CC BY
7
A.P. SAIFULLIN et al., 2023
lumbar fusion through the anterolateral mini-approach: comparison of anterior interbody (olif-af) and percutaneous pedicle (olif-pf) fixations in the surgical treatment of single-level stenosis
A.P. Saifullin, A.Ya. Aleynik, A.E. Bokov, S.G. Mlyavykh
Privolzhsky Research Medical University, Nizhny Novgorod, Russia
Objective. To perform comparative analysis of the clinical efficacy and safety of indirect decompression of the spinal roots and interbody fusion through the lateral pre-psoas approach (OLIF) with anterolateral (OLIF-AF) and posterior percutaneous (OLIF-PF) screw fixations in the surgical treatment of single-segment lumbar stenosis.
Material and Methods. A retrospective comparative analysis of treatment of 88 patients aged 29 to 72 years with single-level lumbar stenosis was carried out. Posterior instrumental fixation (OLIF-PF) was performed in 60 cases, and anterolateral (OLIF-AF) — in 28. Results. The compared groups did not statistically significantly differ from each other in terms of age, gender, body mass index, clinical picture and duration of symptoms before surgery, assessment of neurological status according to the Zurich Claudication Questionnaire (ZCQ), preoperative diagnosis, localization of stenosis, pain assessment in the back and leg before surgery according to a digital rating scale, physical status (ASA), health assessment (SF-12, ODI), follow-up period, as well as smoking and the presence of comorbidities (p > 0.05). In the OLIF-AF group, compared to the OLIF-PF group, a statistically significant advantage was found in terms of blood loss, duration of surgery and anesthesia, the level of radiological exposure, duration of patient's hospitalization and hospital stay in the postoperative period, as well as the duration of antibiotic prophylaxis and intraoperative volume of infusions (p < 0.05). Despite earlier discharge and less use of local anesthesia (35.7 % vs 73.3 %; p = 0.001), patients in the OLIF-AF group had statistically significantly lower level of back pain on the day of discharge (3.0 vs 3.5; p = 0.034) and were less likely to need opioids (3.6 % vs 31.7 %; p = 0.003). With regard to complications and adverse events, there were no statistically significant differences during dynamic follow-up period from 3 to 50 months in both groups (17.9 % vs 28.3 %; p = 0.290), including depending on the timing of complications (early or late). In addition, no statistically significant differences were found for neurological, infectious, gastrointestinal, urological, or implant-related complications (p > 0.05). Conclusions. Indirect decompression of the spinal roots and interbody fusion through the lateral pre-psoas approach in combination with OLIF-AF is an effective and safe technique for the surgical treatment of single-segment lumbar stenosis. This method allows to reduce the invasiveness of surgery and severity of the pain syndrome and to create conditions for enhanced recovery after surgery. Further multicenter randomized trials are needed to comprehensively evaluate long-term outcomes.
Key Words: spine surgery, anterolateral screw fixation, interbody fusion, lateral pre-psoas approach, OLIF, OLIF-AF, enhanced recovery after surgery, spinal stenosis, spondylolisthesis.
Please cite this paper as: Saifullin AP, Aleynik AYa, Bokov AE, Mlyavykh SG. Lumbar fusion through the anterolateral mini-approach: comparison of anterior interbody (OLIF-AF) and percutaneous pedicle (OLIF-PF) fixations in the surgical treatment of single-level stenosis. Khirurgia Pozvonochnika (Russian Journal of Spine Surgery) 2023;20(3):50—62. In Russian. DOI: http://dx.doi.org/10.14531/ss2023.3.50-62.
Symptomatic lumbar spinal stenosis is one of the most frequent causes for patients to consult a neurosurgeon and undergo surgical treatment [1-3]. Moreover, the number of complications in spinal and spinal cord surgery can reach 44-55 % [4-8]. This certainly increases the costs of healthcare, length of hospital stay and rehabilitation of patients. It also necessitates the search
for technologies to optimize the perioperative management of the patient and surgical technique [9-14].
At present, one of the most optimal and effective treatment techniques for symptomatic lumbar spinal stenosis is indirect decompression of the spinal roots and interbody fusion through the lateral pre-psoas approach (oblique lateral interbody
fusion - OLIF) in combination with posterior (posterior fixation - PF) percutaneous transpedicular fixation (OLIF-PF). Nevertheless, this technique requires an intraoperative change of the patient's position that increase injury rate and surgery duration, as well as radiation exposure to both a patient and a healthcare staff [15, 16]. The complications rate in OLIF varies
50
a.p. saifullin et al lumbar fusion through the anterolateral mini-approach in the surgical treatment of single-level stenosis
from 3.7 % [17] to 48.3 % [4] and mean is 13.9 % [18].
One of the possible solutions to these challenges is the new technique of OLIF with anterolateral screw fixation (OLIF-AF) [15, 19, 20] that allows surgery to be performed from a single surgical approach. Nonetheless, isolated papers do not disclose the details of the effect of this technique on the number of complications, the degree of postoperative pain and the features of postoperative recovery in patients.
The objective is to perform a comparative analysis of the clinical efficacy and safety of indirect decompression of the spinal roots and interbody fusion through the lateral pre-psoas approach with anterolateral and posterior percutaneous screw fixations in the surgical treatment of singlesegment lumbar stenosis.
Design: a single-center nonrandomized interventional cohort comparative trial. Evidence level: 3b.
