Elsevier

World Neurosurgery

Volume 130, October 2019, Pages e1077-e1083
World Neurosurgery

Original Article
Analysis 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

https://doi.org/10.1016/j.wneu.2019.07.091Get rights and content

Background

Lateral interbody fusion (LIF) is an effective adjuvant for circumferential minimally invasive surgery (CMIS) treatment of adult spinal deformity (ASD). Accessing L5-S1 via an oblique LIF (OLIF) approach (OLIF 5–1) allows for anterior LIF (ALIF) at the lumbosacral junction without repositioning the patient. We review the early outcomes and complications of OLIF 5–1 at the bottom of a long construct for an MIS approach to treat ASD.

Methods

We queried a prospectively collected registry of 111 consecutive patients with ASD (Cobb angle >20°, sagittal vertical alignment [SVA] >50, or pelvic incidence [PI]–lumbar lordosis [LL] mismatch>10) patients who underwent CMIS correction between January 2015 and January 2019. Sixty patients had ≥4 levels fused and OLIF 5–1. Multilevel pre-psoas LIF + OLIF 5–1 were performed in the first stage. Three days later, stage 2 involved MIS installation of pedicle screws with aggressive rod contouring and derotation/translation.

Results

The mean patient age was 66.8 years (range, 48–79 years), and the mean duration of follow-up was 24 months (range, 3–60 months). A mean of 7 levels were fused (range, 4–9). Significant improvements in L5-S1 segmental lordosis (SL), LL, SVA, PI–LL mismatch, and pelvic tilt were seen following the first stage (P < 0.05). There was no intraoperative vascular, ureteral, or sympathetic chain injury, and no transient or permanent lumbar plexopathy. In 2 patients, OLIF 5–1 was abandoned due to difficult access, and transforaminal LIF was done at L5-S1 at the second stage. Five patients required intraoperative transfusion. No patient experienced postoperative ileus or L5-S1 pseudarthrosis. Significant improvements in visual analog scale pain score, Oswestry Disability Index, 36-Item Short Form Health Survey, and Scoliosis Research Society Outcomes Questionnaire were found.

Conclusions

A single-position MIS OLIF 5–1 at the bottom of a long construct in conjunction with multilevel pre-psoas LIF seems to be a safe and effective technique for improving SL, global LL, and SVA with a low risk of perioperative and postoperative complications.

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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    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.

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