and spinal canal diameter (SCD) (D).
The intraoperative parameters, including operative time, estimated blood loss, fluoroscopic time, O-arm navigation time, and number of fluoroscopic shots, were also recorded.
Sample Size Calculation
The sample size was calculated using a minimal clinically important difference of VAS for back pain, which was 1.2,17 assuming an SD of 1.54.17,18 Based on these assumptions, with a 20% dropout rate, 30 patients per group would give 80% power to detect these differences at a 2-sided significant level of 5%. A P value of less than 0.05 was considered a statistically significant difference.
Randomization
Participants were randomly allocated to the MIS-TLIF or OLIF group using a computerized generation sequence with a block size of 4 in a 1:1 allocation ratio. Patients and outcome assessors were blinded from the treatment allocation throughout the study.
Statistical Analyses
Statistical analyses were performed using Stata 18 (StataCorp, Texas, USA). Participant characteristics are reported as mean (SD) or frequency (percentage). Mixed effects models with random intercept and slope terms were used to analyze the patient-reported outcomes and radiological outcomes, adjusting for parameter values at baseline in the MIS-TLIF group vs the OLIF group as a reference. The intraoperative parameters, which showed a significant skew, were reported as median (interquartile range) and compared using a Wilcoxon rank sum test; those that were normally distributed were compared using an unpaired t test.
RESULTS
Seventy-two participants were assessed for eligibility. Five participants were excluded due to having had previous lumbar spinal surgery. Three participants were excluded due to serious systemic disease. Two patients with profound motor weakness in the lower limbs were also excluded. Two patients could not attend the planned follow-up visits throughout the study. Finally, 60 participants were randomized and allocated equally to the MIS-TLIF and OLIF groups (Figure 2). The demographic and preoperative data were described in Table 1, which showed a comparable baseline between both groups.
The flow diagram of participants throughout the study.
Patient’s preoperative demographic, clinical, and procedure-related characteristics.
Patient-Reported Outcomes
VAS leg pain showed statistically significant improvements from baseline to each postoperative time point in both groups (P < 0.001, Figure 3A). The mean difference in the VAS leg pain scores in the MIS-TLIF vs OLIF group over the total follow-up period was −0.40 (95% CI −0.81–0.02; P = 0.06). The VAS back pain also showed significant improvements from baseline to each postoperative visit (Figure 3B). The mean difference in VAS back pain scores in the MIS-TLIF vs OLIF group over the total follow-up was −0.38 (95% CI −0.87–0.11; P = 0.13).
The patient-reported outcomes. Visual analog scale (VAS) leg pain (A), VAS back pain (B), Oswestry Disability Index (ODI) scores (C), and EQ-5D-5L scores (D).
The ODI scores were significantly improved from baseline to each postoperative period in both groups (Figure 3C). The mean difference in ODI scores in the MIS-TLIF vs OLIF group over the total follow-up was 0.46 (95% CI −1.92–2.88; P = 0.71). The EQ-5D-5L scores also showed significant improvements from baseline to each postoperative period in both groups (Figure 3D). However, the overall difference in improvement in the MIS-TLIF vs OLIF group was not statistically significant (mean difference = 0.17; −1.98–2.31; P = 0.88).
Radiological Outcomes
Radiological parameters significantly improved from baseline to postoperation in all patients (Figure 4). The changes in DH (−0.8 [−1.2 to −0.5] mm; P < 0.001), FH (1.2 [−1.7 to −0.7] mm; P < 0.001), and FA (−6.1 [−9.9 to −2.3] mm2; P = 0.002) were lower in the MIS-TLIF vs OLIF group. CSA change was higher in the MIS-TLIF group compared with the OLIF group (19.4 [10–28.7] mm3; P < 0.001), and SCD change was not different between groups (0.3 [−0.2 to 0.7] mm; P = 0.3). The fusion rates were not significantly different between these 2 procedures at 1 year postoperation. The MIS-TLIF group demonstrated fusion of the operated spinal level in 28 of the 30 patients (93.3%), and the OLIF group showed that 29 of the 30 patients (96.7%) were successfully fused at the operated level.