Material and Methods
This study is approved by the ethical committee (Protocol No. 02 as of 17.02.2023) of the Privolzhsky Research Medical University (Nizhny Novgorod, Russia). In the period from 2019 to 2023, the treatment of 88 patients aged 29-72 years old with single-level lumbar stenosis was studied retrospectively using the OLIF technique. The patients involved in the study were divided into two groups:
• The first group (n = 60): indirect decompression of spinal cord roots and interbody fusion through the lateral pre-psoas approach (OLIF) in combination with posterior percutaneous stabilization of a spinal motion segment (OLIF-PF);
• The second group (n = 28): OLIF in combination with anterolateral instrumented fixation (OLIF-AF) performed by author's modification.
The required sampling size was identified when calculating the power analysis performed on https://clincalc. com, with the significance value (a) = 0.05 and the power of test (1-p) = 0.80. The analysis confirmed the sufficiency of
the number of patients in both groups; the calculation was performed with the identification of the required total sampling according to such compared criteria as duration of anesthesia (n = 4) and surgery (n = 2), volume of blood loss (n = 4), length of hospital stay (n = 18), radiological exposure (n = 24), degree of back pain on the day of discharge (n = 76), as well as use of opioids (n = 56) and local anesthesia (n = 52).
Inclusion criteria:
• age over 18;
• chronic (more than 6 months) progressive vertebral syndrome in combination with neurogenic intermittent claudication and/or nerve root syndrome corresponding to singlelevel unstable degenerative stenosis, as well as combined with degenerative spondylolisthesis;
• no effect from complex non-surgical treatment lasting at least 4 weeks;
• surgical treatment in the volume of single-level indirect decompression, oblique lateral interbody fusion followed by rigid instrumented fixation of the spinal motion segment.
Exclusion criteria:
• previous spinal surgery at the site of planned procedure with instrumented fixation;
• presence of competing pathology in the lumbar spine (pronounced osteoporosis, inflammatory infections, tumors, traumatic injuries).
Perioperative management
Perioperative management of patients in the surgical treatment of singlelevel spinal stenosis complies with the international protocol for enhanced recovery after surgery (ERAS® Society) during interbody fusion [21, 22], with the exception of the following protocol elements: combined therapy for smoking and alcohol cessation 4-8 weeks before surgery; assessment of nutritional status (albumin, transferrin, lymphocytes) for dietary supplementation; preoperative correction of nutrition and minimizing preoperative fasting (drinking water 2 hours and eating 6 hours before surgery) for patients with a low body mass index (BMI); antiseptic dressing at the site of surgical approach before surgery.
Surgical technique
Indirect decompression of spinal roots and interbody fusion through the lateral pre-psoas approach (OLIF) in combination with posterior percutaneous stabilization of a spinal motion segment (Fig. 1, 2) did not differ from the generally accepted ones [23]. Anterolateral instrumented fixation was performed in accordance with the technique described in the papers by Liu et al. [20], Xie et al. [19], Guo et al. [15]. However, there were the following differences: preliminary interfacial anesthesia of the musculus erector spinae and the infiltration of the surgical approach site by local anesthetics were performed. The cage was inserted with pre-filling of the graft with allobone or osteoplastic material only. Bi-cortical anterolateral insertion of titanium screws was performed into the vertebral bodies with an insertion point at a distance of 8 mm from the level of the endplate and at the angle of 30° at the level of L1-L2-L3-L4-L5 followed by their locking with a titanium rod and at the angle of 45° in a monocortical manner at the level of L5-S1 in the caudal or in combination with the cranial direction (Fig. 3, 4). A layered closure of the surgical wound was performed with the application of an aesthetic intradermal suture without the installation of drains (priority reference No. 2022130051 as of 18.11.2022). All surgeries were performed by three spine surgeons with more than 10 years of experience.
Statistical analysis
The data were analyzed using the IBM SPSS Statistics-23 software. Methods of descriptive statistics were used. The distribution of signs of normality was assessed using the Kolmogorov-Smirnov tests. The Mann-Whitney U Test and the Wilcoxon signed-rank test were used for a comparative analysis of non-parametric data. The data are presented by median and interquartile range in the form of Me [25; 75]. Pearson's chi-squared test was used for comparative analysis of nominal data. The differences were considered statistically significant at p < 0.05. Spearman's rank correlation coefficient for nonparametric data and Cramer's
51
V for nominal variables were used to assess the strength of the correlation. The interpretation of the results was done according to the recommendations of Rea & Parker [24].
Results
Demographic profile of patients There were no statistically significant differences (p > 0.05) between the compared groups of OLIF-PF and OLIF-AF in terms of age, gender, BMI, clinical picture and duration of symptoms before surgery, assessment of neurological status according to the Zurich Claudication Questionnaire (ZCQ), preoperative diagnosis, localization of stenosis, pain assessment on the numeric rating scale (NRS) in the back and leg before surgery, physical status (ASA), health assessment (SF-12, ODI - Oswestry Disability Index), follow-up periods (Table 1), as
well as smoking and the presence of concomitant diseases (Fig. 5).
Clinical outcomes
In the OLIF-AF group, compared with the OLIF-PF group, a statistically significant advantage was revealed (Table 2) in terms of the volume of blood loss, the duration of surgery and anesthesia, the level radiological exposure, the time of hospital admission and length of hospital stay of the patient in the postoperative period, as well as the duration of antibiotic prophylaxis and intraoperative volume of infusion (p < 0.05).
Despite earlier discharge and less use of local anesthesia (35.7 % vs 73.3 %; p = 0.001) associated with more frequent interfacial anesthesia of the musculus erector spinae (39.3 % vs 11.7 %; p = 0.003), patients in the OLIF-AF group had statistically significantly lower degree of back pain on the day of discharge
(3.0 vs 3.5; p = 0.034) and needed fewer opioids (3.6 % vs 31.7 %; p = 0.003).
There were no statistically significant differences in the comparative assessment of repeated surgeries in the early postoperative period (up to 30 days), the length of the patient's hospital stay before surgery, the assessment of leg pain on the day of discharge or the formation of interbody fusion (p > 0.05).
