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Nayak R, Razzouk J, Ramos O, Mehta S, Harianja G, Wycliffe N, Danisa O, Cheng W. Oblique lateral interbody fusion at L5-S1: feasibility, surgical approach window, incision line, and influencing factors. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:2604-2610. [PMID: 38409532 DOI: 10.1007/s00586-023-08017-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 10/20/2023] [Indexed: 02/28/2024]
Abstract
PURPOSE The primary aim of this study was to describe the feasibility, surgical approach window (SAW), and incision line (IL) for oblique lateral interbody fusion at L5-S1 (OLIF51) using computed tomography (CT). A secondary aim was to identify associations among approach characteristics and demographic and anthropometric factors. METHODS We performed a radiographic study of 50 male and 50 female subjects who received abdominal CT imaging. SAW was measured as the distance from the midline to the medial border of the iliac vessel. IL was measured at the skin surface corresponding to the distance between the center of the disc space and SAW lateral margin. OLIF51 feasibility was defined as the existence of at least a 1-cm SAW without retraction of soft tissues. RESULTS For the left side, the OLIF51 SAW and IL were 12.1 ± 4.6 and 175.1 ± 55.3 mm. For the right side, these measures were 10.0 ± 4.3 and 185.0 ± 52.5 mm. Correlations of r = 0.648 (p < 0.001) and r = 0.656 (p < 0.001) were observed between weight and IL on the left and right sides, respectively. OLIF51 was not feasible 23% of the time. CONCLUSION To our knowledge, this is the largest CT study to determine the feasibility of performing an OLIF51. Without the use of retraction, OLIF51 is not feasible 23% of the time. Left-sided OLIF51 allows for a larger surgical approach window and smaller incision compared to the right side. Larger incisions are required for adequate surgical exposure in patients with higher weight.
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Affiliation(s)
- Rusheel Nayak
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Jacob Razzouk
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Omar Ramos
- Twin Cities Spine Center, Minneapolis, MN, USA
| | - Shaurya Mehta
- University of California Riverside, Riverside, CA, USA
| | - Gideon Harianja
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Nathaniel Wycliffe
- Department of Radiology, Loma Linda University Health, Loma Linda, CA, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis VA Medical Center, 25805 Barton Road A106, Loma Linda, CA, 92354, USA.
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Wu Y, Ma J, Dai J, Wang Y, Bai H, Lu B, Chen J, Fan X, Ma X. Design and Biomechanical Evaluation of a Bidirectional Expandable Cage for Oblique Lateral Interbody Fusion. World Neurosurg 2023; 180:e644-e652. [PMID: 37805128 DOI: 10.1016/j.wneu.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/01/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVE Oblique lateral interbody fusion (OLIF) surgery is a minimally invasive spinal surgery technique that has become increasingly popular in recent years. The primary objective of the current study was to design a minimally invasive expandable fusion device that can reduce iatrogenic nerve damage and minimize endplate damage during OLIF surgery, while restoring intervertebral height and alignment. The second objective was to use finite element analysis to evaluate the biomechanical stability of the newly designed expandable fusion device after implantation into the intervertebral space. METHODS A new bidirectional expandable cage was designed in this study. A finite element model (FEM) of L3-L5 lumbar segment was modified to simulate decompression and fusion. The modified FEMs were constructed in the following cases: intact model, bidirectional expandable cage (alone, with unilateral pedicle screws [UPSs], and with bilateral pedicle screws [BPSs]) model, conventional OLIF cage (alone, with UPSs, and with BPSs) model. To simulate physiological loadings, the models were subjected to a follower compressive pre-load of 400 N, in addition to 8.0 Nm of flexion, extension, lateral bending, and axial rotation moments. RESULT All modified FEMs exhibited a significant reduction in motion at L3-L5 compared to the intact model. Among the fusion models, the bidirectional expandable cage (BEC) with BPS model displayed the highest stiffness and demonstrated a reduced range of motion (48.5%-75.7%). Additionally, the peak stress on the endplate in the conventional OLIF cage (Conv-OLIF) model was generally lower than that in the BEC models. The cage in the BEC ALONE model exhibited the highest stress (93.87-176.3 MPa) on the endplate in most motion modes, while the cage in the Conv-OLIF+BPS model had the lowest stress (16.67-30.58 MPa) on the endplate in most motion modes. The maximum stress on the fixation in the BEC fusion models was generally lower than that in the Conv-OLIF fusion group under the same loading conditions. The OLIF ALONE model had the lowest stress on the adjacent disc, while the stress level in the BEC ALONE model was very close to it. CONCLUSIONS The BEC implanted models had higher stiffness, and more proper stress distribution on the posterior fixation was comparable to that of the Conv-OLIF models. However, the endplate stress peaks and cage stress peaks of the BEC models were slightly higher than those of the Conv-OLIF models, though still within a clinically acceptable range. Taking into account both biomechanical and clinical perspectives, BEC-assisted unilateral pedicle screw fixation meet clinical demand and may serve as a viable alternative to Conv-OLIF fusion.