The mean difference of each radiographic parameter between postoperative and preoperative timepoints in the minimally invasive transforaminal lumbar interbody fusion (TLIF) group vs the oblique lumbar interbody fusion (OLIF) group.
Perioperative Outcomes
The perioperative outcomes between the 2 groups are shown in Table 2. The mean estimated blood loss was significantly less in OLIF (100 [50–150] mL) compared with MIS-TLIF (150 [60–200] mL, P = 0.03). The mean operative time was similar between both groups (MIS-TLIF: 110.5 [100–136] minutes vs OLIF: 110.5 [100–134] minutes; P = 0.69). The postoperative length of hospital stay was also comparable between these 2 groups (MIS-TLIF: 2.5 ± 0.62 days vs OLIF: 2.36 ± 0.55 days, P = 0.39). Fluoroscopic time (MIS-TLIF: 7 [4–15] minutes vs OLIF: 12 [7–18] minutes; P = 0.02) and the number of fluoroscopic shots (MIS-TLIF: 9 [8–15] vs OLIF: 13 [10–50]; P = 0.045) were significantly lower in the MIS-TLIF group compared with the OLIF group.
Perioperative outcomes.
Approach-Related Complications
The approach-related adverse event rates are shown in Table 3. In the MIS-TLIF group, incidental durotomy occurred in 2 patients, which was directly repaired intraoperatively. One of the 2 patients developed a new onset of contralateral radiculopathy that gradually resolved within 3 months after the operation. In the OLIF group, 4 patients had sympathetic chain injury, which is characterized by elevated skin temperature on the left lower extremity of the approach side. In addition, anterior thigh pain, transient psoas muscle weakness, and contralateral lumbar radiculopathy occurred in 3 different patients following the OLIF procedure. All these symptoms resolved within 3 months after the operations. Another patient in the OLIF group developed postoperative bowel ileus; this patient recovered on postoperative day 5. No approach-unrelated complication occurred in this study.
Comparison of approach-related complications between MIS-TLIF and OLIF procedures.
Discussion
Lumbar interbody fusion has become a widely accepted method for treating various degenerative lumbar spine diseases.19 Previous studies demonstrated that the MI spinal procedure provided similar clinical outcomes, with less blood loss and shorter hospital stays compared with traditional open techniques.4–6 MIS-TLIF and OLIF procedures, which are 2 of the most common MI lumbar spinal fusion procedures, are often considered for treating several degenerative spinal pathologies, including spondylolisthesis.19
MIS-TLIF provides direct decompression of the neural elements from the posterior approach. On the contrary, OLIF indirectly decompresses the neural structures through the distraction of the operated intervertebral disc and ligamentotaxis via the retroperitoneal oblique corridor.13,14 Several studies reported promising results following these 2 procedures.14,20–22 However, controversies regarding the efficacy of the indirect decompression compared with direct decompression still exist, and few studies directly compared the outcomes between these 2 procedures.18,22–24 To the author’s knowledge, this study represented the first randomized controlled trial that compared clinical and radiographic outcomes of these procedures for treating patients who were diagnosed with low-grade degenerative spondylolisthesis.
In this study, we analyzed the outcomes of patients who were diagnosed with single-level low-grade degenerative spondylolisthesis at the L4 to L5 level and underwent MIS-TLIF or OLIF procedures and found comparable clinical outcomes in both groups at each postoperative follow-up visit. These findings are similar to those reported in previous studies. Lin et al conducted a matched pair retrospective study in 50 patients with low-grade spondylolisthesis or lumbar spinal stenosis at the L4 to L5 level and reported no significant difference in postoperative VAS and ODI scores between the MIS-TLIF and OLIF groups.22 Koike et al also conducted a retrospective study in patients with single-level degenerative spondylolisthesis who underwent single-position OLIF or MIS-TLIF. The authors found that the changes in VAS, physical function, and quality of life parameters (JOABPEQ) of the OLIF and MIS-TLIF were almost equivalent. However, OLIF provided significant superiority in the psychological domain.23
In terms of radiological outcomes, all studied parameters were significantly improved from the preoperative to postoperative periods. The changes in DH, FH, and FA were lower in the MIS-TLIF compared with the OLIF group. Several studies also found that OLIF was superior to MIS-TLIF regarding the restoration of disc and foraminal heights.18,22,23 This is because surgeons are usually able to implant a larger cage into the operated disc space, which alleviates significant disc restoration.22 On the contrary, the change in CSA from baseline to postoperation was higher in MIS-TLIF compared with OLIF. This is due to the effect of direct decompression from MIS-TLIF, which directly removed the ipsilateral posterior bony elements and ligamentum flavum to decompress and expand the spinal canal.16 However, despite the lesser spinal canal area achieved from indirect decompression in OLIF, the clinical improvement was favorable and comparable to the direct decompression effect from MIS-TLIF.15 Furthermore, our results demonstrated SCD improvement in both groups without a statistically significant difference. This finding suggests that OLIF can also effectively increase SCD through indirect decompression mechanisms, including ligamentotaxis, restoration of DH, and reduction of the spondylolisthesis.
