|Year : 2020 | Volume
| Issue : 1 | Page : 86-90
Illustrative case of multiple-level oblique lumbar interbody fusion (OLIF)
Niraj B Vasavada, Prateek P Lodha
Department of Spine Surgery and Deformity Correction, Shalby Hospital, Ahmedabad, Gujarat, India
|Date of Submission||01-Mar-2019|
|Date of Decision||29-Apr-2019|
|Date of Acceptance||12-Jan-2020|
|Date of Web Publication||05-Feb-2020|
Dr. Niraj B Vasavada
Dr. Niraj B. Vasavada, Department of Spine Surgery and Deformity Correction, Shalby Hospital, SG Road, Ahmedabad 380015, Gujarat.
Source of Support: None, Conflict of Interest: None
We report the case of an 80-year old man who presented with nonischemic neurogenic claudication having predominantly right leg radiating pain. Magnetic resonance imaging confirmed it as a case of multiple level lumbar canal stenosis (L2-3, L3-4, L4-5) with right sided de-novo lumbar scoliosis. The patient underwent multiple-Level Oblique Lumbar Interbody Fusion (OLIF) with good clinical outcomes.
Keywords: Degenerative disorder of lumbar spine, degenerative scoliosis, lumbar canal stenosis, oblique lumbar interbody fusion
|How to cite this article:|
Vasavada NB, Lodha PP. Illustrative case of multiple-level oblique lumbar interbody fusion (OLIF). Indian Spine J 2020;3:86-90
| Introduction|| |
Oblique lumbar interbody fusion (OLIF) is a minimally invasive lumbar fusion technique. OLIF uses an oblique retroperitoneal corridor (a bare area between aorta and anterior border of psoas major muscle). Classically, from L2-3 disc space to L4-5 disc spaces are accessible through standard OLIF technique. OLIF L5-S1 uses a slightly different approach, which is a modified approach of anterior lumbar interbody fusion in the lateral position. OLIF is based on the concept of indirect decompression of lumbar canal along with foraminal height restoration. It relies on restoring collapsed disc height anteriorly and maintaining it with a large cage to achieve decompression. We, hereby, present a case of three-level OLIF performed in a patient having mild lumbar degenerative scoliosis with L3-4 and L4-5 lumbar canal stenosis.
| Case Report|| |
An 80-year-old man presented with significant back pain (visual analog scale [VAS] = 6) since 7–8 months. He also complained of bilateral leg pain (right more than the left leg) (VAS of right leg = 8 and left leg = 7). He had symptoms of nonischemic neurogenic claudication with walking distance less than 50 m, and standing time of 5min. His Oswestry Disability Index (ODI) was 86. He was nondiabetic with a history of hypertension. The patient was on medicines for hypertension Figure 1].
The patient was evaluated with standing and lying down anteroposterior (AP) X-ray and lateral standing X-ray in neutral, full flexion, and full extension [Figure 2]. He underwent magnetic resonance imaging (MRI) of lumbosacral spine with whole spine screening. Reports suggested that the patient had 10° right-sided scoliosis with apex at L3. No difference was observed in Cobb’s angle between lying down and standing AP X-rays. Lateral dynamic X-ray showed Grade 1 L4-5 dynamic listhesis with posterior disc height loss in extension at L3-4. MRI showed L3-4 and L4-5 severe lumbar canal stenosis secondary to disc herniation, ligamentum flavum infolding, and facet arthritis. L4-5 was more stenotic on MRI than L3-4 [Figure 3].
|Figure 2: Standing and dynamic X-rays of lumbar spine (Red line indicates that Cobb angle is measured between upper and lower vertebra. The lines indicate the upper and lower level for the angle measurement)|
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The patient had failed conservative management for 5 months. Considering the patient’s disability along with his age, it was decided in consultation with the patient to perform a minimally invasive lumbar fusion surgery. Significant back pain, dynamic Grade 1 listhesis at L4-5, and disc height loss in extension at L3-4 were the factors favoring lumbar instrumented fusion. As the apex of the mild lumbar curve was at L3, it was planned to extend the fusion from L2 to L5 to balance the curve.