Complications and adverse events
Despite the lower overall rate of complications and adverse events (Table 3) in the OLIF-AF group, there were no statistically significant differences during case follow-up from 3 to 50 months in both groups (17.9 % vs 28.3 %; p = 0.290). Moreover, there were no statistically significant differences in neurological, infectious, gastrointestinal, urological or implant-associated complications (p > 0.05). Damages to the great vessels, dura mater, abdominal
Fig. 1
Radiological findings of a 48-year-old man with spondylolisthesis of the L3 vertebra and a clinical picture of neurogenic claudication who underwent OLIF-PF: a - MRI before surgery; b - CT scan before surgery; c - radiographs after surgery; d - CT scan after surgery
cavity organs and retroperitoneal space, thromboembolic complications, and other serious complications were not found in both groups.
In the OLIF-AF group, the overall complication rate was 17.9 % (5 out of 28). In the early postoperative period, one patient had an urinary infection associated with an acute respiratory viral infection; and there was an instrumentation malposition with the development of neurological manifestations in two patients with stenosis at the L4-L5 level: in one case, the occurrence of L4 radiculopathy with subsequent successful repeated surgery was noted in the early postoperative period; in the second case, the development of temperature asymmetry in the lower extremities without motor and sensory deficits. Due to the insignificant dynamics at the background of non-surgical treatment,
the removal of the instrumentation was performed after 8 months. It is should be noted that these patients had a history of microdiscectomies at the L4-L5 level.
In the late postoperative period, adjacent segment disease developed at the proximal and distal levels in two patients two years after surgery. After that they underwent successful microsurgical decompression.
In the OLIF-PF group, the overall complication rate was 28.3 % (17 out of 60). In the early postoperative period, dynamic intestinal paresis with its regression associated with non-surgical treatment developed in 4 out of 8 patients; the remaining patients had complications associated with grafts (malposition of pedicle screws followed by successful repeated surgery, separation of tuning forks bilaterally followed by replacement of screws and screw extraction followed
by augmentation of the vertebral body by allobone when trying to reduce the vertebral body, as well as cage subsidence in a female patient with hypothyroidism). An interbody fusion was formed in all of these patients over time.
Late complications and adverse events (more than 30 days) were noted in 9 patients: a superficial infection of the surgical site with secondary intention in two cases; the development of failed back surgery syndrome (FBSS) with the subsequent installation of the neurostimulation circuit in one case; six patients had implant-associated complications (the formation of pseudoarthrosis in a patient with a history of repeated microdiscectomies; five patients had the development of an adjacent level syndrome, while only one patient was referred for repeated stabilization surgery). The remaining patients underwent courses of non-
Fig. 2
Radiological findings of a 51-year-old man with spondylolisthesis of the L5 vertebra, foraminal stenosis, instability at the L5-S1 level and a clinical picture of bilateral radiculopathy of L5 who underwent OLIF-PF: a - MRI before surgery; b - CT scan before surgery; c - CT scan after surgery
surgical and rehabilitation treatment, as well as facet block or radiofrequency denervation with a positive effect.
Discussion
The technology of indirect decompression of spinal roots and interbody fusion through the lateral pre-psoas approach is a minimally invasive surgical technique with the approach to the intervertebral disc performed through an opening between the lumbar muscle and the great vessels to avoid injuries to the vessels and nerves of the lumbar plexus, as well as injury to the muscles, ligaments and bones of the lumbar spine. The performance of OLIF decreases the volume of blood loss, injury rate, duration of surgery and postoperative recovery significantly reducing the risk of complications [4]. In this regard, OLIF is an effective, universal and
minimally traumatic option for lumbar fusion with a relatively small number of complications that indicates its advantage over TLIF, DLIF and ALIF techniques [18].
his surgical technique was first described by Mayer [25]. The term "OLIF" was first expound in 2012 in the paper of Silvestre et al. [23]. A detailed description of the anatomical approach with the possibility of safe surgery at the levels from L1 to S1 vertebrae has been confirmed in various studies [18, 26-28].
OLIF in combination with posterior percutaneous transpedicular fixation (OLIF-PF) [4, 18, 29] is widely used in the treatment of lumbar stenosis, instability of the spinal motion segment and spondylolisthesis. However, the need for an intraoperative change of the patient's position and additional incisions with an increased injury rate and duration of
surgery caused further search for optimal surgical technique [15, 16].
In 2020, Liu et al. [20] and Xie et al. [19] published studies that showed the use of OLIF with anterolateral screw fixation in the treatment of degenerative diseases of the lumbar spine. Since the cage used in the OLIF is larger and covers the bilateral epiphyseal ring, the stability of fixation is greatly enhanced. This biomechanically defines the possibility of reliable instrumental stabilization of both one [19, 20] and two [30] spinal motion segments through a single approach during OLIF-AF. In our study, cancellous screws were used when performing anterior fixation at the L5-S1 level that, when considering the anatomy and biomechanical features of the OLIF of L5-S1, allowed to ensure fixation stability during interbody fusion without the need for posterior fixation in the OLIF-AF group of patients. Previously, it
Fig. 3
Radiological findings of a 59-year-old woman with spondylolisthesis of the L3 vertebra and a clinical picture of neurogenic claudication who underwent OLIF-AF: a - MRI before surgery; b - CT scan before surgery; c - radiographs after surgery; d - CT scan after surgery
a.p. saifullin et al. lumbar fusion through the anterolateral mini-approach in the surgical treatment of single-level stenosis
Fig. 4
Radiological findings of a 39-year-old woman with foraminal stenosis and instability at the L5-S1 level and a clinical picture of bilateral radiculopathy of L5 who underwent OLIF-AF: a - MRI before surgery; b - CT scan before surgery; c - CT scan after surgery
has been proven that an autonomic OLIF in comparison with OLIF-PF can ensure comparable clinical and radiological outcomes associated with the same complications rate. Some researchers consider pronounced osteoporosis [16] and injury to the endplates [31] to be factors limiting the comparison of these techniques that were considered in our paper.