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Affiliation(s)
- Yanfei Wu
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, People's Republic of China; Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China
| | - Jianxiong Ma
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China
| | - Jing Dai
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, People's Republic of China; Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China
| | - Ying Wang
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China
| | - Haohao Bai
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China
| | - Bin Lu
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China
| | - Jiahui Chen
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, People's Republic of China; Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China
| | - Xiancheng Fan
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China
| | - Xinlong Ma
- Clinical College of Orthopedics, Tianjin Medical University, Tianjin, People's Republic of China; Department of Spinal Surgery, Tianjin Hospital, Tianjin, People's Republic of China.
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CreveCoeur TS, Sperring CP, DiGiorgio AM, Chou D, Chan AK. Antepsoas Approaches to the Lumbar Spine. Neurosurg Clin N Am 2023; 34:619-632. [PMID: 37718108 DOI: 10.1016/j.nec.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Lumbar interbody fusion (LIF) is a well-established approach in treating spinal deformity and degenerative conditions of the spine. Since its inception in the 20th century, LIF has continued to evolve, allowing for minimally invasive approaches, high fusion rates, and improving disability scores with favorable complication rates. The anterior to the psoas (ATP) approach utilizes a retroperitoneal pathway medial to the psoas muscle to access the L1-S1intervertebral disc spaces. In contrast to the transpsoas arppoach, its primary advantage is avoiding transgressing the psoas muscle and the contained lumbar plexus, which potentially decreases the risk of injury to the lumbar plexus. Avoiding transgression of the psoas may minimize the risk of transient or permanent neurological deficits secondary to lumbar plexus injury. Indications for ATP approaches may expand as it is shown to be a safe and effective method of achieving spinal arthrodesis.
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Affiliation(s)
- Travis S CreveCoeur
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, NY 10033, USA
| | - Colin P Sperring
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, NY 10033, USA
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Dean Chou
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 5141 Broadway, New York, NY 10034, USA
| | - Andrew K Chan
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 5141 Broadway, 3FW, Room 20, New York, NY 10034, USA.
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Razzouk J, Ramos O, Mehta S, Harianja G, Wycliffe N, Danisa O, Cheng W. CT-based analysis of oblique lateral interbody fusion from L1 to L5: location of incision, feasibility of safe corridor approach, and influencing factors. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07555-1. [PMID: 37118479 DOI: 10.1007/s00586-023-07555-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 12/12/2022] [Accepted: 01/22/2023] [Indexed: 04/30/2023]
Abstract
PURPOSE The primary aim was to measure the safe corridor (SC), surgical incision anterior margin (AM), and posterior margin (PM) for OLIF bilaterally from L1 to L5. The secondary aim was to determine the feasibility of approach via the SC. The tertiary aim was to analyze the influence of demographic and anthropometric factors on OLIF parameters. METHODS We performed a radiographic analysis of 100 subjects who received an abdominal CT. Measurements of the AM, PM, and SC were obtained as well as patient age, sex, height, weight, and BMI. The intraclass correlation coefficient was used to evaluate interrater reliability. To assess associations among variables, Pearson's correlation tests and multivariate linear regression models were constructed. Sex differences were analyzed using Student's t tests. RESULTS At L1-2, L2-3, L3-4, and L4-5, the PM was 6.6, 8.2, 9.4, and 10.2 cm on the left side and 7.2, 7.7, 8.8, and 9.5 cm on the right side in relation to the disk space center. The SC was less than 1 cm 1%, 3%,3%, and 18% of the time on the left side, and 15%, 12%,29%, and 60% on the right side. None of the anthropometric factors demonstrated a strong correlation with incision location. SC was larger on the left side. Interrater ICC was .934. CONCLUSIONS This study is the first to provide guidelines on the appropriate location of the incision line during OLIF based on SC from L1 to L5. SC measurements do not vary by sex. OLIF is more feasible via a left-sided approach.
