Oblique Lumbar Interbody Fusion at L5-S1 Segment Through an Approach Between the Psoas Muscle and the Great Vessels
Summary
The protocol presents an OLIF L5-S1 technique that offers a more feasible approach for lumbosacral fusion sharing a common surgical plane with OLIF L2-5. This facilitates reproducible multi-level interbody fusions extending from L2 to S1 through a retroperitoneal oblique corridor between the Psoas muscle and the great vessels.
Abstract
Over the years, the oblique lateral interbody fusion (OLIF) technique has gained significant recognition for treating various spinal conditions in lumbar segments L2-L5. However, the adoption of OLIF for the L5-S1 segment has not been widely embraced by the spinal surgery community, given that significant concerns remain regarding the applicability of OLIF for lumbosacral fusion. In this study, a cohort of 20 patients underwent interbody fusion at the L5-S1 level using the OLIF technique through a single retroperitoneal oblique approach positioned between the Psoas muscle and the great vessels. The procedure involved discectomy and endplate preparation accomplished through a surgical window created on the anterolateral side of the L5-S1 disc. For secure interbody fusion cage placement, a supplementary cage insertion approach was employed. All patients were followed up for a minimum of 12 months. The mean preoperative visual analog scale (VAS) score for lower back pain was 6.3 ± 1.5 and experienced a significant reduction to 1.2 ± 0.8 at 12 months. The VAS score for lower limb pain significantly decreased from 5.6 ± 1.4 preoperatively to 0.8 ± 0.3 at 12 months after the surgery. Furthermore, the preoperative Oswestry disability index (ODI) improved from 82.4% ± 16.2% to 8.1% ± 2.0% at 12 months. Radiographic evaluations after surgery confirmed improved lumbosacral junction reconstruction for all patients. At the final follow-up, successful bony fusion was observed in all cases. Based on these findings, the OLIF technique for L5-S1 fusion represents an attainable approach for lumbosacral reconstruction. The procedure's success hinges on a comprehensive preoperative plan and precise intraoperative techniques.
Introduction
Lumbar interbody fusion represents the mainstay of treatment for many lumbar disorders. The most commonly performed techniques are posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF). The advent of minimally invasive spine surgery has given rise to the lateral lumbar interbody fusion (LLIF) approach, a minimally invasive transpsoas approach to the lumbar spine. This approach, also known as the minimally invasive lateral transpsoas approach, offers advantages, including reduced blood loss, shorter operative times, decreased hospital stays, and diminished postoperative pain. Despite its merits, LLIF is associated with a risk of injury to the neural structures of the lumbar plexus, a concern held by various spine surgeons1. In response to these challenges, the oblique lumbar interbody fusion (OLIF) technique has emerged as an innovative approach for lumbar spine reconstruction1,2,3,4. As an alternative to LLIF, OLIF holds several theoretical advantages, including avoiding disruption to the Psoas muscle, preventing lumbosacral plexus injury, and consistent access to the lower lumbar levels without necessitating neuromonitoring3,4. In recent years, OLIF has achieved broad recognition as an effective procedure for addressing an array of spinal pathologies within the L2-L5 segments, encompassing degenerative disc disease, lumbar spondylosis, spondylolisthesis, lumbar stenosis, and scoliosis2,5,6,7.
Capitalizing on advancements in surgical techniques and instruments, numerous spine surgeons have ventured into L5-S1 interbody fusion using the OLIF approach (OLIF L5-S1)2,6,7,8,9,10,11,12. Theoretically, the application of OLIF at the lumbosacral junction offers a larger surface area for robust fusion, re-establishment of anterior column support, and simultaneous achievement of indirect decompression and sagittal alignment correction. However, the anatomic intricacies of the retroperitoneal oblique corridor to the L5-S1 disc present technical hurdles to spine surgeons, especially the complexities posed by neurovascular structures and disruptions involving the iliac crest2,9,11,12,13,14. Despite limited recent literature discussing OLIF L5-S1, this approach has not gained the same widespread acceptance within the spine community as OLIF L2-5. Concerns about the feasibility of OLIF L5-S1 for lumbosacral fusion persist in the scientific community2,13,14, with many variations in the L5-S1 OLIF technique employed by previous studies.
Since 2017, OLIF has become one of the techniques of choice for achieving lumbosacral fusions in our department. The potential anatomic space between the iliac vessels and psoas muscle allows the OLIF procedure at L5-S1. Additionally, specialized instruments are available for OLIF at the lumbosacral junction to avoid the obstruction of the iliac crest. This study outlines the developed OLIF L5-S1 technique through detailed case illustrations. The method provides a consistent means to achieve fusion at the lumbosacral segment using a single retroperitoneal oblique corridor between the Psoas muscle and the great vessels.
Protocol
Representative Results
Discussion
An increasing body of evidence from recently published studies suggests that OLIF therapy brings technical advantages and favorable outcomes for lumbar degenerative diseases, especially in the L2-5 segments2,5,6,7. While recognizing these benefits, efforts have been made to extend the use of OLIF to the lumbosacral junction. However, the technical strategy for performing OLIF at L5-S1 remains s…
Disclosures
The authors have nothing to disclose.
Acknowledgements
The study was funded by the Zhejiang Provincial Natural Science Foundation (grant number 2022RC136, 2022KY1455), Alibaba Youth Studio Project (grant number ZJU-032). The funding bodies had no role in the design of the study; in collection, analysis, and interpretation of data; and in drafting the manuscript.
Materials
| Fluoroscopy System | Allengers | ||
| Handheld retractor | gSource | gS 36.9362 | |
| Kirschner wire | Sklar surgical instruments | SKU 40-1535 | |
| OLIF cages | Medtronic Sofamor Danek, Memphis, Tennessee, USA | ||
| Pedicle screws | Beijing Fule Technology Development Co. , Ltd China | ||
| Tonsil sponge | teleflex | MC-008133 | |
| Vascular clamp |
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