This technique is innovative for the surgery of degenerative spinal lesions, since earlier the technique of anterolateral screw fixation was used only in the treatment of spinal injuries, tuberculosis and other spinal lesions [32, 33]. The disadvantage of OLIF compared to TLIF is the impossibility of performing direct decompression of neural structures. Zhou et al. [34] compensated for the latter by performing simultaneous OLIF-AF with percutaneous endoscopic transforaminal discectomy (OLIF-PETD).
This made it possible not to injure the paraspinal muscles and bone structures and to minimize surgical trauma for the patient.
According to the eLibrary, it was impossible to find studies on the application of anterolateral fixation during indirect decompression of spinal roots and interbody fusion through the lateral pre-psoas approach (OLIF-AF) in the domestic literature at the time of writing this paper, and when analyzing the world literature (according to the Pubmed database), only several articles on this issue published from 2020 to 2022 were found [15, 19, 20, 35-38].
Injury rate assessment of surgery
The length of hospital stay, blood loss, the duration of surgery and anesthesia are among the most common parameters of injury rate of surgery. As in similar studies by other authors [15, 35], our study obtained a statistically
55
significant advantage in the OLIF-AF group in terms of intraoperative blood loss and intravenous infusions, surgery duration and anesthesia, radiological exposure and length of hospital stay. Similar outcomes were obtained when comparing OLIF-AF with TLIF [37] and OLIF-PETD with MIS-TLIF [36, 38].
Assessment of radiological outcomes
We have discovered that there was a high percentage of the formation of an interbody fusion without the presence of statistically significant differences in both groups that was confirmed in other studies [15, 35].
There was no comparative analysis of the achieved radiological parameters after surgery in both groups in our study (foraminal height (FH), cross-sectional area (CSA), anterior (ADH), and posterior (PDH) disc height). Other authors have demonstrated that the outcomes obtained in the OLIF-AF and OLIF-PF
a.p. saifullin et al. lumbar fusion through the anterolateral mini-approach in the surgical treatment of single-level stenosis
Table 1
Demographic profile of patients before surgery
Parameters OLIF-PF OLIF-AF p Assessment of the
(n = 60) (n = 28) strength of the correlation
Age, years 56.5 [47.3; 61.8] 54 [46.3; 60.5] 0.431 -0.085**
male Gender, n (%) female 19 (31.7) 8 (28.6) 0.769 0.031**
41 (68.3) 20 (71.4)
BMI, kg/m2 30.9 [26.4; 33.4] 28.9 [25.2; 31.9] 0.130 -0.163**
Preoperative diagnosis, n (%)
Spinal stenosis, instability 17 (28.3) 13 (46.4)
Spondylolisthesis 34 (56.7) 8 (28.6) 0.082 0.238*
Condition after microdiscectomy 9 (15.0) 7 (25.0)
Clinical picture before surgery, n (%)
Axial pain syndrome 39 (65.0) 15 (53.6) 0.109 0.305*
Neurogenic claudication syndrome 32 (53.3) 14 (50.0) 0.771 0.031*
Radiculopathy 31 (51.7) 17 (60.7) 0.427 0.085*
Target level, n (%)
|L2-L3 0 (0.0) 2 (7.1)
L3-L4 9 (15.0) 2 (7.1) 0.074 0.280*
L4—L5 41 (68.3) 16 (57.1)
L5—S1 10 (16.7) 8 (28.7)
Duration of symptoms, n (%)
6—24 months 17 (28.3) 9 (32.1) 0.715 0.039*
Over 24 months 43 (71.7) 19 (67.9)
Smoking, n (%) 11 (18.3) 9 (32.1) 0.150 0.153*
Pain assessment in the back according to NRS before surgery 6 [4.3; 7.8] 6.5 [3.3; 8] 0.968 0.004**
Pain assessment in a leg according to NRS before surgery 5 [2.3; 7.0] 6 [3.3; 8] 0.188 0.142**
Physical status (ASA) before surgery 2 [2.0; 3.0] 2 [2; 3] 0.497 -0.073**
Oswestry index (ODI) before surgery 39 [30.0; 54.0] 46 [22.0; 51.8] 0.860 0.019**
Zurich Claudication Questionnaire (ZCQ)
Block SS-1 (Symptom Severity), 3.5 [3.3; 3.8] 3.4 [2.8; 4.0] 0.547 -0.073**
S1 — S4 (pain subgroup), points
Block SS-2 (Symptom Severity), 2 [1.3; 2.7] 1.7 [1.4; 2.2] 0.449 -0.082**
S5—S7 (neuroischemic subgroup), points
PhF block (Physical Function), S8—S12, points 2.6 [1.6; 2.8] 2.4 [1.5; 3.2] 0.658 0.049**
RE block (Reliability Evaluation), S1—S12, points 2.7 [2.2; 2.9] 2.8 [1.9; 3.1] 0.918 0.011**
SF-12 Health Score
Mental health 32.3 [23.6; 36.3] 29.7 [20.9; 33.9] 0.513 -0.071**
Physical health 39.3 [31.5; 47.9] 37.5 [28.6; 52.2] 0.848 0.021**
Follow-up period, months 18 [11.0; 34.0] 19 [6.5; 27.5] 0.449 -0.082**
* Cramer's V for nominal variables; ** Spearman's correlation analysis; BMI — body mass index; NRS — numerical rating scale for pain.
groups are comparable and do not differ (p < 0.05) from each other [15, 35]. Assessment of complications and adverse events The probability of complications during OLIF is 13.9 % on mean [18] that is less in comparison with such techniques as ALIF - 14.1 % [39], TLIF - 19.25 %
and ELIF - 31.4 % [40]. The frequency of serious complications during OLlF (injuries to the great vessels, ureters and nerves) is 1.9 % and the most frequent complications are temporary weakness, numbness of a hip (13.5 %) and injury to the endplate (18.7 %) [4].
