OLIF: OBLIQUE LUMBAR INTERBODY FUSION. Richard G. Fessler, MD, PhD Rush University Medical Center Chicago, IL

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1 OLIF: OBLIQUE LUMBAR INTERBODY FUSION Richard G. Fessler, MD, PhD Rush University Medical Center Chicago, IL

2 DISCLOSURE Royalty DePuy, Stryker Professional Societies President: ISMISS Vice President: SICCMI Editorial Board Neurosurgery, Neurosurgical Reviews, JSDT, Spinal Surgery, Operative Neurosurgery, Internet Journal of Minimally Invasive Spinal Technology, Pan Arab Journal of Neurosurgery, Journal of Craniovertebral Junction and Spine, The Scientific World Journal In Queue Innovations Co-owner

3 ANATOMY

4 True direct lateral Bean bag Arm support Tape skin Position over break in table POSITIONING

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6 INCISION/DISSECTION

7 LOCALIZATION/STIMULATION

8 DILATION/RETRACTION

9 DISCECTOMY AND TRIAL

10 CAGE PLACEMENT

11 16 study systematic review 2364 levels, 30% 1 level, 17% 2 level; 13% # levels not reported Mean EBL 110 ml, OR time 95 min, fusion 93% Intraoperative complications 1.5% Postoperative complications 9.9% Transient thigh pain and/or numbness 1.5% HF weakness 3% These generally resolved by 3 m Did not evaluate radiographic parameters

12 137 cases, 340 levels RR Complications 11.7% Ileus 2.9% Subsidence 4.4% Vascular injury 2.9% Fusion at 6 m 97.9% Did not examine radiographic parameters

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18 LATERAL ENDOSCOPIC APPROACH* First developed by Fessler and MacMillan in 1992, presented in 1994, and published by McAfee in 1998 Minimally invasive retroperitoneal approach Classic laparoscopy 19 patients: L 2/3 L 4/5 Majority of patients treated had previous posterior surgery Technique further advanced by Ozgur et al in 2006 as XLIF Direct vision Minimize approach morbidity by avoiding retroperitoneal structures 13 patient with axial back pain without severe central stenosis who failed 6m conservative therapy Excluded stenosis, rotatory scoliosis, >grade 1 and mobile spondylolisthesis *Hybrid of LIFF and OLIF

19 RETROPERITONEAL ENDOSCOPIC LUMBAR FUSION Requires four incisions Small enough for tight seal CO 2 insufflation Mark using fluoroscopy

20 BALLOON DISSECTION

21 RETRACT ILIOPSOAS MUSCLE Steinman Pins

22 RELF TECHNIQUE

23 TAP IN OUTER CANNULA Protects all adacent tissues

24 GRAFT PLACEMENT

25 THANK YOU

26 PERCUTANEOUS LUMBAR FUSION SET

27 PLACE GUIDE PIN IN CENTER OF DISC

28 PERFORM DISCECTOMY Trephine over guide pin Curettage and Pituitary Rongeurs

29 DISTRACTION

30 DRILL BED FOR GRAFT Monitor under fluoro Monitor under endoscopic vision

31 PATIENTS L 2/3 = 3 L 3/4 = 5 L 4/5 = 11

32 FOLLOW - UP Mean = 3 years Range = 2-5 years

33 RESULTS: ADDITIONAL POSTERIOR FUSION 7 / 19 patients

34 Fluoroscopic Localization Directly over the mid-disc for one level In between discs for two levels Can use longer incision if >2 Can use multiple incisions LOCALIZATION

35 DISSECTION Cut through superficial fascia Dissect bluntly through muscle layers External oblique Internal oblique Transversalis Reach and palpate psoas Feel for peritoneum Stimulate via dilators

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41 COMPLICATIONS Unique set of approach-related complications Monitor L2-5 myotomes for lumbar plexus Anterior thigh numbness and pain genitofemoral nerve Resolution in 69% and 75% at 6m (Moller et al.) Psoas weakness* Most common; Anand et al. 75% of patients Majority resolve; Moller et al. - 84% at 6 m Retroperitoneal hematoma and surgical hernia Motor nerves to abdominal wall paresis with abnormal bulging Rates highly variable in the literature Rodgers et al patients XLIF 1% approach and 6.2% overall *Did not consider thigh pain and psoas weakness as complications Alimi et al thigh numbness in 4.4 % and weakness in 2.2% - all resolved but 1 case

42 CLINICAL OUTCOMES Alimi et al levels in 90 patients,17.6m clinical f/u 84.8% of patient had excellent, good or fair functional outcome ODI, VAS for back buttock and leg pain all significantly improved Lee et al levels in 90 patients, 1 year f/u 87.8% CT confirmed fusion ODI, VAS all significantly improved Kotwal et al levels in 118 patients, 2 year f/u 88% CT confirmed fusion ODI, VAS significantly improved Rodgers et al. 66 patients, 1 year f/u, 1-2 levels 96.6% CT confirmed fusion 90% patients satisfied or very satisfied