Highlights
- •Oblique anterolateral approach to L5–S1 is feasible via 3 different techniques.
- •The “facet line” objectively assesses the relationship between left CIV and L5–S1.
- •Inclusion of L5–S1 in OLIF does not significantly increase the complications.
- •Including L5–S1 in OLIF is complex and involves a distinct learning curve.
Abstract
Background context
The oblique prepsoas retroperitoneal approach to the lumbar spine for interbody fusion
or oblique lumbar interbody fusion (OLIF) provides safe access to nearly all lumbar
levels. A wide interval between the psoas and aorta allows for a safe and straightforward
left-sided oblique approach to the discs above L5. Inclusion of L5–S1 in this approach,
however, requires modifications in the technique to navigate the complex and variable
vascular anatomy distal to the bifurcation of the great vessels. While different oblique
approaches to L5–S1 have been described in the literature, to our knowledge, no previous
study has provided guidance for the choice of technique.
Purpose
Our objectives were to evaluate our early experience with the safety of including
L5–S1 in OLIF using 3 different approach techniques, as well as to compare early complications
between OLIF with and without L5–S1 inclusion.
Study design
Retrospective cohort study.
Patient sample
Of the 87 patients who underwent lumbar interbody fusion at 167 spinal levels via
an OLIF approach, 19 included L5–S1 (group A) and 68 did not (group B).
Outcome measures
Demographics, levels fused, indications, operative time (ORT), estimated blood loss
(EBL), vascular ligation, intraoperative blood transfusion, length of stay (LOS),
discharge to rehabilitation facility, and complications (intraoperative, early ≤90
days, and delayed >90 days) were retrospectively assessed and compared between the
groups.
Methods
A retrospective chart and imaging review of all consecutive patients who underwent
OLIF at a single institution was performed. Indications for OLIF included symptomatic
lumbar degenerative stenosis, deformity, and spondylolisthesis. The L5–S1 level, when
included, was approached via one of the following 3 techniques: (1) a left-sided intrabifurcation
approach; (2) left-sided prepsoas approach; and (3) right-sided prepsoas approach.
Vascular anatomic variations at the lumbosacral junction were evaluated using the
preoperative magnetic resonance imaging (MRI), and a “facet line” was proposed to
assess this relationship. A minimum of 6 months of follow-up data were assessed for
approach-related morbidities.
Results
Demographics and operative indications were similar between the groups. The mean follow-up
was 10.8 (6–36) months. ORT was significantly longer in group A than in group B (322
vs. 256.3 min, respectively; p=.001); however, no difference in ORT between the two
groups was found in the subanalyses for 2- and 3-level surgeries. Differences in EBL
(260 vs. 207.91 cc, p=.251) and LOS (2.76 vs. 2.48 days, p=.491) did not reach statistical
significance. Ligation of the iliolumbar vein, segmental veins, median sacral vessels,
or any vascular structure, as needed for adequate exposure, was required in 13 (68.4%)
patients from group A and 4 (5.9%) from group B (p<.00001). Two patients suffered
minor vascular injuries (1 in each group); however, no major vascular injuries were
seen. Complications were not significantly different between groups A and B, or between
the three approaches to L5–S1, and trended lower in the latter part of the series
as the learning curve progressed.
Conclusions
Inclusion of L5–S1 in OLIF is safe and feasible through three different approaches
but likely involves greater operative complexity. In our early experience, inclusion
of L5–S1 showed no increase in early complications. This is the first series that
reports the use of 3 different oblique approaches to L5–S1. The proposed “facet line”
in the preoperative MRI may guide the choice of approach.
Keywords
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Article info
Publication history
Published online: October 19, 2020
Accepted:
October 14,
2020
Received in revised form:
September 11,
2020
Received:
June 10,
2020
Footnotes
FDA device/drug status: Not applicable.
Author Disclosure: CAB: Nothing to disclose. DT: Nothing to disclose. FM: Nothing to disclose.
Identification
Copyright
Published by Elsevier Inc.