56
The percentage of complications in the group with anterolateral fixation was lower in our study, though we did not get statistically significant differences (17.9 % vs 28.3 %; p = 0.290). According to other researchers, complications occurred in 14.3 % [20] to 45.8 % [15] of cases during OLIF-AF. Meanwhile, there
a.p. saifullin et al lumbar fusion through the anterolateral mini-approach in the surgical treatment of single-level stenosis
70605040302010-
67
13
10 11 7 4 7
57
54
53
18
V
42
25
15
10
Hi
14
4 3' 54 3
Diabetes Thyroid Pulmonary Coronary Peripheral Gastro- Obesity Dyslipidemia Infection Anemia Cancer Osteoporosis Urological
mellitus disorders disease vascular vascular diseases intestinal (p = 0.130) (p = 0. 764) (hepatitis (p = 0.116) (p = 0.424) (p = 0.764) diseases
(p = 0.394) (p = 0.299) (p = 0.513) diseases (varicose veins) diseases B and C) (p = 0.058)
(p = 0.237) (p = 0.733) (p = 0.738) (p = 0.083)
] OLIF-PF (n = 60) I OLIF-AF (n = 28)
5
4
0
0
Table 2
Comparison of clinical data between OLIF-PF and OLIF-AF groups
Parameters OLIF-PF OLIF-AF P Assessment of the
(n = 60) (n = 28) strength of the correlation
Duration of antibiotic prophylaxis, days 2 [2; 3] 2 [1; 2] 0.002 -0.325**
Volume of intravenous infusions (intraoperative), ml 1000 [1000; 1100] 750 [500; 1100] 0.012 -0.267**
Use of local anesthesia, n (%) 44 (73.3) 10 (35.7) 0.001 0.360*
ESPB, n (%) 7 (11.7) 11 (39.3) 0.003 0.319*
Anesthesia time, min 240 [211.3; 275.0] 135 [110.0; 160.0] 0.000 -0.712**
Surgery time, min 195 [160.0; 213.8] 80 [66.3; 100.0] 0.000 -0.715**
Volume of blood loss, ml 80 [61.3; 100.0] 50 [20.0; 50.0] 0.000 -0.629**
Length of hospital stay (before surgery), days 2 [1.0; 3.8] 2 [1.0; 3.0] 0.474 -0.077**
Length of hospital stay (after surgery), days 5 [4; 6] 4 [3; 5] 0.000 -0.447**
Length of hospital stay (total), days 7 [7; 8] 6 [5; 7] 0.000 -0.410**
Radiological exposure (during hospital stay), mSv 7.2 [4.4; 11.9] 4.7 [1.6; 7.4] 0.005 -0.298**
Pain in the back according to NRS at discharge 3.5 [2.0; 5.0] 3 [1.3; 4.0] 0.034 0.227**
Pain in a leg according to NRS at discharge 3 [1; 5] 3 [2; 4] 0.673 0.045**
Opioid use, n (%) 19 (31.7) 1 (3.6) 0.003 0.312*
Repeated hospital admission (30 days), n (%) 0 (0) 0 (0) - -
Repeated surgery (30 days), n (%) 1 (1.7) 1 (3.6) 0.577 0.060*
MSCT in the postoperative period, n (%) 33 (55.0) 10 (35.7) 0.092 0.180*
Formed interbody fusion Yes 32 (98.4) 10 (100.0) 0.213 0.188*
(n = 43), n (%) No 1 (1.6) 0 (0.0)
* Cramer's V for nominal variables; ** Spearman's correlation analysis; NRS — numerical rating scale for pain; ESPB (Erector spine plane block) —
interfascial anesthesia of the musculus erector spinae.
57
Table 3
Comparison of complications and adverse events between OLIF-PF and OLIF-AF groups
Complications OLIF-PF (n = 60) OLIF-AF (n = 28) P Assessment of the strength of the correlation
Complications and adverse events, total 17 (28.3) 5 (17.9) 0.290 0.113*
Early complications and adverse events 8 (13.3) 3 (10.7) 0.464 0.078*
Late (more than 30 days) complications and adverse events 9 (15.0) 2 (7.1) 0.299 0.111*
Surgical site infection 2 (3.3) 0 (0.0) 0.328 0.104*
Neurological complications 1 (1.7) 0 (0.0) 0.492 0.073*
Gastrointestinal complications 4 (6.7) 0 (0.0) 0.162 0.149*
Implant-associated complications 10 (16.7) 4 (14.3) 0.517 0.069*
Urological complications 0 (0.0) 1 (3.6) 0.141 0.157*
Thromboembolic complications 0 (0.0) 0 (0.0) — —
* Cramer's V for nominal variables.
were also no statistically significant differences between the OLIF-AF and OLIF-PF groups (45.8 % vs 48.1 %; p = 0.869) [15]. There were no differences in the complications rate when comparing OLIF-AF with TLIF (25.0 % vs 23.9 %; p = 0.545) [37], as well as OLIF-PETD with MIS-TLIF (6.5 % vs 5.9 %; p = 0.924) [36].
