Oblique lumbar interbody fusion is a minimally invasive procedure for treating degenerative lumbar disease. Its advantages include correcting coronal and sagittal spinal alignment and indirect neural decompression. However, achieving a successful outcome is limited in some patients who need direct decompression for central canal lesions including hard stenotic lesions (endplate or facet articular osteophytes and ossification of posterior longitudinal ligaments) and sequestration of the disk. Biportal endoscopic spinal surgery is a minimally invasive technique, which directly decompresses the lesion. By taking advantage of two procedures, in a long-level lumbar lesion, alignment correction and direct decompression can be both achieved. Herein, the authors introduce multilevel lumbar fusion through oblique lumbar interbody fusion and selective direct decompression through biportal endoscopic spinal surgery and discuss the surgical indications, surgical pitfalls, and recommendations for application. Consequently, it is regarded as a minimally invasive interbody fusion method for patients with multilevel lumbar degenerative degeneration.
Since the introduction of minimally invasive retroperitoneal anterior lumbar interbody fusion, otherwise called lateral lumbar interbody fusion (LLIF) in 1997, oblique lumbar interbody fusion (OLIF) has become a standard lumbar interbody fusion technique that can overcome the shortcomings of conventional posterior lumbar arthrodesis [
Meanwhile, biportal endoscopic posterior decompression (BEPD) through direct neural decompression by the minimally invasive posterior interlaminar or paraspinal approach has some advantages such as early postoperative rehabilitation, shorter hospital stay, and less immediate postoperative pain than open decompressive laminectomy [
In selected patients in whom multilevel lumbar fusion surgery with coronal and/or sagittal deformity correction is required, we believe that combining two minimally invasive procedures, OLIF and BEPD, is the best practice to restore global spinal alignment and obtain direct neural decompression. Thus, we aimed to illustrate some cases to describe the surgical techniques and highlight the advantages of this combined surgery.
This retrospective case series study was approved by the Institutional Review Board of Hallym University Kangnam Sacred Heart Hospital (IRB no., 2022-04-014). Written informed consents were obtained from the patients. Five patients with multilevel (more than three levels) lumbar spondylosis with lumbosacral radiculopathy who received OLIF and BEPD between February 2019 and April 2021 were included in this study. All patients received a two-stage surgery. First, OLIF was performed, and magnetic resonance imaging (MRI) was taken 2 days postoperatively. Thereafter, a second-stage surgery was performed 5 days postoperatively. Selective decompressive laminectomy using the biportal endoscopic technique for the insufficient levels of central canal decompression on postoperative MRI and percutaneous pedicle screw fixation were performed. All procedures were performed by a single orthopedic spinal surgeon. The inclusion criteria were as follows: three or more levels of degenerative lumbar disease between the L2 and S1 which was refractory to >3 months of conservative treatment, a space-occupying stenotic lesion in the lumbar spinal canal and/or neural foramen confirmed on MRI, degenerative lumbar scoliosis, and global sagittal imbalance. The exclusion criteria were as follows: other pathological conditions such as acute fracture, infection, or tumor; inaccessible approach for OLIF, such as vascular anatomy or previous abdominal surgery; and requiring spinopelvic fixation in patients with osteoporosis (if there is no percutaneous system).
After induction of general anesthesia and appropriate intravenous line access, the patient was placed on a bendable surgical table in a right-sided lateral decubitus position. A bendable table was useful to approach the space between the 12th rib and iliac crest. After confirming the position by fluoroscopic guidance, the patient was draped in a sterile fashion.
After confirming the target disk level under fluoroscopy, the skin incision sites were marked. For multilevel OLIF from the L2 to S1, three incisions were needed for the L2–3, L3–4–5, and L5–S1. Each curved-linear skin incision of approximately 4–5 cm was made, centered on the target segment and parallel to the external oblique muscle. In the case of L5–S1, the procedure was performed similarly to the previously introduced method (
As a timed scheduled surgery, if the radiating pain and central canal stenotic lesion did not remarkably improve on postoperative MRI, selective-level biportal endoscopic direct posterior decompression was planned. In the second operating procedure, after general anesthesia was induced, the patient was placed prone on the Jackson frame. Then, surgical draping in a water-proof, sterile fashion was completed.
