Comparison of clinical effect and muscle injury imaging between oblique lateral lumbar interbody fusion and transforaminal lumbar interbody fusion in the treatment of single-segment degenerative lumbar spinal stenosis / 中国骨伤

OBJECTIVE@#To compare the efficacy and muscle injury imaging between oblique lateral lumbar interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis.@*METHODS@#The clinical data of 60 patients with single-segment degenerative lumbar spinal stenosis who underwent surgical treatment from January 2018 to October 2019 was retrospectively analyzed. The patients were divided into OLIF groups and TLIF group according to different surgical methods. The 30 patients in the OLIF group were treated with OLIF plus posterior intermuscular screw rod internal fixation. There were 13 males and 17 females, aged from 52 to 74 years old with an average of (62.6±8.3) years old. And 30 patients in the TLIF group were treated with TLIF via the left approach. There were 14 males and 16 females, aged from 50 to 81 years old with an average of (61.7±10.4) years old. General data including operative time, intraoperative blood loss, postoperative drainage volume, and complications were recorded for both groups. Radiologic data including disc height (DH), the left psoas major muscle, multifidus muscle, longissimus muscle area, T2-weighted image hyperintensity changes and interbody fusion or nonfusion were observed. Laboratory parameters including creatine kinase (CK) values on postoperative 1st and 5th days were analyzed. Visual analogue scale(VAS) and Oswestry disability index(ODI) were used to assess clinical efficacy.@*RESULTS@#There was no significant difference in the operative time between two groups(P>0.05). The OLIF group had significantly less intraoperative blood loss and postoperative drainage volume compared to the TLIF group(P<0.01). The OLIF group also had DH better recovery compared to the TLIF group (P<0.05). There were no significant differences in left psoas major muscle area and the hyperintensity degree before and after the operation in the OLIF group (P>0.05). Postoperativly, the area of the left multifidus muscle and longissimus muscle, as well as the mean of the left multifidus muscle and longissimus muscle in the OLIF group, were lower than those in the TLIF group (P<0.05) .On the 1st day and the 5th day after operation, CK level in the OLIF group was lower than that in the TLIF group(P<0.05). On the 3rd day after operation, the VAS of low back pain and leg pain in the OLIF group were lower than those in the TLIF group (P<0.05). There were no significant differences in the ODI of postoperative 12 months, low back and leg pain VAS at 3, 6, 12 months between the two groups(P>0.05). In the OLIF group, 1 case of left lower extremity skin temperature increased after the operation, and the sympathetic chain was considered to be injured during the operation, and 2 cases of left thigh anterior numbness occurred, which was considered to be related to psoas major muscle stretch, resulting in a complication rate of 10% (3/30). In the TLIF group, one patient had limited ankle dorsiflexion, which was related to nerve root traction, two patients had cerebrospinal fluid leakage, and the dural sac was torn during the operation, and one patient had incision fat liquefaction, which was related to paraspinal muscle dissection injury, resulting in a complication rate of 13% (4/30). All patients achieved interbody fusion without cage collapse during the 6- month follow-up.@*CONCLUSION@#Both OLIF and TLIF are effective in the treatment of single-segment degenerative lumbar spinal stenosis. However, OLIF surgery has obviously advantages, including less intraoperative blood loss, less postoperative pain, and good recovery of intervertebral space height. From the changes in laboratory indexes of CK and the comparison of the left psoas major muscle, multifidus muscle, longissimus muscle area, and high signal intensity of T2 image on imaging, it can be seen that the degree of muscle damage and interference of OLIF surgery is lower than that of TLIF.

Factors Affecting Postoperative Sagittal Alignment after Lateral Lumbar Interbody Fusion in Adult Spinal Deformity: Posterior Osteotomy, Anterior Longitudinal Ligament Rupture, and Endplate Injury