Assessment of the effect
on pain syndrome
OLIF-PF requires dissection of the paravertebral muscles to install instrumentation. Postoperative atrophy of the paravertebral muscles is closely associated with the denervation of the paravertebral muscles, the subsequent inefficiency of surgery and the presence of postoperative lower back pain in some patients [41]. OLIF-AF does not require dissection of the paravertebral muscles that theoretically results in lower postoperative pain. In a study by Guo et al. [15] and according to the outcomes of our study, the significantly lower degree of back pain was revealed in the early postoperative period in the OLIF-AF group. This confirms the significance of reducing injury to the paravertebral muscles for enhanced recovery of patients after surgery. Similar data were
obtained when comparing OLIF-PETD with MIS-TLIF (2.4 ± 0.5 vs 3.1 ± 0.7; p = 0.009) [36].
Limitations and perspectives
of the study
This clinical study had the following limitations:
• the retrospective type of the study that increases the risk of systematic errors;
• procedures were performed for single-level L2-S1 stenosis and the level of surgery can affect various parameters, the complications rate and the treatment outcomes;
• different periods of follow-up (from 3 to 51 months) and differences in the number of patients in the groups that could also impact the final outcomes of the study.
Despite the all limitations, the obtained results provide essential primary data for assessment of the reliability and effectiveness of anterolateral instrumented fixation during indirect decompression of spinal roots and interbody fusion through the lateral pre-psoas approach. These findings may contribute to the arrangement of further prospective
randomized trials for the formulation of indications and limitations for the implementation of OLIF-AF.
Conclusion
Indirect decompression of the spinal roots and interbody fusion through the lateral pre-psoas approach with anterolateral instrumented fixation is an effective and reliable technique for the surgical treatment of single-segment lumbar stenosis. This technique allows to reduce injury rate of surgery and the severity of the pain syndrome and creates conditions for enhanced recovery after surgery. It is required to perform further multicenter randomized trials to comprehensively evaluate long-term outcomes.
The study had no sponsors.
The authors declare that they have no conflict of
interest.
The study was approved by the local ethics committee of the institution. All authors contributed significantly to the research and preparation of the article, read and approved the final version before publication.
58
References
1. Wu AM, Chen CH, Shen ZH, Feng ZH, Weng WQ, Li SM, Chi YL, Yin LH, Ni WF.
The outcomes of minimally invasive versus open posterior approach spinal fusion in treatment of lumbar spondylolisthesis: the current evidence from prospective comparative studies. Biomed Res Int. 2017;2017:8423638. DOI: 10.1155/2017/8423638.
2. Byvaltsev VA, Kalinin AA, Stepanov IA, Aliyev MA, Shepelev VV, Pestryakov YuYa. Meta-analysis of prospective cohort studies that compare outcomes of minimally invasive and open transforaminal lumbar interbody fusion in surgical treatment of patients with lumbar spine degenerative disease. Genij Ortopedii. 2019;25(1):111-119. DOI: 10.18019/1028-4427-2019-25-1-111-119.
3. Wu AM, Hu ZC, Li XB, Feng ZH, Chen D, Xu H, Huang QS, Lin Y, Wang XY, Zhang K, Zhao J, Ni WF. Comparison of minimally invasive and open transforami-nal lumbar interbody fusion in the treatment of single segmental lumbar spondylo-listhesis: minimum two-year follow up. Ann Transl Med. 2018;6:105. DOI: 10.21037/ atm.2018.02.11.
4. Abe K, Orita S, Mannoji C, Motegi H, Aramomi M, Ishikawa T, Kotani T, Akazawa T, Morinaga T, Fujiyoshi T, Hasue F, Yamagata M, Hashimoto M, Yamauchi T, Eguchi Y, Suzuki M, Hanaoka E, Inage K, Sato J, Fujimoto K, Shiga Y, Kanamoto H, Yamauchi K, Nakamura J, Suzuki T, Hynes RA, Aoki Y, Takahashi K, Ohtori S. Perioperative complications in 155 patients who underwent oblique lateral interbody fusion surgery: perspectives and indications from a retrospective, multicenter survey. Spine. 2017;42:55-62. DOI: 10.1097/BRS.0000000000001650.
5. Zhang Q, Han XG, Xu YF, Fan MX, Zhao JW, Liu YJ, He D, Tian W. Robotic navigation during spine surgery. Expert Rev Med Devices. 2020;17:27-32. DOI: 10.1080/1 7434440.2020.1699405.
6. Friedman GN, Benton JA, Echt M, De la Garza Ramos R, Shin JH, Coumans JCE, Gitkind A, Yassari R, Leveque JC, Sethi RK, Yanamadala V. Multidisciplinary approaches to complication reduction in complex spine surgery: a systematic review. Spine J. 2020;20:1248-1260. DOI: 10.1016/j.spinee.2020.04.008.
7. Noh SH, Ha Y, Park JY, Kuh SU, Chin DK, Kim KS, Cho YE, Lee HS, Kim KH. Modified global alignment and proportion scoring with body mass index and bone mineral density analysis in global alignment and proportion score of each 3 categories for predicting mechanical complications after adult spinal deformity surgery. Neu-rospine. 2021;18:484-491. DOI: 10.14245/ns.2142470.235.
8. Camino-Willhuber G, Cabrera JP, Carazzo C, Guiroy A, Gagliardi M, Terrasa S, Joaquim AF. Reporting complications in spinal surgery-a systematic literature review. World Neurosurg. 2021;150:e765-e770. DOI: 10.1016/j.wneu.2021.03.143.
9. Ha DH, Kim TK, Oh SK, Cho HG, Kim KR, Shim DM. Results of decompression alone in patients with lumbar spinal stenosis and degenerative spondylolisthesis: a minimum 5-year follow-up. Clin Orthop Surg. 2020;12:187-193. DOI: 10.4055/cios19110.