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Affiliation(s)
- Jacob Razzouk
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Omar Ramos
- Twin Cities Spine Center, Minneapolis, MN, USA
| | - Shaurya Mehta
- University of California Riverside, Riverside, CA, USA
| | - Gideon Harianja
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Nathaniel Wycliffe
- Department of Radiology, Loma Linda University Health, Loma Linda, CA, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Wayne Cheng
- Division of Orthopaedics, Jerry L. Pettis VA Medical Center, 25805 Barton Road A106, Loma Linda, CA, 92354, US.
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Wang K, Zhang X, Zhao Z, Chou D, Jian F, Wu H. A modified oblique lumbar interbody fusion: A better way to establish an exposure under direct microscopic vision. Front Surg 2023; 10:1130489. [PMID: 36950057 PMCID: PMC10025467 DOI: 10.3389/fsurg.2023.1130489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/15/2023] [Indexed: 03/08/2023] Open
Abstract
Study design This is a retrospective study. Objective To demonstrate a modified oblique lumbar interbody fusion (OILF) technique for L1-L5. Methods The modified technique splits anterior portion of psoas belly to access the oblique corridor (OC) anteroinferior to psoas, minimizing psoas manipulation and retraction and avoiding nerve injury while offering excellent microscopic visualization. Psoas weakness and neurovascular complication rates in patients treated with traditional OLIF (T-OLIF) or anteroinferior psoas OLIF (AP-OLIF) were retrospectively reviewed. Clinical outcomes were also reviewed. Results A total of 162 cases treated with T-OLIF (n = 73) and AP-OLIF (n = 89) for degenerative lumbar disease were included. The mean operative time and blood loss were less with AP-OLIF (P < 0.01). Approach related complications were 14 (19.1%) with T-OLIF and 4 (4.5%) with AP-OLIF. Postoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores improved in both T-OIF and AP-OIF groups (P < 0.01). Conclusion The modified OLIF technique (AP-OLIF) is characterized by an easy exposure of the lumbar spine under direct microscopic vision, resulting in less psoas weakness and neurovascular injury.
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Affiliation(s)
- Kai Wang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xiangyu Zhang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Zirun Zhao
- Department of Radiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Dean Chou
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, United States
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
- Correspondence: Hao Wu
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Zhang L, Chen S, Wang K, Wu H. Microsurgical treatment of lumbar paravertebral tumors via lateral retroperitoneal approach: operative technique and a series of 6 patients. BMC Surg 2022; 22:324. [PMID: 36030237 PMCID: PMC9419385 DOI: 10.1186/s12893-022-01774-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To investigate the surgical techniques and postoperative therapeutic effectiveness of microsurgical treatment of lumbar paravertebral tumors via lateral retroperitoneal approach. METHODS The clinical data of 6 cases with lumbar paravertebral tumors treated by lateral retroperitoneal approach in the Neurosurgery department of Xuanwu Hospital, Capital Medical University were analyzed retrospectively. The mean operation time, blood loss, incision length, length of hospital stay, and the resection rate of paravertebral tumors were collected, and the score of The Ability to Perform Activities of Daily Living (ADL) and incidence of postoperative complications was recorded. RESULTS The operation time ranged from 56 to 181 min, with an average of (94.8 ± 48.3) minutes. The blood loss was between 5 and 100 ml, with an average of (31.7 ± 37.5) ml. The incision length was 6-7 cm, with an average of (6.7 ± 0.5) cm. The hospitalization length was between 5 and 11 days, with an average of (8.7 ± 2.6) days. The resection rate of paravertebral tumors was 100%. Postoperative pathological diagnosis results revealed 4 cases of schwannoma, 1 case of ganglioneuroma, and 1 case of malignant small round cell tumor. During the 3-month follow-up, there were no tumor recurrence, abdominal infection, incision infection, incisional hernia, or death, and there was no significant decrease in the ADL score compared with that before the operation. CONCLUSION The surgical treatment of lumbar paravertebral tumors via the lateral retroperitoneal approach has the advantages of the short operation time, minimally invasive procedures, quick postoperative recovery, and fewer complications.
