Comparison of Oblique Lateral Interbody Fusion (OLIF) and Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF) for Treatment of Lumbar Degeneration Disease

A Prospective Cohort Study

Hai-Feng Zhu, MM; Xiang-Qian Fang, MD; Feng-Dong Zhao, MD; Jian-Feng Zhang, MD; Xing Zhao, MD; Zhi-Jun Hu, MD; Shun-Wu Fan, MD

Disclosures

Spine. 2022;47(6):E233-E242.

Abstract and Introduction

Abstract

Study Design: Prospective cohort study.

Objective: To assess the differences in the clinical and radiological outcomes between oblique lateral interbody fusion (OLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

Summary of Background Data: Nowadays, there is still a controversy regarding whether OLIF is superior to MI-TLIF in the management of degenerative lumbar disease.

Methods: Between August 3, 2019 and February 3, 2020, 137 patients were assigned to OLIF or MI-TLIF at their request and the surgeon's discretion: 71 in the OLIF group and 66 in the MI-TLIF group. The perioperative data, patient-reported outcomes, radiographic outcomes, and complications were compared between the two groups.

Results: The OLIF group showed shorter operation time (110.5 vs.183.8 minutes, P < 0.001), lesser estimated blood loss (123.1 vs. 232.0 mL, P < 0.001), shorter length of hospital stay (5.5 vs. 6.7 days, P < 0.001), and lower serum creatine kinase (CK) (1 day postoperatively) (376.0 vs. 541.8 IU/L, P < 0.01) than that of MI-TLIF group. Both groups showed no significant differences in the visual analog scale (VAS) scores of lower back and leg pain and the Oswestry Disability Index (ODI) scores preoperatively and at 1, 3, and 12 months postoperatively, respectively (P > 0.05). Compared with the MI-TLIF group, the OLIF group showed better restoration of disc height (DH) (4.7/4.6/4.7 vs. 3.7/3.7/3.7 mm, P < 0.01) and lumbar lordosis angle (LLA) (10.5°/10.8°/11.1° vs. 5.8°/5.7°/5.3°, P < 0.001), but not the value of segmental lordosis angle (SLA) (P > 0.05) at 1 day, 1 month, and 1 year postoperatively, respectively. The complication rate of OLIF was higher than that of MI-TLIF (29.4% vs. 9.7%, P < 0.01).

Conclusion: Compared with MI-TLIF, OLIF showed similar results in terms of patient-reported outcomes, restoration of SLA and fusion rate, and superior results with respect to restoration of DH and LLA, operation time, estimated blood loss, length of hospital stay, and serum CK levels (1 day postoperatively). Even though the complication rate of OLIF is higher than that of MI-TLIF, it does not bring persistent and substantial damage to the patients.

Level of Evidence: 3

Introduction

Conventional posterior/transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion techniques have yielded satisfactory clinical outcomes for degenerative lumbar diseases.^[1,2] However, iatrogenic paraspinal muscle injury, posterior tension band disruption, and approach-related complications are a concern.^[2,3] Thus, surgical approaches, including direct lateral interbody fusion, extreme lateral interbody fusion, and oblique lateral interbody fusion (OLIF)^[4] have been popularized, and minimally invasive (MI) procedures are adopted,^[5] alongside mini-open techniques and unilateral or bilateral Wiltse procedures.

The efficacy of OLIF and MI-TLIF for the management of degenerative lumbar disease has been demonstrated in several studies.^[6–8] However, based on the English literature,^[9–13] it is difficult to draw a conclusion regarding whether OLIF is superior to MI-TLIF because of small sample sizes, heterogeneity of study objectives and evaluation indices, and a low level of evidence. Therefore, we aimed to assess the clinical and radiological outcomes of OLIF and MI-TLIF. We suppose that OLIF provides better clinical and radiological outcomes compared with MI-TLIF.

