Incidence and Risk Factors for Lumbar Sympathetic Chain Injury After Oblique Lumbar Interbody Fusion

Abstract

Objective: Oblique lumbar interbody fusion (OLIF), performed using a retroperitoneal approach, can lead to complications related to the approach, such as lumbar sympathetic chain injury (LSCI). Although LSCI is a common complication of OLIF, its reported incidence varies across studies due to an absence of specific diagnostic criteria. Moreover, research on the risk factors of postoperative sympathetic chain injuries after OLIF remains limited. Therefore, this study aimed to describe the incidence, and identify independent risk factors for LSCI, in patients with degenerative lumbar spinal diseases who underwent OLIF.

Methods: Between October 2020 and August 2023, a retrospective review was conducted at our institute on 200 patients who underwent OLIF at 1 to 4 consecutive spinal levels (L1-5) for degenerative spinal diseases including spinal stenosis, spondylolisthesis, degenerative scoliosis. We excluded those with infections, trauma, tumors, and lower extremity edema/warmth due to other causes. The patients were categorized into 2 groups: those with and without LSCI symptoms. Demographic data, operative data, and pre- and postoperative parameters were evaluated for their association with LSCI using a univariate logistic regression model. Variables with a p-value <0.1 in the univariate analysis were included in a multivariate model to identify the independent risk factors.

Results: Thirty-five of 200 patients (17.5%) developed LSCI symptoms after OLIF. Multivariate logistic regression analysis indicated that prolonged retraction time, particularly exceeding 31.5 miniutes, remained an independent risk factor (adjusted odds ratio, 12.59; p<0.001).

Conclusion: This study demonstrated that prolonged retraction time was an independent risk factor for LSCI following OLIF, particularly when it exceeded 31.5 minutes. Protecting the lumbar sympathetic chain during surgery and minimizing retraction time are crucial to avoiding LSCI following OLIF.

Keywords: Fusion; Incidence; Injury; Lumbar; Risk factor; Sympathetic.

Fig. 1.

Visual examination of swelling and discoloration in the left lower extremity resulting from lumbar sympathetic chain injury on the affected side.

Fig. 2.

Intraoperative image during the OLIF L4–5 procedure showing that the LSC was in the pathway of intervertebral disc access and required anterior retraction during discectomy, endplate preparation, and cage insertion. LSC, lumbar sympathetic chain; IVD, intervertebral disc.

Fig. 3.

T2-weighted image at the L4–5 disc level in axial view. (a) The distance from the lateral border of the abdominal aorta to the anteromedial border of the left psoas muscle (AAPM), the surgical corridor. (b) The distance from the lateral border of the left LSC to the anteromedial border of the left psoas muscle (LSC-PM). (c) The distance from the medial border of the left LSC to the lateral border of the abdominal aorta (LSC-AA). (d) The distance from the anterior border of the vertebral body to the anterior border of the left psoas muscle. (e) The distance from the lateral border of the vertebral body to the lateral border of the left psoas muscle. Yellow arrow showing the left LSC. Pink dashed line showing the cross-sectional area of the left psoas muscle. PM, psoas major muscle; IVC, inferior vena cava; AA, abdominal aorta; LSC, lumbar sympathetic chain.

Fig. 4.

Measurement of the cage position in the lateral x-ray image. The cage position is determined by the formula a/b× 100 (%). (a) The distance from the posterior border of the superior endplate of the lower vertebral body to the center of the interbody cage. (b) The length of the superior endplate of lower vertebral body.

Fig. 5.

Receiver operating characteristic (ROC) curve analysis indicated that retraction times exceeding 31.5 minutes achieved a sensitivity of 0.78 and a specificity of 0.70, with the area under the ROC curve measuring 0.74 (95% confidence interval [CI], 0.63–0.85).