STUDY DESIGN: Prospective cohort study. PURPOSE: To identify factors that affect sagittal alignment correction in lateral lumbar interbody fusion (LIF) surgery for adult spinal deformity (ASD) and to investigate the degree of correction in each condition. OVERVIEW OF LITERATURE: LIF is a useful procedure for ASD, but the degree of correction can be affected by posterior osteotomy, intraoperative endplate injury, or anterior longitudinal ligament (ALL) rupture. METHODS: Radiographical data for 30 patients who underwent LIF for ASD were examined prospectively. All underwent two-stage surgery (LIF followed by posterior fixation). Radiographical parameters were measured preoperatively, after LIF, and after posterior fixation; these included the segmental lordotic angle, lumbar lordosis (LL), and other sagittal alignment factors. RESULTS: LL was corrected from 16.5°±16.7° preoperatively to 33.4°±13.8° after LIF (p<0.001) and then to 52.1°±7.9° following posterior fixation (p<0.001). At levels where Schwab grade 2 osteotomy was performed, the acquired segmental lordotic angles from the preoperative value to after posterior fixation and from after LIF to after posterior fixation were 19.5°±9.2° and 9.9°±3.9°, respectively. On average, 12.4° more was added than in cases without osteotomy. Endplate injury was identified at 21 levels (19.4%) after LIF, with a mean loss of 3.4° in the acquired segmental lordotic angle (5.3°±8.4° and 1.9°±5.9° without and with endplate injury, respectively). ALL rupture was identified at seven levels (6.5%), and on average 19.3° more was added in these cases between the preoperative and postoperative values than in cases without ALL rupture. CONCLUSIONS: LIF provides adequate sagittal alignment restoration for ASD, but the degree of correction is affected by grade 2 osteotomy, intraoperative endplate injury, and ALL rupture.

Comparative Radiographic Outcomes of Lateral and Posterior Lumbar Interbody Fusion in the Treatment of Degenerative Lumbar Kyphosis

STUDY DESIGN: Retrospective case–control study. PURPOSE: To compare surgical invasiveness and radiological outcomes between posterior lumbar interbody fusion (PLIF) and lateral lumbar interbody fusion (LLIF) for degenerative lumbar kyphosis. OVERVIEW OF LITERATURE: LLIF is a minimally invasive interbody fusion technique; however, few reports compared the clinical outcomes of conventional PLIF and LLIF for degenerative lumbar kyphosis. METHODS: Radiographic data for patients who have undergone lumbar interbody fusion (≥3 levels) using PLIF or LLIF for degenerative lumbar kyphosis (lumbar lordosis [LL] <20°) were retrospectively examined. The following radiographic parameters were retrospectively evaluated preoperatively and 2 years postoperatively: segmental lordotic angle, LL, pelvic tilt (PT), pelvic incidence (PI), C7 sagittal vertical axis, and T1 pelvic angle. RESULTS: Nineteen consecutive cases with PLIF and 27 cases with LLIF were included. There were no significant differences in patients' backgrounds or preoperative radiographic parameters between the PLIF and the LLIF groups. The mean fusion level was 5.5±2.5 levels and 5.8±2.5 levels in the PLIF and LLIF groups, respectively (p=0.69). Although there was no significant difference in surgical times (p=0.58), the estimated blood loss was significantly greater in the PLIF group (p<0.001). Two years postoperatively, comparing the PLIF and LLIF groups, the segmental lordotic angle achieved (7.4°±7.6° and 10.6°±9.4°, respectively; p=0.03), LL (27.8°±13.9° and 39.2°±12.7°, respectively; p=0.006), PI–LL (19.8°±14.8° and 3.1°±17.5°, respectively; p=0.002), and PT (22.6°±7.1° and 14.2°±13.9°, respectively; p=0.02) were significantly better in the LLIF group. CONCLUSIONS: LLIF provided significantly better sagittal alignment restoration in the context of degenerative lumbar kyphosis, with less blood loss.

Minimally Invasive Lateral Lumbar Interbody Fusion: Indications, Outcomes and Complications / 대한정형외과학회잡지

The aim of this review was to evaluate minimally invasive lateral lumbar interbody fusion on the latest update. Lumbar interbody fusion was introduced recently. This study performed, a literature review of the indications, clinical outcomes, fusion rate, and complications regarding recently highlighted minimally invasive lateral lumbar interbody fusion. The indications of lateral lumbar interbody fusion are similar to the conventional anterior and posterior interbody fusion in degenerative lumbar diseases. In particular, lateral lumbar interbody fusion is an effective minimally invasive surgery in spinal stenosis, degenerative spondylolisthesis, degenerative adult deformity, degenerative disc disease and adjacent segment disease. In addition, the clinical outcomes and fusion rates of lateral lumbar interbody fusion are similar compared to conventional lumbar fusion. On the other hand, non-specific complications including hip flexor weakness, nerve injury, vascular injury, visceral injury, cage subsidence and pseudohernia have been reported. Lateral lumbar interbody fusion is a very useful minimally invasive surgery because it has advantages over conventional anterior and posterior interbody fusion without many of the disadvantages. Nevertheless, nonspecific complications during lateral lumbar interbody fusion procedure remain a challenge to be improved.