MRI was reviewed, which showed safe zone at L2-3, L3-4 between anterior border of psoas and left lateral wall of aorta, and at L4-5 between left lateral wall of common iliac artery and psoas [Figure 4]. Hence, it was decided to consider the patient for L2-3, L3-4, and L4-5 OLIF with posterior percutaneous screw fixation in single stage.
|Figure 4: Safe zone (The Red curve indicates the bare area for OLIF corridor)|
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Advantages of OLIF
OLIF uses a minimally invasive anterolateral muscle-splitting approach. Hence, it has all the benefits of minimally invasive transforaminal lumbar interbody fusion. Advantages of the OLIF approach are that it facilitates minimally invasive spine surgery with rapid postoperative mobilization. OLIF also allows aggressive deformity correction, having high-fusion rates with comprehensive disc space clearance.,, Lumbar plexus and psoas injury are unlikely as dissection is performed anterior to the psoas. However, potential risks involved with OLIF surgery include sympathetic dysfunction and vascular injury.
Detailed consent was obtained after thorough explanation of all the risks and benefits. The patient was first approached anterolaterally. Single longitudinal incision was placed about 1 inch anterior to the anterior border of L2, L3, and L4 vertebra. Incision was placed from the L3 superior endplate to L4 inferior endplate. Skin and subcutaneous tissue was cut. Subcutaneous adipose tissue was dissected bluntly to expose external oblique muscle. The muscle fibers were dissected bluntly, in line with the fibers, to expose internal oblique muscle. Internal Oblique muscle fibers were split bluntly in line of its fibers to expose transversus abdominis muscle (the fibers of internal oblique are perpendicular to external oblique muscles. Transversus abdominis has transverse muscle fibers). The fibers of transversus abdominis were dissected bluntly to expose deep transversalis fascia. The fascia was opened with blunt dissector to expose retroperitoneal space. Using surgeon’s finger, the peritoneum, gradually, was reflected anteriorly along with the ureter to reach the transverse process of the desired level. Surgeon’s finger was slid down over the psoas muscle to reach its anterior border to feel the bare area. Blunt dissection with finger was performed at the anterior border of the psoas muscle to expose the disc space [Figure 5]. Pedicle access kit (PAK) needle was placed under fluoroscope at the center of the disc space (we do not use intraoperative neuromonitoring for OLIF cases). Guide wire was inserted from the needle inside the disc space. PAK needle was removed. Sequential dilators were inserted over the guide wire. Outermost dilator read the length of the retractor blade to be used. The tubular retractor was assembled and slid over the dilator. The retractor was fixed with table-mount arm. This soft docking was checked under vision for the proper position at the bare area, to confirm the retractor was not through the psoas muscle. Once the position was confirmed, pins were inserted from the retractor to fix the retractor with vertebral body. We used inferior pin at L2-3 and L3-4, whereas superior pin at L4-5. Disc space was prepared, and the cage size was decided. In this case, L2-3, L3-4, and L4-5 OLIF were carried out using 10-, 12-, and 14-mm OLIF 6° cages (CLYDESDALE OLIF25, Medtronic Sofamor Danek, Memphis, USA India Medtronic), following the standard surgical steps for OLIF. We used allograft from our bone bank. Once cage positions were confirmed under fluoroscope, the retractor was slowly removed and checked for bleeding. Abdominal muscles fall back, and they do not need suturing. Subcutaneous sutures were obtained with absorbable sutures. Skin was closed with skin stapler.
The patient was flipped prone after completing the procedure and percutaneous screws/rods were inserted (Longitude, India Medtronic) as per the standard surgical steps. Estimated blood loss during the total procedure was 50mL. Total surgical time was three hours for OLIF and percutaneous screw fixation.
The patient was mobilized within 6h after surgery. No radicular pain was reported immediately after surgery. Postoperative X-rays showed good implant position with balanced coronal profile of lumbar spine, significant restoration of foramina height and disc height [Figure 6]. Postoperative MRI showed adequate indirect decompression of L3-4 and L4-5 lumbar canal [Figure 7].,
At 3-month follow-up, VAS for back pain was 2, no leg pain was observed, walking distance improved to 2 km, and standing time was 30min. The patient’s ODI improved from preoperative 86 to 26 postoperatively at 3 months.
| Conclusion|| |
OLIF can provide clinically meaningful indirect decompression at foramen and lumbar canal along with correction of sagittal and coronal profile of lumbar spine.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]