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Affiliation(s)
- Lei Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, 45 Changchun Street, 45 Changchun Street, Beijing, People's Republic of China, 100053
| | - Shichao Chen
- Department of Neurosurgery, Capital Medical University Affiliated Beijing Ditan Hospital, 8 Jingshundong Street, Beijing, People's Republic of China, 100015
| | - Kai Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, 45 Changchun Street, 45 Changchun Street, Beijing, People's Republic of China, 100053.
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, 45 Changchun Street, 45 Changchun Street, Beijing, People's Republic of China, 100053.
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Tannoury C, Das A, Saade A, Bhale R, Chen K, Tannoury T. The Antepsoas (ATP) Surgical Corridor for Lumbar and Lumbosacral Arthrodesis: A Radiographic, Anatomic, and Surgical Investigation. Spine (Phila Pa 1976) 2022; 47:1084-1092. [PMID: 35834370 DOI: 10.1097/brs.0000000000004360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 03/12/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To investigate the size of prepsoas surgical corridors, developed between the iliopsoas and prespinal vessels, at all disk levels between L1 and S1 granted by left and right lateral antepsoas (ATP) approaches. Secondary aims include evaluation of presurgery radiographic prepsoas windows between L1 and S1 with respect to the intraoperative findings. SUMMARY OF BACKGROUND DATA The ATP technique is an evolving alternative to the transpsoas and direct anterior exposures for lumbar fusion. However, the vascular morphometric data of the ATP approach remain underexplored, especially at L5-S1. MATERIALS AND METHODS Patients indicated for ATP lumbar-lumbosacral fusion between September 2018 and February 2020 were enrolled (n=121). Data were collected prospectively, including the following (in mm): intraoperative manual measurements of the premobilization psoas-vessel (pre-PV) window, the final postmobilization psoas-vessel (post-PV) window, and the preoperative radiographic psoas-to-vessel distance at the respective studied disk levels. RESULTS A total of 121 patients (75 female, mean age: 55.3 yr, 81.8% right-sided approach) underwent a total of 279 levels of spinal fusion. Irrespective of the ATP access laterality, we noted ample postmobilization psoas-vessel (post-PV differential) corridors: largest at L4-L5 (36-38 mm) followed by L5-S1 (31-35 mm), L3-L4 (32-33 mm), L2-L3 (28-30 mm), and L1-L2 (20-24 mm). Similarly, the relative increases of the psoas-vessel corridors (post-PV and pre-PV differentials, averaged: 31 mm at L5-S1, 32 mm at L4-L5, 26 mm at L3-L4, 25 mm at L2-L3, and 14 mm at L1-L2) were also significant in both lateral approaches. In right flank approaches, the right vascular structures projected more dorsally compared with left-sided vasculature ( P <0.05). CONCLUSION The ATP access offers generous bilateral prepsoas surgical windows to L1-S1 intervertebral disks, allowing for a safe anterior column release, decompression, instrumentation, and fusion.