Changes in Sagittal Alignment Following Short-Level Lumbar Interbody Fusion: Comparison between Posterior and Lateral Lumbar Interbody Fusions

STUDY DESIGN: Retrospective case-control study.PURPOSE: We aimed to compare radiologic outcomes between posterior (PLIF) and lateral lumbar interbody fusion (LLIF) in short-level spinal fusion surgeries.OVERVIEW OF LITERATURE: Although LLIF enables surgeons to insert large lordotic cages, it is unknown whether LLIF more effectively corrects local and global sagittal alignments compared with PLIF in short-level spinal fusion surgeries.METHODS: Radiographic data acquired from patients with lumbar interbody fusion (≤3 levels) using PLIF or LLIF for degenerative lumbar diseases were analyzed. The following radiographic parameters were evaluated preoperatively and at 2 years postoperatively: segmental lordotic angle, disk height, lumbar lordosis (LL), pelvic tilt (PT), C7 sagittal vertical axis, and thoracic kyphosis (TK).RESULTS: In total, 144 patients with PLIF (193 fused levels) and 101 with LLIF (159 fused levels) were included. Patients’ backgrounds and preoperative radiographic parameters for any level of fusion did not differ significantly between PLIF and LLIF procedures. The LLIF group exhibited significantly greater changes at 1-level fusion compared to the PLIF group in the parameters of segmental lordotic angle (5.1°±5.8° vs. 2.1°±5.0°, p<0.001), disk height (4.2±2.3 mm vs. 2.2±2.0 mm, p<0.001), LL (7.8°±7.6° vs. 3.9°±8.6°, p=0.004), and PI–LL (−6.9°±6.8° vs. −3.6°±10.1°, p=0.03). While, a similar trend was observed regarding 2-level fusion, significantly greater changes were only observed in LL (12.1°±11.1° vs. 4.2°±9.1°, p=0.047) and PI–LL (−11.2°±11.3° vs. −3.0°±9.3°, p=0.043), PT (−6.4°±4.9° vs. −2.5°±5.3°, p=0.049) and TK (7.8°±11.8° vs. −0.3°±9.7°, p=0.047) in the LLIF group at 3-level fusion.CONCLUSIONS: LLIF provides significantly better local sagittal alignment than PLIF in 1- or 2-level fusion cases and improves spinopelvic alignment and local alignment for 3-level fusion cases. Thus, LLIF was demonstrated to be a useful lumbar interbody fusion technique, constituting a powerful tool for achieving sagittal realignment with minimal surgical invasiveness.

Comparative Measurements of Preoperative and Postoperative Radiological and Clinical Parameters of Direct Lumbar Interbody Fusion in Degenerative Spinal Disease Patients

STUDY DESIGN: Retrospective study of prospectively-collected data.OBJECTIVES: To evaluate the radiological outcomes of direct lateral lumbar interbody fusion (DLIF).SUMMARY OF LITERATURE REVIEW: DLIF, as a minimally invasive spinal surgical procedure, is useful for degenerative spinal diseases. However, few reports have evaluated the clinical and radiological outcomes of DLIF in Korea.MATERIALS AND METHODS: We analyzed 44 patients who underwent DLIF at our hospital from September 2015 to September 2017. Of these patients, 89 segments were included in this study. We measured preoperative and postoperative radiological values including the disc height, central canal area, height of the foramen, and segmental sagittal angle on magnetic resonance imaging. We also measured patients' visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores as clinical parameters.RESULTS: Statistically significant improvements were found in the height of the left and right foramina (20.8% and 25.6%, respectively), the height of the intervertebral discs (86.0% and 84.3%, respectively), the cross-sectional area of the central nervous system (33.1%), lumbar lordosis, and the lumbar segmental angle (2.7° and 8.7°, respectively) after surgery. The VAS and ODI scores also showed significant improvements (65.7% and 67.7%, respectively) when compared with the preoperative level.CONCLUSIONS: DLIF was found to be effective for the treatment of diseases such as foraminal stenosis, degenerative spondylolisthesis, and adjacent segment diseases through indirect neuro-decompression of the bilateral foramina and central vertebrae.