Skin incisions for biportal endoscopic portals were marked surgically under fluoroscopy (
By using the percutaneous pedicle screw and rod insertion system, pedicle screws were inserted percutaneously under C-arm fluoroscopic guidance and by making additional small skin incisions. After rod fixation, the wound was closed.
In this study, multilevel OLIF with selective BEPD was conducted in four men and one woman with a mean age of 74 years. Of the cases, three required four levels of surgery, and two required three levels. The average hospital day was 12.8 days; average operative time, 379 minutes; average estimated blood loss (EBL), 470 mL (range, 250–800 mL); and average surgical drainage volume, 352 mL (range, 249–424 mL). Blood transfusion was performed at an average of 1.2 times with 400 mL of packed red blood cells. The average serum hemoglobin decreased by 2.0 (12.4–10.4) (
LLIF has comparably favorable long-term surgical outcomes with posterior lumbar interbody fusion (PLIF), although LLIF has better performance in multilevel surgery, such as less blood loss, shorter operative time, and better restoration of global spinal alignment, than PLIF [
However, OLIF has some limitations. In the cases of hard stenotic lesions including lateral recess and foraminal stenosis by osteophyte formation, calcified disk or posterior endplates, ossification of the posterior longitudinal ligament, synovial cysts, and severe central stenotic lesion, indirect decompression via OLIF alone may not be sufficient [
BEPD has some advantages, such as better immediate postoperative clinical outcomes, early functional outcomes, less intraoperative blood loss, and accessibility for any posterior lesion such as central canal stenosis and foraminal stenosis [
The main notable aspect of this minimally invasive hybrid technique is the low intraoperative and postoperative blood loss. In the previous results of EBL after lumbar interbody fusion [
This study had some limitations. First, this was a single-institution retrospective study with a small number of cases. Second, the follow-up period was insufficient to present the surgery outcomes. Finally, we investigated patients with moderate coronal and sagittal imbalance and without osteoporosis. Thus, confirming the results through a multicenter prospective study with a larger number of cases is necessary.
In conclusion, OLIF with selective BEPD is a feasible option. Specifically, considering 3–4 levels of lumbar interbody fusion in older people, this minimally invasive hybrid technique is expected to restore segmental coronal and sagittal spinal alignment and allow direct neural decompression to the necessary level while reducing the risk of perioperative complications.
No potential conflict of interest relevant to this article was reported.
Conceptualization: MSK, HJP; data curation: KHY, HJP; formal analysis: WML, JHK; funding acquisition: not applicable; methodology: HJP; project administration: HJP; visualization: WML; writing–original draft: WML, KHY; writing–review & editing: all authors; and final approval of the manuscript: all authors.
Procedures of the multilevel oblique lumbar interbody fusion.
Procedures of multilevel selective posterior decompression by biportal endoscopic spinal surgery.
Radiographic illustration of one case. Preoperative whole spine radiographs
Radiographic illustration of another case.
Radiographic illustration of a nonunion case.
