Minimally invasive anterior spinal interbody fusion- Oblique lumbar

interbody fusion

Dr . Manoranjitha kumari MChDr. Manas Panigrahi MCh FACS

Dr M B V Prasad MSKrishna Institute Of Medical Sciences,

Secunderabad

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

Introduction....

• Inter body fusion procedures-described by cloward 50 years ago

Various approaches:PLIFTLIF

ALIFOLIFXLIF

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%.

• 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

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

• 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.

• 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

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.

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

Indications

• Degenerative disc disease with or without radiculopathy

• Spondylolisthesis• Failed posterior fusion• Scoliosis

• 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.

• 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.

Rao et alJan 2015Neurosurgery

Good solid fusion

Rao et alJan 2015Neurosurgery

Post Op pain relief

Mean VAS 0-2.5

‘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.

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

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.

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

OLIF cageTLIF/PLIF cage

Technique

Marking disc space under fluoroscopy

The disc space needed to be addressed

Skin incision

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

• 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

• 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

Post op pain relief

VAS 0-6VAS 1-2VAS 2-2

Case 1

• 84 y m• Neurogenic claudication

Case 1

• 84 y m• Neurogenic claudication

Post op VAS -2

Case 2

• 16 f• Acute bilateral radicular

sypmtoms

Case 2

• 16 f• Acute bilateral radicular

sypmtoms

Post op

• VAS -1

Restoration of disc space height

Case 3

• 45 m• Neurogenic claudication

Case 3

• 45 m• Neurogenic claudication

Post op

• VAS -1

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.

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.