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Affiliation(s)
- Chadi Tannoury
- Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston University, Boston, MA
| | - Avilash Das
- Boston University School of Medicine, Boston University, Boston, MA
| | | | - Rahul Bhale
- Boston University School of Medicine, Boston University, Boston, MA
| | - Kathleen Chen
- Boston University School of Medicine, Boston University, Boston, MA
| | - Tony Tannoury
- Boston Medical Center, Boston, MA
- Boston University School of Medicine, Boston University, Boston, MA
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Deng D, Liao X, Wu R, Zhou Y, Huang X, Shi C, Shi B, Min S. Surgical safe zones for oblique lumbar interbody fusion of L1-5: A cadaveric study. Clin Anat 2021; 35:178-185. [PMID: 34704286 DOI: 10.1002/ca.23804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/20/2021] [Accepted: 10/21/2021] [Indexed: 11/09/2022]
Abstract
To evaluate the operating range and morphology of the surgical safe zone for oblique lumbar interbody fusion (OLIF). Twenty embalmed full-torso cadaveric specimens were dissected. The oblique corridor and the distance between adjacent lumbar arteries were measured in a static state and with psoas major retraction. The morphology and size of the safe zone for OLIF and the location of the lumbar sympathetic trunk were also recorded. The oblique corridor of the L1-L5 segments was significantly greater in the retracted state than in the static state (p < 0.05). With psoas major retraction, the distances between adjacent lumbar arteries at L1-4 were significantly greater (p < 0.05) than those in the static state. The lumbar sympathetic trunk is just located in the safe zone and travels downward adjacent to the psoas major. The shape of the safe zone for OLIF was approximately an oblique upward parallelogram at L1/2 and L2/3, an isosceles trapezoid at L3/4, and an irregular quadrangle or triangle at L4/5. The safe zone for OLIF at L1/2, L2/3, and L3/4 was significantly larger during retraction than in the static state (p < 0.05). On the lateral side of the lumbar spine there is a natural surgical safe zone for OLIF, which can provide a sufficient operating space. The safe zone has a certain morphological pattern in L1-5 segments and psoas major retraction can significantly enlarge it.
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Affiliation(s)
- Donghai Deng
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Department of Orthopedics, Foshan First People's Hospital, Foshan, China
| | - Xuqiang Liao
- Department of Orthopedics, Foshan First People's Hospital, Foshan, China
| | - Ruihui Wu
- Department of Orthopedics, Foshan First People's Hospital, Foshan, China
| | - Yunfei Zhou
- Department of Orthopedics, Foshan First People's Hospital, Foshan, China
| | - Xingqiu Huang
- Department of Orthopedics, Foshan First People's Hospital, Foshan, China
| | - Chenglong Shi
- Department of Orthopedics, Foshan First People's Hospital, Foshan, China
| | - Benchao Shi
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shaoxiong Min
- Department of Orthopedics, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,Department of Spinal Surgery, Peking University Shenzhen Hospital, Shenzhen, China
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Kuzmik GA, Wozny TA, Ammanuel S, Eichler CM, Mummaneni PV, Chou D. Oblique Lumbar Interbody Fusion From L2 to S1: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E438. [PMID: 34409982 DOI: 10.1093/ons/opab283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 06/28/2021] [Indexed: 11/14/2022] Open
Abstract
This surgical video demonstrates the technique of an oblique lumbar interbody fusion (OLIF) in the lumbar spine from L2 to L5 as well as an oblique approach to the L5-S1 level. It demonstrates the surgical approach, technical nuances of OLIF, and pearls of the surgery. The video discusses the importance of the release of the disc space to allow for height restoration and deformity correction, endplate preparation to enhance arthrodesis, and appropriate implant sizing. The concept of the approach is the minimally invasive blunt dissection through the abdominal wall musculature and mobilization of the retroperitoneal fat. Unlike the transpsoas approach, the surgery is performed anterior to the psoas, avoiding the lumbar plexus.1 For L5-S1, the approach is still performed in the lateral position but with an oblique approach. A vascular surgeon performs the L5-S1 approach, and the disc space is accessed through the iliac bifurcation.2 The discectomy and interbody fusion are performed similarly to a standard anterior lumbar interbody fusion (ALIF), but in a lateral position and at an oblique angle. The patient consented to this procedure and for filming a video of this case.