In this study, we found that the estimated blood loss in the OLIF group was significantly less compared with that of the MIS-TLIF group. This finding was consistent with findings in several previous studies22,24 because the OLIF technique is performed through the retroperitoneal space, while the MIS-TLIF requires more dissection of the paraspinal muscles and more bone work for direct decompression, which causes more bleeding.24 Regarding the operative time and postoperative hospital stays, we found no significant difference between the 2 procedures. Previous studies reported mixed results. Koike et al found that the operation time was comparable between MIS-TLIF and OLIF procedures.23 Lin et al reported that the operative time was significantly shorter in the OLIF group compared with the MIS-TLIF.22 The difference in these results might be due to the difference in surgical techniques and whether the surgeons completed the OLIF in a single lateral position or not. Using a single lateral position for the OLIF procedure in this study helps shorten the operative time in this study. Ouchida et al also showed significantly shortened operative time when performing the lateral lumbar interbody fusion surgery in a single position compared with the repositioning.25
Regarding the complications, our results were within the range of the previous studies. Weiss et al reported that the most frequently documented complications following MIS-TLIF were radiculitis (2.8%–57.1%), screw malposition (0.3%–12.7%), and incidental durotomy (0.3%–8.6%).26 In the MIS-TLIF group of this study, we found that 6.6% and 3.3% of patients had incidental durotomy and contralateral radiculopathy, respectively. Li et al found that the most consistently reported postoperative complications following the OLIF procedure were transient thigh pain and/or numbness (3%) and hip flexion weakness (1.2%).24 For the sympathetic chain injury, we found that 13.3% of patients had this complication following the OLIF procedure. This incidence rate is consistent with a study by Kim et al, who reported that 13.4% of 29 patients who underwent OLIF L4 to L5 had this neurological injury.27 Similarly, a more recent prospective study by Singhatanadgige et al reported a 17.5% incidence at the same spinal level.28
In addition, we found that both techniques achieved comparable and high fusion rates (>90%), which is similar to a previous report by Li et al.24 For MIS-TLIF, Singhatanadgige et al reported that the fusion rate at 12 months was 95.9%.29 Limthongkul et al showed that the overall fusion rate reached 96.4% following the OLIF procedure.30
Limitations
This study has some limitations. First, we were unable to blind the surgeon; however, the surgeon was not involved in assessing the study outcomes. Second, this study included only the L4 to L5 spinal level. Therefore, the clinical results, radiological outcomes, and complications may differ when other spinal levels or multilevel procedures were performed. Third, we analyzed the data up to only 1 year after the operations. This period may not be long enough to detect differences in longer-term outcomes and late sequelae, including pseudarthrosis, cage subsidence, and adjacent segment pathologies. Lastly, this study was conducted by a single surgeon at a single tertiary referral center, so the results may not be generalizable.
Conclusions
Both MIS-TLIF and OLIF procedures can achieve equivalent satisfactory clinical results for patients with low-grade degenerative spondylolisthesis. However, the OLIF technique resulted in better improvement of several radiological outcomes and less blood loss compared with the MIS-TLIF.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Ethics Approval Institutional Review Board of King Chulalongkorn Memorial Hospital, Bangkok, Thailand (IRB number 663/63). Thai Clinical Trial Registry (TCTR ID: TCTR20200830001)
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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