10. Sayfullin AP, Aleynik AY, Bokov AE, Israelyan YA, Mlyavykh SG. Enhanced recovery after surgery (ERAS) in spine surgery: systematic review. Russian journal of neurosur-gery. 2022;24(1):83-100. DOI: 10.17650/1683-3295-2021-24-1-83-100.
11. Koucheki R, Koyle M, Ibrahim GM, Nallet J, Lebel DE. Comparison of interventions and outcomes of enhanced recovery after surgery: a systematic review and metaanalysis of 2456 adolescent idiopathic scoliosis cases. Eur Spine J. 2021;30:3457-3472. DOI: 10.1007/s00586-021-06984-0.
12. Gadiya AD, Koch JEJ, Patel MS, Shafafy M, Grevitt MP, Quraishi NA. Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review. Spine Deform. 2021;9:893-904. DOI: 10.1007/ s43390-021-00310-w.
13. Tong Y, Fernandez L, Bendo JA, Spivak JM. Enhanced Recovery After Surgery trends in adult spine surgery: a systematic review. Int J Spine Surg. 2020;14:623-640. DOI: 10.14444/7083.
14. Genov PG, Timerbaev VKh, Dolgasheva NS, Efanov AA, Grin' AA, Rebrova OYu.
The effect of various multimodal analgesia regimens during surgical treatment of patients with spinal stenosis on the rate of failed back surgery syndrome. Zh Vopr Neirokhir Im N N Burdenko. 2019;83(2):71-79. DOI: 10.17116/neiro20198302171.
15. Guo Y, Wang X, Li Y, Jiang K, Chen B, An J, Hao D, Hu H. Oblique lateral inter-body fusion with anterolateral screw fixation is as effective as with posterior percutaneous pedicle screw fixation in treating single-segment mild degenerative lumbar diseases. Med Sci Monit. 2022;28:e934985-1-e934985-12. DOI: 10.12659/MSM.934985.
16. He W, He D, Sun Y, Xing Y, Wen J, Wang W, Xi Y, Liu M, Tian W, Ye X. Standalone oblique lateral interbody fusion vs. combined with percutaneous pedicle screw in spondylolisthesis. BMC Musculoskelet Disord. 2020;21:184. DOI: 10.1186/ s12891-020-03192-7.
17. Woods KR, Billys JB, Hynes RA. Technical description of oblique lateral interbody fusion at L1-L5 (OLIF25) and at L5-S1 (OLIF51) and evaluation of complication and fusion rates. Spine J. 2017;17:545-553. DOI: 10.1016/j.spinee.2016.10.026.
18. Aleinik AYa, Mlyavykh SG, Qureshi S. Lumbar spinal fusion using lateral oblique (pre-psoas) approach (review). Sovrem Tekhnologii Med. 2021;13(5):70-81. DOI: 10.17691/stm2021.13.5.09.
19. Xie T, Wang C, Yang Z, Xiu P, Yang X, Wang X, Wang D, Song Y, Zeng J. Minimally invasive oblique lateral lumbar interbody fusion combined with anterolateral screw fixation for lumbar degenerative disc disease. World Neurosurg. 2020;135: e671-e678. DOI: 10.1016/j.wneu.2019.12.105.
20. Liu J, Feng H. Oblique lateral interbody fusion (OLIF) with supplemental antero-lateral screw and rod instrumentation: a preliminary clinical study. World Neurosurg. 2020;134:e944-e950. DOI: 10.1016/j.wneu.2019.11.046.
21. Debono B, Wainwright TW, Wang MY, Sigmundsson FG, Yang MMH, Smid-Nanninga H, Bonnal A, Le Huec JC, Fawcett WJ, Ljungqvist O, Lonjon G, de Boer HD. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J. 2021;21:729-752. DOI: 10.1016/j.spinee.2021.01.001.
22. Sayfullin AP, Bokov AE, Mordvinov AA, Mlyavykh SG. Enhanced recovery after surgery: the current state in spinal neurosurgery. Russian journal of neurosurgery. 2023;25(2):89-105. DOI: 10.17650/1683-3295-2023-25-2-89-105.
23. Silvestre C, Mac-Thiong JM, Hilmi R, Roussouly P. Complications and morbidities of mini-open anterior retroperitoneal lumbar interbody fusion: oblique lumbar inter-body fusion in 179 patients. Asian Spine J. 2012;6:89-97. DOI: 10.4184/asj.2012.6.2.89.
24. Grjibovski AM. Analysis of nominal data (independent observations). Ekologiya Che-loveka (Human Ecology). 2008;6:58-68.
25. Mayer HM. A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine. 1997;22:691-700. DOI: 10.1097/00007632-199703150-00023.
26. Davis TT, Hynes RA, Fung DA, Spann SW, MacMillan M, Kwon B, Liu J, Acosta F, Drochneret TE. Retroperitoneal oblique corridor to the L2-S1 intervertebral discs in the lateral position: an anatomic study. J Neurosurg Spine. 2014;21: 785-793. DOI: 10.3171/2014.7.SPINE13564.
27. Molinares DM, Davis TT, Fung DA. Retroperitoneal oblique corridor to the L2-S1 intervertebral discs: an MRI study. J Neurosurg Spine. 2016;24:248-255. DOI: 10.3171/2015.3.SPINE13976.
28. Kanemura T, Satake K, Nakashima H, Segi N, Ouchida J, Yamaguchi H, Imagama S. Understanding retroperitoneal anatomy for lateral approach spine surgery. Spine Surg Relat Res. 2017;1:107-120. DOI: 10.22603/ssrr.1.2017-0008.