Does the Access Angle Change the Risk of Approach-Related Complications in Minimally Invasive Lateral Lumbar Interbody Fusion? An MRI Study

OBJECTIVE: To investigate the potential risk of approach-related complications at different access angles in minimally invasive lateral lumbar interbody fusion.METHODS: Eighty-six axial magnetic resonance images were obtained to analyze the risk of approach-related complications. The access corridor were simulated at different access angles and the potential risk of neurovascular structure injury was evaluated when the access corridor touching or overlapping the corresponding structures at each angle. Furthermore, the safe corridor length was measured when the corridor width was 18 and 22 mm.RESULTS: When access angle was 0°, the potential risk of ipsilateral nerve roots injury was 54.7% at L4–L5. When access angle was 45°, the potential risk of abdominal aorta, contralateral nerve roots or central canal injury at L4–L5 was 79.1%, 74.4%, and 30.2%, respectively. The length of the 18 mm-wide access corridor was largest at 0° and it could reach 44.5 mm at L3–L4 and 46.4 mm at L4–L5. While the length of the 22 mm-wide access corridor was 42.3 mm at L3–L4 and 44.1 mm at L4–L5 at 0°.CONCLUSION: Changes in the access angle would not only affect the ipsilateral neurovascular structures, but also might adversely influence the contralateral neural elements. It should be also noted to surgeons that alteration of the access angle changed the corridor length.

Does the Access Angle Change the Risk of Approach-Related Complications in Minimally Invasive Lateral Lumbar Interbody Fusion? An MRI Study

OBJECTIVE: To investigate the potential risk of approach-related complications at different access angles in minimally invasive lateral lumbar interbody fusion. METHODS: Eighty-six axial magnetic resonance images were obtained to analyze the risk of approach-related complications. The access corridor were simulated at different access angles and the potential risk of neurovascular structure injury was evaluated when the access corridor touching or overlapping the corresponding structures at each angle. Furthermore, the safe corridor length was measured when the corridor width was 18 and 22 mm. RESULTS: When access angle was 0°, the potential risk of ipsilateral nerve roots injury was 54.7% at L4–L5. When access angle was 45°, the potential risk of abdominal aorta, contralateral nerve roots or central canal injury at L4–L5 was 79.1%, 74.4%, and 30.2%, respectively. The length of the 18 mm-wide access corridor was largest at 0° and it could reach 44.5 mm at L3–L4 and 46.4 mm at L4–L5. While the length of the 22 mm-wide access corridor was 42.3 mm at L3–L4 and 44.1 mm at L4–L5 at 0°. CONCLUSION: Changes in the access angle would not only affect the ipsilateral neurovascular structures, but also might adversely influence the contralateral neural elements. It should be also noted to surgeons that alteration of the access angle changed the corridor length.

Contralateral Nerve Root Compression after Direct Lateral Lumbar Interbody Fusion / 대한정형외과학회잡지

Direct lateral lumbar interbody fusion (DLIF) has been introduced as an effective new thoracolumbar fusion technique for patients with degenerative lumbar diseases. DLIF associated with easy-to-learn, high fusion rate, improved restoration of spinal alignment, and early patient mobilization due to minimally invasive nature. However, ipsilateral L2–L5 nerve root irritation and injury are well-known complications. However, damage to the contralateral nerve root has been rarely reported and, to the best of our knowledge, there have not been any reports about contralateral nerve root injury after DLIF in Korea. Thus, we report a case of contralateral nerve root compression due to osteophyte from the lower endplate of the vertebral body and position of intervertebral cage after DLIF.

Effect of Sagittal Balance on Risk of Falling after Lateral Lumbar Interbody Fusion Surgery Combined with Posterior Surgery