Patients’ demographics and perioperative outcomes
Case | Sex | Age (yr) | BMI (kg/m2) | BMD (T-scores) | Op level | Op name | Hospital day | Op time (min) | EBL (mL) | Hemovac drainage (mL) | Transfusion (400 mL pRBC) | Hb (g/dL) | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Preop | Postop | ||||||||||||
Case 1 | M | 75 | 22.4 | −1.0 | 4 | OLIF L2-3-4-5-S1; BEPD L2-3-4 | 12 | 380 | 400 | 358 | 2 | 10.0 | 8.0 |
Case 2 | M | 76 | 24.5 | −1.6 | 4 | OLIF L2-3-4-5-S1; BEPD L3-4-5 | 13 | 425 | 400 | 424 | 1 | 14.2 | 11.7 |
Case 3 | M | 76 | 24.1 | −1.6 | 3 | OLIF L2-3-4-5; BEPD L2-3; discectomy L4-5 | 10 | 360 | 250 | 353 | 0 | 14.3 | 10.6 |
Case 4 | M | 68 | 19.6 | −1.0 | 3 | OLIF L3-4-5-S1; BEPD L4-5 | 11 | 300 | 800 | 249 | 2 | 13.3 | 11.8 |
Case 5 | F | 75 | 23.0 | −2.4 | 4 | OLIF L2-3-4-5-S1; BEPD L3-4-5 | 18 | 430 | 500 | 376 | 1 | 10.5 | 9.9 |
Mean | 74 | 22.7 | −1.5 | 3.6 | 12.8 | 379 | 470 | 352 | 1.2 | 12.4 | 10.4 |
BMI, body mass index; BMD, bone mineral density; Op, operative; EBL, estimated blood loss; pRBC, packed red blood cells; Hb, hemoglobin; Preop, preoperative; Postop, postoperative; M, male; F, female; OLIF, oblique lumbar interbody fusion; BEPD, biportal endoscopic posterior decompression.
Radiographic outcomes
Case | Lumbar lordosis (°) | Pelvic tilt (°) | Sacral slope (°) | Pelvic incidence (°) | PI-LL mismatch (°) | C7SVA (mm) | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
| |||||||||||||
Preop | Postop | Diff | Preop | Postop | Diff | Preop | Postop | Diff | Preop | Postop | Diff | Preop | Postop | Diff | Preop | Postop | Diff | |
Case 1 | 27.0 | 48.4 | 21.4 | 18.8 | 15.5 | −3.3 | 30.5 | 34.1 | 3.6 | 49.3 | 49.6 | 0.3 | 22.3 | 1.2 | −21.1 | 209.1 | 112.9 | −96.2 |
| ||||||||||||||||||
Case 2 | 31.0 | 47.5 | 16.5 | 4.7 | 10.0 | 5.3 | 33.0 | 27.6 | −5.4 | 37.7 | 37.6 | −0.1 | 6.7 | −9.9 | −16.6 | 170.8 | 49.3 | −121.5 |
| ||||||||||||||||||
Case 3 | 40.0 | 55.5 | 15.5 | 26.2 | 28.0 | 1.8 | 34.2 | 32.4 | −1.8 | 60.4 | 60.4 | 0.0 | 20.4 | 4.9 | −15.5 | 99.4 | 13.7 | −85.7 |
| ||||||||||||||||||
Case 4 | 20.1 | 41.9 | 21.8 | 16.9 | 8.9 | −8.0 | 26.7 | 35.1 | 8.4 | 43.6 | 44.0 | 0.4 | 23.5 | 2.1 | −21.4 | 135.8 | 45.8 | −90.0 |
| ||||||||||||||||||
Case 5 | 21.1 | 46.3 | 25.2 | 33.1 | 26.3 | −6.8 | 18.3 | 24.6 | 6.3 | 51.4 | 50.9 | −0.5 | 30.3 | 4.6 | −25.7 | 165.1 | 44.4 | −120.7 |
| ||||||||||||||||||
Mean | 27.8 | 47.9 | 20.1 | 19.9 | 17.7 | −2.2 | 28.5 | 30.8 | 2.2 | 48.5 | 48.5 | 0.0 | 20.6 | 0.6 | −20.1 | 156.0 | 53.2 | −102.8 |
PI, pelvic incidence; LL, lumbar lordosis; C7SVA, C7 sagittal vertical axis; Preop, preoperative; Postop, postoperative; Diff, the difference between the postoperative and preoperative values.