oblique lumbar interbody fusion

1. Minimally invasive anterior spinal
interbody fusion- Oblique lumbar
interbody fusion
Dr . Manoranjitha kumari MCh
Dr. Manas Panigrahi MCh FACS
Dr M B V Prasad MS
Krishna Institute Of Medical Sciences,

2. Introduction
• Lumbar interbody fusion has become a
popular technique for treating spinal
conditions such as spondylolisthesis,
degenerative disc disease, recurrent disc
herniation, pseudarthrosis and spinal
deformity

3. Introduction....
• Inter body fusion procedures-
described by cloward 50 years ago
Various approaches:
PLIF
TLIF
ALIF
OLIF
XLIF

4. RATIONALE FOR ALIF
Superior biomechanical and perioperative
outcomes
• In a normal lumbar spine in the upright
standing position, the anterior and middle
weight-bearing columns of the spine support
approximately80%of the spinal load, and the
posterior column supports approximately
20%.

5. • However, with aging and the consequences of
the degenerative cascade, including
dehydration of the nucleus and repetitive
annular injuries reducing the height of the
disk, the weight-bearing distribution shifts so
that the posterior column supports a greater
percentage of the axial load

6. Matge G, Leclercq TA. Rationale for interbody fusion with threaded titanium
cages at cervical and lumbar levels: results on 357 cases. Acta Neurochir (Wien).
2000;142(4):425-434.

7. • With ALIF, an interbody fusion device is used
to redistribute the weight-bearing distribution
to the original ratio.
• According to the Woolf law, the fusion
potential increases if grafts are placed under
the direct compression that supports the
placement of the graft in the anterior column.
Mummaneni PV, Haid RW, Rodts GE. Lumbar interbody fusion: state-of
the-art technical advances. J Neurosurg Spine. 2004;1(1):24-30.

8. • Additionally, the anterior and middle columns
provide 90% of the more vascular osseous
surface area, and this wide cancellous bed for
graft contact enhances the fusion potential
over the posterolateral space

9. Advantages of anterior approach
• Compared with posterior approaches, the
retroperitoneal approach in OLIF spares
iatrogenic trauma to the paraspinal
musculature, posterior spinal nerves, and
posterior bony elements.

10. Advantages of anterior approach
• nerve root retraction and entrance into the
spinal canal are unnecessary, thereby
eliminating epidural scarring and perineural
fibrosis
Chung SK, Lee SH, Lim SR, et al. Comparative study of laparoscopic L5-S1 fusion
versus open mini-ALIF, with a minimum 2-year follow-up. Eur Spine J. 2003;12 (6):613-
617

11. Indications
• Degenerative disc disease with or without
radiculopathy
• Spondylolisthesis
• Failed posterior fusion
• Scoliosis

12. • Although there is ongoing debate as to
whether the anterior approach is better than
the posterior approach, Jiang et al reported in
a systematic review that clinical outcomes and
failed fusion rates were similar in both
techniques.

13. • Radiological outcomes, including height
restoration and focal and lumbar lordosis,
were superior in anterior approach, whereas
cost, blood loss, and operative time were
greater in ALIF compared with transforaminal
lumbar interbody fusion.
Jiang SD, Chen JW, Jiang LS. Which procedure is better for lumbar
interbody fusion: anterior lumbar interbody fusion or transforaminal lumbar
interbody fusion? Archives of Orthopaedic and Trauma Surgery.
2012;132(9):1259-1266.

15. Rao et al
Jan 2015
Neurosurgery
Good solid fusion

16. Rao et al
Jan 2015
Neurosurgery
Post
Op pain relief
Mean VAS 0-
2.5

17. ‘Mayer’ described the technique of interbody
fusion Using retro periotoneal corridor
Mayer HM. A new microsurgical technique for minimally invasive anterior
lumbar interbody fusion. Spine (Phila Pa 1976) 1997;22:691-9.

18. Advantages of OLIF than direct
anterior approach
• Anterior to psoas muscle-
avoids injury to psoas muscle
and lumbar plexus there by
less incidence of cruralgia
• Away from peritoneum and
vasculature
( beware of ileolumbar vein and
transitional bifircation of great
vessels)
• Preserves sympathetic plexus-
decreased incidence of
retrograde ejaculation

19. Advantages of OLIF....
• Direct visualisation and
discectomy, easy to do
end plate preparation
• Can be performed L2-L3
to L4-L5
• Upto 3 level fusion can
be done using 4 cm
incion by “sliding
window” technique
Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in
extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976) 2011;36:26-32.

20. Advantages of OLIF
• Lesser incidence of hernias and ileus
• Decreased blood loss
• Increased surface area of the OLIF cage which
is 3 times more than TLIF cage gives better
and strong arthodesis

21. OLIF cage
TLIF/PLIF cage

22. Technique

26. Marking disc space under fluoroscopy

27. The disc space needed to be addressed

28. Skin incision

33. Our experience at KIMS
• 10 cases in 1 year, age ranging from 16 years-84 years, 3
female 7 male were treated
Primary Sx 8
PIVD 4
Listhesis 3
Sport injury 1
secondary 2
Failed back
instability
2
Single level 7
Two levels 3
Posterior
pedicle
screws
6
Lateral
interbody
rods
4

34. • Posterior pedicle screw fixation done in 5
patients at second stage within 48 hours
• Lateral interbody rod fixation – 3 patients on
the same sitting
• All patients iliac bone graft was used
• 2 patients with oseoporosis treated
cannulated screws with bone cement

35. • Average duration of surgery 120 minutes+/-15
minutes
• average blood loss 75 ml to 100 ml
• Average duration of stay 5-7 days
• Procedure related complication - nil

36. Post op pain relief
VAS 0-6
VAS 1-2
VAS 2-2

37. Case 1
• 84 y m
• Neurogenic claudication

38. Case 1
• 84 y m
• Neurogenic claudication

39. Post op VAS -2

40. Case 2
• 16 f
• Acute bilateral radicular
sypmtoms

41. Case 2
• 16 f
• Acute bilateral radicular
sypmtoms

42. Post op
• VAS -1
Restoration of disc
space height

44. Case 3
• 45 m
• Neurogenic claudication

45. Case 3
• 45 m
• Neurogenic claudication

46. Post op
• VAS -1

47. Discussion
• OLIF is a minimally invasive fusion procedure
• Lesser complication rate when compared to
ALIF
• Longterm follow up (5 and half years)of
patients with OLIF showed similar outcome as
that ALIF with lesser morbidity
Saraph V, Lerch C, Walochnik N, Bach CM, Krismer M, Wimmer C. Comparison of
conventional versus minimally invasive extraperitoneal approach for anterior
lumbar interbody fusion. Eur Spine J 2004;13:425-31.

48. Conclusion:
• OLIF restores the biomechanics of lumbar
spine by preserving disc space height achieves
strong fusion and helps in weight
transmission through anterior and middle
column of spine there by avoiding undue
stress on the posterior construct and
instrument failures.