OLIF: OBLIQUE LUMBAR INTERBODY FUSION Richard G. Fessler, MD, PhD Rush University Medical Center Chicago, IL
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
ANATOMY
True direct lateral Bean bag Arm support Tape skin Position over break in table POSITIONING
INCISION/DISSECTION
LOCALIZATION/STIMULATION
DILATION/RETRACTION
DISCECTOMY AND TRIAL
CAGE PLACEMENT
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
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
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
RETROPERITONEAL ENDOSCOPIC LUMBAR FUSION Requires four incisions Small enough for tight seal CO 2 insufflation Mark using fluoroscopy
BALLOON DISSECTION
RETRACT ILIOPSOAS MUSCLE Steinman Pins
RELF TECHNIQUE
TAP IN OUTER CANNULA Protects all adacent tissues
GRAFT PLACEMENT
THANK YOU
PERCUTANEOUS LUMBAR FUSION SET
PLACE GUIDE PIN IN CENTER OF DISC
PERFORM DISCECTOMY Trephine over guide pin Curettage and Pituitary Rongeurs
DISTRACTION
DRILL BED FOR GRAFT Monitor under fluoro Monitor under endoscopic vision
PATIENTS L 2/3 = 3 L 3/4 = 5 L 4/5 = 11
FOLLOW - UP Mean = 3 years Range = 2-5 years
RESULTS: ADDITIONAL POSTERIOR FUSION 7 / 19 patients
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
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
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. 2011-600 patients XLIF 1% approach and 6.2% overall *Did not consider thigh pain and psoas weakness as complications Alimi et al. 2014 thigh numbness in 4.4 % and weakness in 2.2% - all resolved but 1 case
CLINICAL OUTCOMES Alimi et al. 2014 145 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. 2014 116 levels in 90 patients, 1 year f/u 87.8% CT confirmed fusion ODI, VAS all significantly improved Kotwal et al. 2012 237 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