Eur Spine J DOI 10.1007/s00586-016-4465-9
OPEN OPERATING THEATRE (OOT)
Minimally invasive anterior oblique lumbar interbody fusion (OLIF) Christoph Mehren1,2,3 • Andreas Korge1,2,3
Ó Springer-Verlag Berlin Heidelberg 2016
Keywords OLIF Anterior lumbar fusion Retroperitoneal approach to the lumbar spine Mini ALIF
Learning targets Minimally invasive oblique muscle splitting retroperitoneal approach to the lumbar spine L2–L5 for interbody fusion.
Introduction The anterior interbody fusion of the lumbar spine is a fixed constituent in spine surgery. The now called OLIF approach to the lumbar spine is using an anatomical pathway through the retroperitoneal space in between the psoas muscle and the big abdominal vessels. With this kind of minimally anterior psoas-respecting approach, invented by Mayer already [1], an intraoperative neuromonitoring is not needed.
Electronic supplementary material The online version of this article (doi:10.1007/s00586-016-4465-9) contains supplementary material, which is available to authorized users. & Christoph Mehren [email protected] 1
Scho¨n Klinik Mu¨nchen Harlaching, Spine Center, Munich, Germany
2
Academic Teaching Hospital and Spine Research Institute, Paracelsus Private Medical University, Salzburg, Austria
3
Paracelsus Private Medical University, Salzburg, Austria
Case description 50-year-old male presented with severe low back pain and failed conservative therapy. In the MRI an osteochondrosis Type Modic I L3/4 is diagnosed. In the standing X-ray a segmental tilt to the right can be observed. There are no clinical symptoms or radiological evidence of spinal stenosis or radiculopathy.
Surgical strategy The patient is placed in a right side lateral decubitus position and the operating table is slightly tilted backwards about 20°–30°. Under fluoroscopic control the center of the involved disc is marked on the skin. Through a 4 cm small skin incision at the left abdominal wall the retroperitoneal space is entered with a blunt, muscle-splitting technique. Identification and preparation to the anterior-lateral aspect of the lumbar spine and the medial border of the psoas muscle. Retraction of the psoas muscle towards lateral and isolation of the disc space is performed. The incision of the anterolateral annulus is followed by a subtotal discectomy and further preparation of the graft bed. The intervertebral cage is inserted under fluoroscopic control. The different layers are closed with resorbable sutures. Afterwards the patient is turned around for posterior stabilisation. Watch surgery online
123
Eur Spine J
Postoperative information Routinely antibiotics for 24 h and early mobilisation on the same day without limitation for standing and sitting. Thromboembolic prophylaxis with fractionated heparin is necessary until full mobilisation. Light cost up to the first bowel movement.
minimally invasive retroperitoneal approach (OLIF) is a very feasible, effective and safe access for a lateral anterior lumbar fusion L2–L5 without the need of expensive intraoperative neuromonitoring due to the anatomical pathway in between the abdominal vessels and the anterior border of the psoas muscle.
Discussion and conclusion
References
Davis et al. [2] recently described an anatomical oblique corridor to the lumbar spine in a cadaveric study. By using this routinely existing gap anterior to the psoas muscle many of the complications associated with anatomical structures could be avoided. This technique is in direct competition to the transpsoatic XLIF procedure. Both techniques are minimally invasive with a very low overall complication rate. Even within the fact that a neurological deficit was observed in only 0.7 % up to 9.6 % in a 18 months follow-up [3, 4] with the XLIF procedure, the intraoperative setup—in renouncement of the complete neuromonitoring technique—is quite different. This
1. Mayer HM (1997) A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine (Phila Pa 1976) 22:691–699 (discussion 700) 2. Davis TT, Hynes RA, Fung DA et al (2014) Retroperitoneal oblique corridor to the L2–S1 intervertebral discs in the lateral position: an anatomic study. J Neurosurg Spine 21:785–793. doi:10.3171/2014.7.SPINE13564 3. Rodgers WB, Gerber EJ, Patterson J (2011) Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976) 36:26–32. doi:10.1097/BRS.0b013e3181e1040a 4. Lykissas MG, Aichmair A, Hughes AP et al (2014) Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J 14:749–758. doi:10. 1016/j.spinee.2013.06.066
123
OPEN OPERATING THEATRE (OOT)
Minimally invasive anterior oblique lumbar interbody fusion (OLIF) Christoph Mehren1,2,3 • Andreas Korge1,2,3
Ó Springer-Verlag Berlin Heidelberg 2016
Keywords OLIF Anterior lumbar fusion Retroperitoneal approach to the lumbar spine Mini ALIF
Learning targets Minimally invasive oblique muscle splitting retroperitoneal approach to the lumbar spine L2–L5 for interbody fusion.