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Affiliation(s)
- Gregory A Kuzmik
- Department of Neurological Surgery, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Thomas A Wozny
- Department of Neurological Surgery, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Simon Ammanuel
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Charles M Eichler
- Division of Vascular Surgery, Department of Surgery, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, School of Medicine, University of California San Francisco, San Francisco, California, USA
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Cheng C, Wang K, Zhang C, Wu H, Jian F. Clinical results and complications associated with oblique lumbar interbody fusion technique. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:16. [PMID: 33553309 PMCID: PMC7859744 DOI: 10.21037/atm-20-2159] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Oblique lumbar interbody fusion (OLIF) is a minimally invasive technique performed through the antero-oblique trajectory to address a wide range of lumbar pathologies. However, it can lead to complications. We reviewed the results of OLIF and discussed the effective methods to avoid such complications. Methods Seventy-nine consecutive patients who underwent OLIF between May 2016 and July 2019 were retrospectively analyzed. They were divided into three groups: stand-alone, posterior, and lateral fixation, according to whether they were followed up with auxiliary internal fixation as well as the fixation methods. Preoperative and last follow-up visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were used to assess the improvement in the lower back and leg pain as well as neurological conditions. We analyzed intervertebral disc height (DH), segmental lumbar lordotic angle (SLL), lumbar lordotic angle (LL), pelvic tilt (PT), pelvic incidence-lumbar lordosis (PI-LL) mismatch, and the cross-section area (CSA) on axial magnetic resonance imaging (MRI) image in different groups. Complications, including thigh symptoms, cage subsidence, neurological injury, and vascular injury, were also noted. Results Seventy-nine patients were followed up postoperatively for 23.2±11.5 (range, 12-48) months. Forty-eight (61%) patients underwent stand-alone surgery (without fixation), 15 (19%) patients underwent supplemental percutaneous pedicle screw fixation (posterior fixation), and 16 (20%) patients underwent lateral vertebral instrumentation (lateral fixation). In all three groups, the VAS score and the ODI score had significantly decreased at the final follow-up compared to pre-operation. The DH, SLL, LL, CSA, PT, and PI-LL mismatch had also improved by final follow-up. The most common approach-related complication was thigh symptoms. Of the 79 patients, ipsilateral transient psoas paresis occurred in 9 (11.4%), ipsilateral transient quadriceps weakness in 2 (2.5%), and groin/thigh numbness and pain in 17 (21.5%). Cage subsidence occurred in 8 (10.1%) patients, including five cases of grade 0, one of grade I, and two of grade II. Three (3.8%) patients in this study had a vascular injury. Conclusions OLIF is a minimally invasive and effective technique for dealing with degenerative lumbar diseases. However, it should also be noted that this approach carries risks of complications.
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Affiliation(s)
- Cheng Cheng
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China.,Department of Neurosurgery, the Third Medical Centre, Chinese PLA (People's Liberation Army) General Hospital, Beijing, China
| | - Kai Wang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Can Zhang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
