Elsevier

The Spine Journal

Volume 17, Issue 4, April 2017, Pages 545-553
The Spine Journal

Clinical Study
Technical description of oblique lateral interbody fusion at L1–L5 (OLIF25) and at L5–S1 (OLIF51) and evaluation of complication and fusion rates

https://doi.org/10.1016/j.spinee.2016.10.026Get rights and content

Abstract

Background Context

The oblique lateral interbody fusion (OLIF) procedure is aimed at mitigating some of the challenges seen with traditional anterior lumbar interbody fusion (ALIF) and transpsoas lateral lumbar interbody fusion (LLIF), and allows for interbody fusion at L1–S1.

Purpose

The study aimed to describe the OLIF technique and assess the complication and fusion rates.

Study Design

This is a retrospective cohort study.

Patient Sample

The sample is composed of 137 patients who underwent OLIF procedure.

Outcome Measures

The outcome measures were adverse events within 6 months of surgery: infection, symptomatic pseudarthrosis, hardware failure, vascular injury, perioperative blood transfusion, ureteral injury, bowel injury, renal injury, prolonged postoperative ileus (more than 3 days), incisional hernia, pseudohernia, reoperation, neurologic deficits (weakness, numbness, paresthesia), hip flexion pain, retrograde ejaculation, sympathectomy affecting lower extremities, deep vein thrombosis, pulmonary embolism, myocardial infarction, pneumonia, and cerebrovascular accident. The outcome measures also include fusion and subsidence rates based on computed tomography (CT) done at 6 months postoperatively.

Methods

Retrospective chart review of 150 consecutive patients was performed to examine the complications associated with OLIF at L1–L5 (OLIF25), OLIF at L5–S1 (OLIF51), and OLIF at L1–L5 combined with OLIF at L5–S1 (OLIF25+OLIF51). Only patients who had at least 6 months of postoperative follow-up, including CT scan at 6 months after surgery, were included. Independent radiology review of CT data was performed to assess fusion and subsidence rates at 6 months.

Results

A total of 137 patients underwent fusion at 340 levels. An overall complication rate of 11.7% was seen. The most common complications were subsidence (4.4%), postoperative ileus (2.9%), and vascular injury (2.9%). Ileus and vascular injuries were only seen in cases including OLIF51. No patient suffered neurologic injury. No cases of ureteral injury, sympathectomy affecting the lower extremities, or visceral injury were seen. Successful fusion was seen at 97.9% of surgical levels.

Conclusions

Oblique lateral interbody fusion is a safe procedure at L1–L5 as well as L5–S1. The complication profile appears acceptable when compared with LLIF and ALIF. The oblique trajectory mitigates psoas muscle and lumbosacral plexus-related complications seen with the lateral transpsoas approach. Furthermore, there is a high fusion rate based on CT data at 6 months.

Introduction

In 1906, Muller described an anterior transperitoneal approach to treat tuberculous spondylitis [1], [2]. Since that time, there has been a trend toward lesser invasive methods of achieving similar surgical goals as the Muller procedure.

In 1932, Capener described a theoretical anterior treatment for L5–S1 spondylolisthesis, which involved driving a bone peg from the fibula or tibia through the L5 vertebral body and into the sacrum [3]. Then, in 1933, Burns performed the actual operative undertaking described by Capener, and later recommended a metal peg to prevent reabsorption of the graft [4]. The retroperitoneal approach described by Iwahara in 1944 was the next leap in the progression of lumbar fusion techniques [5]. In the 1950s, Hodgson and others further developed bone grafting ideas for Pott disease, leading to the use of iliac crest autograft and paving the way for the modern anterior lumbar interbody fusion (ALIF) [6].

Toward the end of the 20th century, a series of catalytic advancements was seen, including the emergence of Bagby and Kuslich intervertebral cages [7]. Anteriorly placed intervertebral cages allowed for high fusion rates, restoration of lumbar lordosis and disc height, and indirect neural decompression. Using the operative microscope, Mayer first presented his technique in 1995 [8], then went on to describe the minimally invasive retroperitoneal (L2–L5) and transperitoneal (L5–S1) ALIF in 1997, using a mini-incision to achieve similar goals as traditional open procedures. Mayer reported successful outcomes and lower complication rates along with less blood loss than traditional ALIF [9].

The extreme lateral interbody fusion (XLIF) was introduced in 2004, and this was followed by the direct lateral interbody fusion (DLIF) in 2007 [10], [11]. Lateral approaches have increasingly been used to treat degenerative disease, tumors, trauma, and scoliosis. Despite the heavy reliance on neurophysiological monitoring to navigate past the lumbosacral plexus, there remains morbidity associated with psoas disruption as well as lumbosacral plexus vulnerability.

The authors of this manuscript describe a novel procedure, the oblique lateral interbody fusion (OLIF), which is an antepsoas approach. By using an oblique trajectory, this procedure aims to avoid disruption of the psoas muscle and lumbosacral plexus. This shift from direct lateral to oblique is analogous to the shift from Cloward's posterior lumbar interbody fusion to the transforaminal lumbar interbody fusion by Harms and Rolinger in 1982 [12], [13]. The authors describe the OLIF surgical technique and assess complication and computed tomography (CT) fusion rates retrospectively.

Section snippets

Materials and methods

Evidence & Methods

Context

Substantive advantages are associated with anterior and lateral (transpsoas) interbody techniques. There are also a number of downsides, including the fact that transpsoas approaches cannot access the L5-S1 level. The authors present their experience with a modified lateral approach that they maintain allows access to L5-S1 among other lumbar disc spaces and decreases the morbidity associated with a transpsoas technique. The authors term their technique the

Results

A total of 137 patients underwent OLIF at 340 surgical levels. The patients were divided into three groups: 43 patients who underwent OLIF25 only, 10 patients who underwent OLIF51 only, and 84 patients who underwent OLIF25 combined with OLIF51. There were 64 men and 73 women, with ages ranging from 26 to 89 years (mean age of 62 years). The patient demographics and indications for surgery are summarized in Table 1.

Adverse events were seen in 16 patients, giving an overall complication rate of

Discussion

From the patient's left side, there is a clear corridor from L2 to L5 between the psoas and the aorta that averages approximately 18 mm. This corridor can be further expanded to an average of 26 mm by gentle sweeping of the most medial or anterior fibers of the psoas in the lateral or posterior direction [15]. The L5–S1 disc space can be reached through the oblique corridor by staying medial to the left psoas and left common iliac vein. Particular attention should be paid to transitional

Conclusions

Oblique lateral interbody fusion is a safe procedure at L1–L5 as well as L5–S1. The complication profile appears acceptable when compared with lateral lumbar interbody fusion and anterior lumbar interbody fusion. The oblique trajectory mitigates psoas muscle and lumbosacral plexus-related complications seen with the lateral transpsoas approach. Furthermore, there is a high fusion rate based on CT data at 6 months. Prospective studies are forthcoming to assess clinical outcomes.

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FDA device/drug status: Not applicable.

Author disclosures: KRMW: Grant: Medtronic (D, Paid to the institution), pertaining to submitted manuscript; Consulting: Medtronic (C), outside the submitted work. JBB: Royalties: NuVasive (F), outside the submitted work; Consulting: Medtronic (C), NuVasive (B), St Jude Medical (B), Alphatec (C), outside the submitted work. RAH: Royalties: Medtronic (G), outside the submitted work; Consulting: Medtronic (E), Spine Wave (B), outside the submitted work; Speaking and/or Teaching Arrangements: Medtronic (E), outside the submitted work; Trips/Travel: Medtronic (C), outside the submitted work.

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