Introduction The anterior interbody fusion of the lumbar spine is a fixed constituent in spine surgery. The now called OLIF approach to the lumbar spine is using an anatomical pathway through the retroperitoneal space in between the psoas muscle and the big abdominal vessels. With this kind of minimally anterior psoas-respecting approach, invented by Mayer already [1], an intraoperative neuromonitoring is not needed.
Electronic supplementary material The online version of this article (doi:10.1007/s00586-016-4465-9) contains supplementary material, which is available to authorized users. & Christoph Mehren [email protected] 1
Scho¨n Klinik Mu¨nchen Harlaching, Spine Center, Munich, Germany
2
Academic Teaching Hospital and Spine Research Institute, Paracelsus Private Medical University, Salzburg, Austria
3
Paracelsus Private Medical University, Salzburg, Austria
Case description 50-year-old male presented with severe low back pain and failed conservative therapy. In the MRI an osteochondrosis Type Modic I L3/4 is diagnosed. In the standing X-ray a segmental tilt to the right can be observed. There are no clinical symptoms or radiological evidence of spinal stenosis or radiculopathy.
Surgical strategy The patient is placed in a right side lateral decubitus position and the operating table is slightly tilted backwards about 20°–30°. Under fluoroscopic control the center of the involved disc is marked on the skin. Through a 4 cm small skin incision at the left abdominal wall the retroperitoneal space is entered with a blunt, muscle-splitting technique. Identification and preparation to the anterior-lateral aspect of the lumbar spine and the medial border of the psoas muscle. Retraction of the psoas muscle towards lateral and isolation of the disc space is performed. The incision of the anterolateral annulus is followed by a subtotal discectomy and further preparation of the graft bed. The intervertebral cage is inserted under fluoroscopic control. The different layers are closed with resorbable sutures. Afterwards the patient is turned around for posterior stabilisation. Watch surgery online
123
Eur Spine J
Postoperative information Routinely antibiotics for 24 h and early mobilisation on the same day without limitation for standing and sitting. Thromboembolic prophylaxis with fractionated heparin is necessary until full mobilisation. Light cost up to the first bowel movement.
minimally invasive retroperitoneal approach (OLIF) is a very feasible, effective and safe access for a lateral anterior lumbar fusion L2–L5 without the need of expensive intraoperative neuromonitoring due to the anatomical pathway in between the abdominal vessels and the anterior border of the psoas muscle.
Discussion and conclusion
References
Davis et al. [2] recently described an anatomical oblique corridor to the lumbar spine in a cadaveric study. By using this routinely existing gap anterior to the psoas muscle many of the complications associated with anatomical structures could be avoided. This technique is in direct competition to the transpsoatic XLIF procedure. Both techniques are minimally invasive with a very low overall complication rate. Even within the fact that a neurological deficit was observed in only 0.7 % up to 9.6 % in a 18 months follow-up [3, 4] with the XLIF procedure, the intraoperative setup—in renouncement of the complete neuromonitoring technique—is quite different. This
1. Mayer HM (1997) A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine (Phila Pa 1976) 22:691–699 (discussion 700) 2. Davis TT, Hynes RA, Fung DA et al (2014) Retroperitoneal oblique corridor to the L2–S1 intervertebral discs in the lateral position: an anatomic study. J Neurosurg Spine 21:785–793. doi:10.3171/2014.7.SPINE13564 3. Rodgers WB, Gerber EJ, Patterson J (2011) Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976) 36:26–32. doi:10.1097/BRS.0b013e3181e1040a 4. Lykissas MG, Aichmair A, Hughes AP et al (2014) Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J 14:749–758. doi:10. 1016/j.spinee.2013.06.066
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