29. Zhang YH, White I, Potts E, Mobasser JP, Chou D. Comparison perioperative factors during minimally invasive pre-psoas lateral interbody fusion of the lumbar spine
59
using either navigation or conventional fluoroscopy. Global Spine J. 2017;7:657-663. DOI: 10.1177/2192568217716149.
30. Zhao L, Xie T, Wang X, Yang Z, Pu X, Zeng J. Whether anterolateral single rod can maintain the surgical outcomes following oblique lumbar interbody fusion for doublesegment disc disease. Orthop Surg. 2022;14:1126-1134. DOI: 10.1111/os.13290.
31. Yang X, Luo C, Liu L, Song Y, Li T, Zhou Z, Hu B, Zhou Q, Xiu P. Minimally invasive lateral lumbar intervertebral fusion versus traditional anterior approach for localized lumbar tuberculosis: a matched-pair case control study. Spine J. 2020;20:426-434. DOI: 10.1016/j.spinee.2019.10.014.
32. Schreiber U, Bence T, Grupp T, Steinhauser E, Mrckley T, Mittelmeier W, Beisseet R. Is a single anterolateral screw-plate fixation sufficient for the treatment of spinal fractures in the thoracolumbar junction? A biomechanical in vitro investigation. Eur Spine J. 2005;14:197-204. DOI: 10.1007/s00586-004-0770-9.
33. Zhou T, Gu Y. Hybrid surgery of percutaneous transforaminal endoscopic surgery (PTES) combined with OLIF and anterolateral screws rod fixation for treatment of multi-level lumbar degenerative diseases with intervertebral instability. J Orthop Surg Res. 2023;18:117. DOI: 10.1186/s13018-023-03573-3.
34. Wu MT, Chung TT, Chen SC, Kao TJ, Song WS. Oblique lateral interbody fusion in heterogenous lumbar diseases: Anterolateral screw fixation vs. posterior percutaneous pedicle screw fixation - A single center experience. Front Surg. 2022;9:989372. DOI: 10.3389/fsurg.2022.989372.
35. Zhou T, Fan W, Gu Y, Che W, Zhang L, Wang Y. Percutaneous transforaminal endoscopic surgery combined with mini-incision OLIF and anterolateral screws rod fixation vs. MIS-TLIF for surgical treatment of single-level lumbar spondylolisthesis. Front Surg. 2022;9:1049448. DOI: 10.3389/fsurg.2022.1049448.
36. Zhao L, Xie T, Wang X, Yang Z, Pu X, Lu Y, Song Y, Zeng J. Comparing the medium-term outcomes of lumbar interbody fusion via transforaminal and oblique approach in treating lumbar degenerative disc diseases. Spine J. 2022;22:993-1001. DOI: 10.1016/j.spinee.2021.12.006.
37. Deng C, Feng H, Ma X, Chen C, Mei J, Sun L. Comparing oblique lumbar interbody fusion with lateral screw fixation and percutaneous endoscopic transforaminal discec-tomy (OLIF-PETD) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for the treatment of lumbar disc herniation complicated with lumbar instability. BMC Musculoskelet Disord. 2022;23:1104. DOI: 10.1186/s12891-022-06075-1.
38. Bateman DK, Millhouse PW, Shahi N, Kadam AB, Maltenfort MG, Koerner JD, Vaccaro AR. Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications. Spine J. 2015;15:1118-1132. DOI: 10.1016/j. spinee.2015.02.040.
39. Joseph JR, Smith BW, La Marca F, Park P. Comparison of complication rates of minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion: a systematic review of the literature. Neurosurg Focus. 2015;39:E4. DOI: 10.3171/2015.7.FOCUS15278.
40. Ross JS, Robertson JT, Frederickson RC, Petrie JL, Obuchowski N, Modic MT, de Tribolet N. Association between peridural scar and recurrent radicular pain after lumbar discectomy: magnetic resonance evaluation. ADCON-L European Study Group. Neurosurgery. 1996;38:855-861; discussion 861-863.
Address correspondence to:
Saifullin Aleksandr Petrovich
Privolzhsky Research Medical University,
10/1 Minin and Pozharsky sq., Nizhny Novgorod, 603005, Russia,
sayfullin-a.p@mail.ru
Received 18.05.2023 Review completed26.07.2023 Passed for printing 01.08.2023
Aleksandr Petrovich Saifullin, neurosurgeon, postgraduate student of the Department of Neurosurgery of the University Clinic, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky sq., Nizhny Novgorod, 603005, Russia, ORCID: 0000-0003-0108-398X, sayfullin-a.p@mail.ru;
Alexandr Yakovlevich Aleynik, MD, PhD, neurosurgeon, Institute of Traumatology and Orthopedics, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky sq., Nizhny Novgorod, 603005, Russia, ORCID: 0000-0002-1761-1022, aaleynik23@gmail.com;
Andrei Evgenyevich Bokov, MD, PhD, Head of the Department of Oncology and Neurosurgery of the Institute of Traumatology and Orthopedics, Head of the Department of Traumatology, Orthopedics and Neurosurgery n.a. M.V. Kolokoltsev, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky sq., Nizhny Novgorod, 603005, Russia, ORCID: 0000-0002-5203-0717, andrei_bokov@mail.ru;
Sergey Gennadyevich Mlyavykh, DMSc, Associate Professor of the Department of Traumatology, Orthopedics and Neurosurgery n.a. M.V. Kolokoltsev, Privolzhsky Research Medical University, 10/1 Minin and Pozharsky sq., Nizhny Novgorod, 603005, Russia, ORCID: 0000-0002-6310-4961, serg. mlyavykh@gmail. com.
60
61
62