PURPOSE: To demonstrate the impact of correcting sagittal balance (SB) on functional outcomes of surgical treatment for degenerative spinal disease and actual falls via utilization of new minimally invasive lumbar fusion techniques via a lateral approach. MATERIALS AND METHODS: From November 2011 to March 2015, we enrolled 56 patients who underwent minimally invasive lateral lumbar interbody fusion (LLIF) and matched 112 patients receiving decompression/postero-lateral fusion (PLF) surgery for lumbar spinal stenosis. According to SB status using C7-plumb line-distance (C7PL) and surgery type, patients were divided into three groups: SB PLF, sagittal imbalance (SI) PLF, and LLIF groups. We then compared their outcomes. RESULTS: The mean C7PL was 6.2±13.6 mm in the SB PLF group, 72.9±33.8 mm in the SI PLF group, and 74.8±38.2 mm in the LLIF group preoperatively. Postoperatively, C7PL in only the LLIF group improved significantly (p=0.000). Patients in the LLIF group showed greater improvement in fall-related functional test scores than the SI PLF group (p=0.007 for Alternate-Step test, p=0.032 for Sit-to-Stand test). The average number of postoperative falls was 0.4±0.7 in the SB PLF group, 1.1±1.4 in the SI PLF group, and 0.8±1.0 in the LLIF group (p=0.041). Oswestry Disability Index and the Euro-QoL 5 dimension visual analogue scale scores also showed greater improvements in the LLIF group than in the SI PLF group at postoperative 1 year (p=0.003, 0.016). CONCLUSION: Surgical correction of SI in patients with lumbar spinal stenosis using a combination of minimal invasive LLIF and posterior surgery achieved better surgical outcomes and a lower incidence of actual falls than PLF surgery.

Mini-Open Anterior Lumbar Interbody Fusion Combined with Lateral Lumbar Interbody Fusion in Corrective Surgery for Adult Spinal Deformity

STUDY DESIGN: Prospective observational study. PURPOSE: To introduce the techniques and present the surgical outcomes of mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segments of the spine combined with lateral lumbar interbody fusion (LLIF) for the correction of adult spinal deformity OVERVIEW OF LITERATURE: Although LLIF is increasingly used to correct adult spinal deformity, the correction of sagittal plane deformity with LLIF alone is reportedly suboptimal. METHODS: Thirty-two consecutive patients with adult spinal deformity underwent LLIF combined with mini-open ALIF at the L5–S1 or L4–S1 levels followed by 2-stage posterior fixation. ALIF was performed for a mean 1.3 levels and LLIF for a mean 2.7 levels. Then, percutaneous fixation was performed in 11 patients (percutaneous group), open correction with facetectomy with or without laminectomy in 16 (open group), and additional pedicle subtraction osteotomy (PSO) in 5 (PSO group). Spinopelvic parameters were compared preoperatively and postoperatively. Hospitalization data and clinical outcomes were recorded. RESULTS: No major medical complications developed, and clinical outcomes improved postoperatively in all groups. The mean postoperative segmental lordosis was greater after ALIF (17.5°±5.5°) than after LLIF (8.1°±5.3°, p <0.001). Four patients (12.5%) had lumbar lordosis with a pelvic incidence of ±9° preoperatively, whereas this outcome was achieved postoperatively in 30 patients (93.8%). The total increase in lumbar lordosis was 14.7° in the percutaneous group, 35.3° in the open group, and 57.0° in the PSO group. The ranges of potential lumbar lordosis increase were estimated as 4°–25°, 23°–42°, and 45°–65°, respectively. CONCLUSIONS: Mini-open ALIF combined with LLIF followed by posterior fixation may be a feasible technique for achieving optimal sagittal balance and reducing the necessity of more extensive surgery.

Minimally Invasive Lateral Lumbar Interbody Fusion: Surgical Technique and Review

STUDY DESIGN: Review of the current surgical technique and literature. OBJECTIVES: The aim of this study was to review the surgical technique and the current evidence on minimally invasive lateral lumbar interbody fusion (LLIF). SUMMARY OF LITERATURE REVIEW: Spinal fusion is a useful method in the treatment of various degenerative lumbar diseases. Recently, minimally invasive LLIF has been developed, enabling spine surgeons to perform anterior interbody fusion in a minimally invasive manner. MATERIALS AND METHODS: Review of the surgical technique and the literature. RESULTS: Minimally invasive LLIF may reduce the incidence of complications of anterior lumbar interbody fusion. LLIF may restore disc height more effectively than posterior lumbar interbody fusion and indirectly decompress the neural canal without nerve root or dural retraction or perineural scaring. The current indications for LLIF are almost equivalent to those of anterior and posterior lumbar interbody fusion. Recent studies have reported no differences in the fusion rate or clinical outcomes between LLIF and the conventional anterior or posterior interbody fusion techniques. However, LLIF has nonspecific complications, such as anterior thigh pain and hip flexor weakness. CONCLUSIONS: Minimally invasive LLIF is a promising surgical alternative to the conventional anterior or posterior fusion techniques. LLIF has the advantages of less intraoperative bleeding and soft tissue injury, and a faster return to work. However, postoperative nonspecific complications are problems that need to be addressed.