Original ArticleAnalysis of Spino-Pelvic Parameters and Segmental Lordosis with L5-S1 Oblique Lateral Interbody Fusion at the Bottom of a Long Construct in Circumferential Minimally Invasive Surgical Correction of Adult Spinal Deformity
Introduction
Lumbar fusion has become a common treatment modality for such conditions such as degenerative disc disease, spondylolisthesis, and spinal deformity. The oblique lateral interbody fusion (OLIF) approach is one of the many available lateral interbody fusion (LIF) surgical modalities, including anterior LIF (ALIF), lateral LIF, direct LIF, extreme LIF, transforaminal LIF, and posterior LIF, that are used in cases that require interbody fusion of lumbar vertebrae. The number of fusion surgeries performed in the United States increased by almost 2.4-fold (113%) between 1998 and 2008.1, 2, 3
The advent of minimally invasive surgery (MIS) brought the OLIF, extreme LIF, and direct LIF approaches to the forefront of lumbar fusion advancement by providing similar outcomes as seen with open approaches but with lower overall morbidity and less muscle damage.4, 5, 6, 7, 8
In 1997, Mayer9 laid the foundation for OLIF by describing an MIS anterior approach to the lumbar spine through retroperitoneal access for the L2-3 to L4-5 discs and transperitoneal access for the L5-S1 disc. However, due to a high rate of complications, including vascular laceration and dural tear, in 2012, Silvestre et al.10 modified Mayer's approach and introduced the currently used OLIF procedure. Since then, a number of studies have shown that OLIF is safe, with acceptable outcomes and a low rate of complications.11, 12, 13, 14, 15 However, performing OLIF at the L5-S1 level (OLIF 5–1) remains controversial, given the risks of vessel mobilization and obstruction by the iliac wing.10
We believe that the risks of OLIF 5–1 surgery can be overcome with meticulous planning and skilled surgical technique. The ability to access L5-S1 through the same lateral position as a lateral LIF with an OLIF approach allows for anterior fusion at the lumbosacral junction, providing interbody lumbosacral support through an MIS technique without the need to reposition the patient. In the present study, we examined early outcomes and complications of OLIF 5–1 performed at the bottom of a long construct in MIS treatment of adult spinal deformity (ASD).
Section snippets
Materials and Methods
This is a single-center study drawing on a prospective database of patients who underwent circumferential MIS (CMIS) correction for ASD (Cobb angle >20°, sagittal vertical alignment (SVA) >50 mm, or pelvic incidence (PI)–lumbar lordosis [LL] mismatch >10) by the senior author between January 2015 and January 2019. Institutional Review Board approval for the study was obtained.
Patients with at least 4 levels fused spanning the L5-S1 junction were included. Indications for surgery included
Results
A total of 60 patients (39 females and 21 males) met the inclusion criteria. The mean patient age was 66.8 ± 7.6 years (range, 48 to 79 years). An average of 7 levels (range, 4 to 9) were fused.
The average blood loss was 314 ± 155 mL (range, 100 to 700 mL) during stage 1 and 328 ± 167 mL (range, 50 to 800 mL) during stage 2. The mean length of stay was 8.9 ± 3.7 days (range, 2 to 18 days). The mean operating time 247.9 ± 59 minutes (range, 139 to 366 minutes) for stage 1 and 245.6 ± 69 minutes
Discussion
Long-construct CMIS for ASD is a challenging task. High complication rates, difficulty in deformity correction, prolonged surgical times, and increased radiation exposure are all concerns associated with this type of surgical intervention. Perhaps one of the most important and difficult tasks is achieving lumbosacral junction fusion at the bottom of a long construct in ASD surgery. Our group has published extensively on this topic and has outlined the continually developing protocol for
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Cited by (25)
“Selection, planning and execution of minimally invasive surgery in adult spinal deformity correction”
2023, Seminars in Spine SurgeryA comparison of long-term efficacy of K-rod-assisted non-fusion operation and posterior lumbar interbody fusion for single-segmental lumbar disc herniation
2022, Journal of Clinical NeuroscienceCitation Excerpt :When degenerative changes occur in the lumbar spine, these parameters change; for instance, the PI value will increase in patients with degenerative lumbar spondylolisthesis [30,32–34]. Meanwhile, surgery affects spino-pelvic parameters as well as LL [35–38]. We found no significant differences in the PI value between the PLIF group and K-rod group before or after operation.
Factors affecting disc angle restoration in oblique lateral interbody fusion at L5–S1
2021, Spine JournalCitation Excerpt :Nevertheless, the rationale for anterior lumbosacral fusion is that it might provide a better radiological outcome [14,15]. Recent studies with OLIF at L5–S1 reported favorable radiological outcomes [15–17]. However, the factors associated with a greater DA restoration with OLIF at L5–S1 have not been studied.
Inclusion of L5–S1 in oblique lumbar interbody fusion–techniques and early complications–a single center experience
2021, Spine JournalCitation Excerpt :Access to L5–S1, however, is more challenging due to the bifurcation of the great vessels. While inclusion of L5–S1 in multilevel OLIF may simplify the procedure, as multiple levels are addressed in the same lateral decubitus position [14,15] and often through the same incision site, it requires a careful and detailed assessment of the vascular anatomy, often necessitating ligation, careful mobilization, and retraction of vascular structures. Due to such complexity and the learning curve involved when including L5–S1 in OLIF, one may hypothesize that L5–S1 inclusion increases the likelihood of complications and morbidity associated with the procedure.
Conflict of interest statement: N. Anand serves as a board/committee member for the American Academy of Orthopedic Surgeons; serves on the Educational and Publication Committees of the International Society for the Advancement of Spine Surgery, the Educational Committee of the Society for Minimally Invasive Spine Surgery, and the editorial/governing board of European Spine Journal; serves as a board/committee member of the Scoliosis Research Society; receives IP royalties from and serves as a paid consultant and paid presenter/speaker for Medtronic; receives IP royalties, publishing royalties, and financial/material support from Elsevier; receives IP royalties from and serves as a paid presenter/speaker for Globus Medical; and holds stock/stock options from GYS Tech, Medtronic, Paradigm Spine, and Theracell. E. Nomoto serves in a consulting/teaching capacity for Nuvasive, DePuy Synthes, and Medtronic. A. Alayan receives research support from Acumed.