Efficacy and safety of a modified lateral lumbar interbody fusion in L4-5 lumbar degenerative diseases compared with traditional XLIF and OLIF: a retrospective cohort study of 156 cases

Abstract

Background: The authors designed a modified lateral lumbar interbody fusion (LLIF) procedure named as XOLIF and compared the efficacy and safety with traditional LLIF procedures.

Methods: Patients were divided into XLIF, OLIF, and XOLIF group according to the surgical approach. Cases of psoas major and vascular space stenosis, psoas major muscle elevation, psoas major muscle hypertrophy, and high iliac crest were recorded. Basic information, composition ratio of specific cases, Visual analog scale (VAS), Oswestry Disability Index (ODI), interbody fusion rate and complications were compared between the 3 groups.

Results: The study included 156 cases of L4-5 LLIF. There was no statistical difference in age, gender, BMI among the three groups. Cases with stenosis between psoas muscle and artery accounted for 11.8 and 18.4% of the XLIF and XOLIF group, respectively, while no case of this type had undergone OLIF surgery, the difference was statistically significant (P < 0.05). The proportions of high iliac crest cases in the OLIF and XOLIF group were 12.5 and 18.4%, respectively, while the XLIF group with vertical approach is not suitable for cases with high iliac crest. The postoperative VAS and ODI of the three groups were significantly improved compared with those before operation. There were 51 cases (32.7%) of complications including 21cases in XLIF group, 20 cases in OLIF Group and 10 cases in XOLIF group. XOLIF group has more advantages in reducing lumbar plexus injury and the risk of vascular injury.

Conclusions: XOLIF showed good clinical efficacy and technical advantages with a low incidence of intraoperative and postoperative complications, especially in the specific cases.

Keywords: Complication; Extreme lateral interbody fusion; Lateral lumbar interbody fusion; Modified procedure; Oblique lumbar interbody fusion.

Fig. 1

a Measurement of the size of the space between psoas major muscle and large artery, and the thickness of psoas major muscle by preoperative axial T2-weighted MRI image at surgical segment. b Typical psoas major muscle elevation from axial T2-weighted MRI images at surgical segment

Fig. 2

The operative segment is confirmed to be in absolute lateral position under fluoroscopy and the surface location is marked. a The spinous process is located in the center between two pedicles in anteroposterior X-ray. b The upper endplate of caudal vertebrae overlaps in a line and the affected disc space is marked with 2 K-wires in lateral X-ray. c The surface location of the affected disc space is marked on the patient’s lateral side

Fig. 3

Schematic diagram of the intraoperative procedure. a Initial position with a guide rod after dissecting aponeurosis of anterior edge of psoas major muscle under direct vision. b Expose the operation area with 2 blades retractor and Kirschner wire. c Implant a cage vertically after discectomy

Fig. 4

Postoperative VAS (a) and ODI (b) were significantly reduced compared with those of preoperation

Fig. 5

Preoperative and postoperative radiographs of a case with lumbar spinal stenosis. a Preoperative sagittal T2-weighted MRI image. b Preoperative axial T2-weighted MRI image indicated lumbar stenosis at L4-5. c Preoperative axial CT showed that lumbar stenosis at L4-5. d, e Preoperative flexion-extension stress lateral radiographs. f, g Anteroposterior X-ray of lumbar spine after XLIF

Fig. 6

A case was revised with TLIF for contralateral nerve root injury. a Anteroposterior X-ray of lumbar spine after XLIF. b Axial CT showed that the right nerve root was compressed by the cage after XLIF. c Axial T2-weighted MRI image after revision indicated right decompression. d Anteroposterior X-ray of lumbar spine after revision