J Korean Neurosurg Soc.  2021 May;64(3):447-459. 10.3340/jkns.2020.0342.

Learning Curve and Complications Experience of Oblique Lateral Interbody Fusion : A Single-Center 143 Consecutive Cases

• Oh BK
• Son DW
• Lee SH
• Lee JS
• Sung SK
• Lee SW
• Song GS

• KMID: 2515501
• DOI: http://doi.org/10.3340/jkns.2020.0342

Abstract

Objective
: Oblique lateral interbody fusion (OLIF) is becoming the preferred treatment for degenerative lumbar diseases. As beginners, we performed 143 surgeries over 19 months. In these consecutive cases, we analyzed the learning curve and reviewed the complications in our experience.
Methods
: This was a retrospective study; however, complications that were well known in the previous literature were strictly recorded prospectively. We followed up the changes in estimated blood loss (EBL), operation time, and transient psoas paresis according to case accumulation to analyze the learning curve.
Results
: Complication-free patients accounted for 43.6% (12.9%, early stage 70 patients and 74.3%, late stage 70 patients). The most common complication was transient psoas paresis (n=52). Most of these complications occurred in the early stages of learning. C-reactive protein normalization was delayed in seven patients (4.89%). The operation time showed a decreasing trend with the cases; however, EBL did not show any significant change. Notable operation-induced complications were cage malposition, vertebral body fracture, injury to the ureter, and injury to the lumbar vein.
Conclusion
: According to the learning curve, the operation time and psoas paresis decreased. It is important to select an appropriately sized cage along with clear dissection of the anterior border of the psoas muscle to prevent OLIF-specific complications.

Keyword

Intervertebral disc; Retroperitoneal space; Spinal fusion/adverse effect; Psoas muscle; Learning curve

Figure

• 

  Fig. 1. Changes in complications with case accumulation. The proportion of complications was relatively high in the initial 70 patients, and psoas paresis was the most common complication. The incidence of complications significantly decreased in the 70 patients in the late stage. P1 and P2 : two cases of peritoneal laceration, V1 and V2 : two cases of vascular injury, R1 and R2 : two cases of reoperation (R1 : cage repositioning, R2 : vertebral body fracture), U1 : one case of injury to the ureter.

• 

  Fig. 2. Binomial logistic regression curve for the change in psoas paresis with case accumulation. A : 1+2-level OLIF. B : 1-level OLIF. C : 2-level OLIF. In both 1- and 2-level OLIF, psoas paresis decreased significantly according to the accumulation of cases. OLIF : oblique lateral interbody fusion, CI : confidence interval.

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  Fig. 3. Scatter plot of the change in operation time (upper 4 graphs) and estimated blood loss (lower 4 graphs) according to consecutive cases in four groups. R : Spearman’s rank correlation coefficient, 1Lv : 1-level oblique lateral interbody fusion (OLIF), 2Lv : 2-level OLIF, +D : with decompressive laminectomy, -D : indirect decompression.

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  Fig. 4. A-D : Case of cage malposition (red arrow) requiring revision surgery. Intraoperative C-arm image at the primary operation. A : The posterior margin of the cage is located inside the posterior margin of the vertebral body. B : The right lateral margin of the cage is located on the interpedicle line. CT image after the primary operation. C and D : Cage is located in the right neural foramen. E and F : Intraoperative cage reposition (blue arrow) using C-arm image at reoperation. After cephalic retraction of the root (E), the impactor is placed on the cage and repositioned under the C-arm guide (F). G and H : CT image after reoperation. Cage repositioning confirmed. CT : computed tomography.

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  Fig. 5. Case of vertebral body fracture (red arrow) requiring revision surgery. Preoperative (A), Immediate postoperative (B); L3 anterior vertebral body fracture. C : POD 10 day (POD #10); segmental kyphosis progressed. D : Postoperative CT; the coronal vertebral body fracture of L3. E : After reoperation; posterior fixation extending to L2. POD : postoperative day, CT : computed tomography.

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  Fig. 6. Case with a complication of injury to the ureter. Preoperative CT image. A : The course of the ureter is indicated by the yellow line. B : The ureter at the L3/4 area is marked with yellow circles. The right ureter is located above the psoas muscle, while the left ureter is located at the border of the vertebral body and the psoas muscle. Immediate postoperative image. C : L3–4 1 level OLIF with L1–L5 posterior fusion, left ureter with double J catheter inserted. Intraoperative images. D : Ureter (white arrows), injury site (asterisk). E : Indocyanine leakage was found at the site of injury of the ureter (dotted circle). F : A double J catheter was inserted, and primary closure was implemented (white arrows). Four months postoperative retrograde pyelography. G-I : Mild stenosis at the suture site; however, the contrast passage was good. CT : computed tomography, OLIF : oblique lateral interbody fusion.

Reference

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