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Xi Z, Chou D, Mummaneni PV, Ruan H, Eichler C, Chang CC, Burch S. Anterior lumbar compared to oblique lumbar interbody approaches for multilevel fusions to the sacrum in adults with spinal deformity and degeneration. J Neurosurg Spine 2020; 33:461-470. [PMID: 32534496 DOI: 10.3171/2020.4.spine20198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In adult spinal deformity and degenerative conditions of the spine, interbody fusion to the sacrum often is performed to enhance arthrodesis, induce lordosis, and alleviate stenosis. Anterior lumbar interbody fusion (ALIF) has traditionally been performed, but minimally invasive oblique lumbar interbody fusion (OLIF) may or may not cause less morbidity because less retraction of the abdominal viscera is required. The authors evaluated whether there was a difference between the results of ALIF and OLIF in multilevel anterior or lateral interbody fusion to the sacrum. METHODS Patients from 2013 to 2018 who underwent multilevel ALIF or OLIF to the sacrum were retrospectively studied. Inclusion criteria were adult spinal deformity or degenerative pathology and multilevel ALIF or OLIF to the sacrum. Demographic, implant, perioperative, and radiographic variables were collected. Statistical calculations were performed for significant differences. RESULTS Data from a total of 127 patients were analyzed (66 OLIF patients and 61 ALIF patients). The mean follow-up times were 27.21 (ALIF) and 24.11 (OLIF) months. The mean surgical time was 251.48 minutes for ALIF patients and 234.48 minutes for OLIF patients (p = 0.154). The mean hospital stay was 7.79 days for ALIF patients and 7.02 days for OLIF patients (p = 0.159). The mean time to being able to eat solid food was 4.03 days for ALIF patients and 1.30 days for OLIF patients (p < 0.001). After excluding patients who had undergone L5-S1 posterior column osteotomy, 54 ALIF patients and 41 OLIF patients were analyzed for L5-S1 radiographic changes. The mean cage height was 14.94 mm for ALIF patients and 13.56 mm for OLIF patients (p = 0.001), and the mean cage lordosis was 15.87° in the ALIF group and 16.81° in the OLIF group (p = 0.278). The mean increases in anterior disc height were 7.34 mm and 4.72 mm for the ALIF and OLIF groups, respectively (p = 0.001), and the mean increases in posterior disc height were 3.35 mm and 1.24 mm (p < 0.001), respectively. The mean change in L5-S1 lordosis was 4.33° for ALIF patients and 4.59° for OLIF patients (p = 0.829). CONCLUSIONS Patients who underwent multilevel OLIF and ALIF to the sacrum had comparable operative times. OLIF was associated with a quicker ileus recovery and less blood loss. At L5-S1, ALIF allowed larger cages to be placed, resulting in a greater disc height change, but there was no significant difference in L5-S1 segmental lordosis.
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Affiliation(s)
- Zhuo Xi
- 1Department of Neurological Surgery
- 4Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | | | | | | | | | | | - Shane Burch
- 3Department of Orthopedic Surgery, University of California, San Francisco, California; and
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Choi J, Rhee I, Ruparel S. Assessment of Great Vessels for Anterior Access of L5/S1 Using Patient Positioning. Asian Spine J 2020; 14:438-444. [PMID: 32791768 PMCID: PMC7435306 DOI: 10.31616/asj.2020.0078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/20/2020] [Indexed: 01/06/2023] Open
Abstract
STUDY DESIGN This was a prospective cross-sectional study. PURPOSE The aim was to describe the effect of patient positioning, from supine to lateral decubitus position, on the width of the L5/S1 anterior disk space defined by the great vessels. OVERVIEW OF LITERATURE The application of the lateral decubitus position interbody fusion has been rapidly increasing; however, there are concerns regarding the access to the lumbosacral region due to the great vessels, which necessitates further morphometric data. METHODS A total of 20 consecutive live patients awaiting lumbar surgery were subjected to two magnetic resonance imaging scans on the same day in both supine and lateral decubitus positions at a single center to investigate the anterior L5/S1 disk space. RESULTS The bare anterior L5/S1 disk window was present in all patients of this study population, and the mean width was 27 mm in the supine and 22 mm in the lateral decubitus position, with a mean reduction of 5.2 mm between the positions. The oblique corridor angle was measured at a mean of 33°. CONCLUSIONS The bare window of L5/S1 disk space was present within this population group, and it was found to be mobile and changed significantly with patient positioning. Therefore, the spine surgeon or the access surgeon must consider the increased potential vascular risk during disk access in lateral decubitus anterior lumbar interbody spinal fusion surgery.
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Affiliation(s)
- John Choi
- Spine Ortho Clinic, The Bays Hospital, Mornington, Australia
| | - Isaac Rhee
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Sameer Ruparel
- Department of Orthopaedic-Spine Surgery, Global Hospital, Mumbai, India
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Zehri A, Soriano-Baron H, Peterson KA, Kittel C, Brown PA, Hsu W, Neal M, Wilson JL. Changes in the Operative Corridor in Oblique Lumbar Interbody Fusion Between Preoperative Magnetic Resonance Imaging and Intraoperative Cone-Beam Computed Tomography Using Morphometric Analysis. Cureus 2020; 12:e8687. [PMID: 32699686 PMCID: PMC7370664 DOI: 10.7759/cureus.8687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The oblique lumbar interbody fusion or anterior-to-psoas (OLIF/ATP) technique relies on a corridor anterior to the psoas and posterior to the vasculature for lumbar interbody fusion. This is evaluated preoperatively with CT and/or MRI. To date, there have been no studies examining how intraoperative, lateral decubitus positioning may change the dimensions of this corridor when compared to preoperative imaging. Objective Our objective was to evaluate changes in the intraoperative corridor in the supine and lateral positions utilizing preoperative and intraoperative imaging. Methods We performed a retrospective analysis among patients who have undergone an OLIF/ATP approach at two tertiary care centers from 2016 to 2018 by measuring the distance between the left lateral border of the aorta or iliac vessels and anteromedial border of the psoas muscle from L1-L2 through L4-5 disc spaces. We compared this corridor between supine, preoperative MRI axial and intraoperative CT acquired in the right lateral decubitus position. Results Thirty-three patients, 15 of whom were female, were included in our study. The average age of the patients was 65.4 years and the average BMI was 31 kg/m2. The results revealed a statistically significant increase (p<.05) in the intraoperative corridor from supine to lateral decubitus positioning at all levels. However, age, BMI, and gender had no statistically significant impact on the preoperative versus intraoperative corridor. Conclusion This is the first study to provide objective evidence that lateral decubitus positioning increases the intraoperative corridor for OLIF/ATP. Our study demonstrates that lateral decubitus positioning provides a more favorable corridor for the OLIF/ATP technique from L1-L5 disc levels.
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Affiliation(s)
- Aqib Zehri
- Neurological Surgery, Wake Forest Baptist Health, Winston-Salem, USA
| | | | - Keyan A Peterson
- Neurological Surgery, Wake Forest Baptist Health, Winston-Salem, USA
| | - Carol Kittel
- Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Patrick A Brown
- Radiology and Neurological Surgery, Wake Forest Baptist Health, Winston-Salem, USA
| | - Wesley Hsu
- Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Matthew Neal
- Neurological Surgery, Mayo Clinic, Scottsdale, USA
| | - Jonathan L Wilson
- Neurological Surgery, Wake Forest Baptist Health, Winston-Salem, USA
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The Oblique Corridor at L4-L5: A Radiographic-Anatomical Study Into the Feasibility for Lateral Interbody Fusion. Spine (Phila Pa 1976) 2020; 45:E552-E559. [PMID: 31770312 DOI: 10.1097/brs.0000000000003346] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional radioanatomical study. OBJECTIVE The aim of this study was to analyze the prevalence, size, and location of the oblique corridor (OC), and the morphology of the psoas muscle at the L4-L5 disc level. SUMMARY OF BACKGROUND DATA Lateral lumbar interbody fusion via the OC has the advantage of avoiding injury to the psoas muscle and lumbar plexus. However, the varying anatomy of major vascular structures and the iliopsoas may preclude a safe oblique access to the L4-L5 level. METHODS Five hundred axial magnetic resonance images of the L4-L5 disc level were shortlisted. OCs were categorized into four grades: Grade 0 = no corridor, Grade 1 = small corridor (≤1 cm), Grade 2 = moderate corridor (1-2 cm) and Grade 3 = large corridor (>2 cm). OC location was labeled as antero-oblique, oblique, or oblique-lateral. Psoas morphology was categorized based on a modified Moro's classification, where the anterior section was further subdivided into types AI-AIV. Oblique approach was considered nonviable either when there was no corridor due to vascular obstruction (Grade 0) or when the psoas was high-rising (Types AII-AIV). RESULTS 10.5% of the selected 449 patients had no measurable OC (grade 0) at the L4-L5 level. There were 35% and 37.2% patients with a grade 1and 2 OC, respectively. The location of the OC was anterior oblique, oblique, and oblique lateral in 3.7%, 89.6%, and 6.7%, respectively. According to the modified Moro's classification, 19.4% had a high-rising psoas. Predominantly, psoas was either in line with the disc (Type I; 30.7%) or low-rising (Type AI; 47.4%). CONCLUSION Twenty-five percent of the patients did not have an accessible OC either due to obstruction by vascular structures or due to a high-rising psoas. Hence, proper evaluation of the relevant anatomy preoperatively is recommended for early adopters of this technique, as varying anatomy precludes universal suitability of oblique lateral interbody fusion for the L4-L5 level. LEVEL OF EVIDENCE 3.
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