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Next Section

Table 1. The Demographic and Clinical Characteristics and Perioperative Data of the Patients of OLIF and MI-TLIF Groups
	OLIF	MI-TLIF	P Value; t/Z/χ² Value
No. of patients	68	62	-
Sex (M/F)	36/32	33/29	P = 0.974; t = 0.001
Age, yr	60.2 ± 6.2	61.1 ± 5.3	P = 0.363; t = 0.914
BMI, kg/m²	23.2 ± 2.5	23.9 ± 3.6	P = 0.168; t = 1.387
Preoperative diagnosis			P = 0.962; χ² = 0.290
Lumbar disc herniation	11	9	-
DS	28	25	-
I degree	16	13	-
II degree	12	12	-
Segmental instability	13	11	-
Lumbar spinal stenosis	16	17	-
Operation segment			P = 0.778; χ² = 0. 503
L2–3	12	14	-
L3–4	18	15	-
L4–5	38	33	-
VAS of low back	6.7 ± 1.6	6.4 ± 1.3	P = 0.317; Z = –1.001
VAS of leg	5.6 ± 2.0	5.5 ± 2.5	P = 0.808; Z = –0.243
ODI (%)	61.1 ± 10.3	58.6 ± 11.0	P = 0.110; Z = –1.600
Sagittal alignment
DH, mm	8.9 ± 2.2	8.6 ± 2.0	P = 0.334; t = 0.969
SLA, °	17.4 ± 5.2	15.8 ± 4.9	P = 0.063; t = 1.872
LLA, °	39.7 ± 12.0	41.6 ± 10.9	P = 0.348; t = 0.943
Operation time, min	110.5 ± 37.8	183.8 ± 65.5	P = 0.000; t = 7.900
Estimate blood loss, mL	123.1 ± 39.8	232.0 ± 83.2	P = 0.000; t = 9.652
Length of hospital stay, d	5.5 ± 1.1	6.7 ± 2.0	P = 0.000; t = 4.005
Serum creatine kinase, IU/L
Preoperatively	92.7 ± 51.4	88.1 ± 32.0	P = 0.540; t = 0.615
1 day postoperatively	376.0 ± 140.8	541.8 ± 400.0	P = 0.002; t = 3.207
3 days postoperatively	215.8 ± 124.6	248.6 ± 228.0	P = 0.305; t = 1.030

BMI indicates body mass index; CK, creatine kinase; DH, disc height; DS, degenerative spondylolisthesis; LLA, lumbar lordosis angle; ODI, Oswestry Disability Index; SLA, segmental lordosis angle; VAS, visual analog scale.

Table 2. Summary of Treatments of Complications of OLIF and MI-TLIF Groups
Case	Operation	Complications	Treatment and Prognosis
1–6	OLIF	Endplate injury	Thoracic lumbar braces were used for protection and strength, and successful fusion were achieved in 10–12 months
7	OLIF	Ovarian vein injury	Hemostasis was attempted by local pressing hemostasis
8	OLIF	Segmental vessel injury	Hemostasis was attempted by vascular ligation after pressing the two ends of the damaged vessels with two periosteal detachers.
9	OLIF	Left sympathetic chain injury	Symptoms was resolved 4 days after surgery with neurotrophic treatment
10	OLIF	Vertebral fracture	The fracture in the right front of the L2 vertebral body was healed well after stay in bed for 1 month and a thoracic lumbar brace protection for 2 months
11–15	OLIF	Transient thigh pain and numbness	Symptoms was resolved 6–9 days after surgery with neurotrophic treatment
16	OLIF	Psoas weakness	Symptoms was resolved 4 days after surgery with neurotrophic treatment
17–20	OLIF	Cage sedimentation	Symptoms was controlled with the help of thoracic lumbar braces for protection
21	MI-TLIF	Endplate injury	A thoracic lumbar braces was used for protection and strength, and successful fusion were achieved in 9 months
22	MI-TLIF	Neurological injury	Symptoms was resolved 2 weeks after surgery with neurotrophic treatment
23	MI-TLIF	Dural tear	The crevasse was closed directly and the leakage of cerebrospinal fluid was not happened postoperatively
24	MI-TLIF	Cage sedimentation	Symptoms was controlled with the help of thoracic lumbar braces for protection
25	MI-TLIF	Urinary tract infection	Infection was controlled by oral levofloxacin for 2 weeks
26	MI-TLIF	Wound infection	Infection was controlled by closed continuous irrigation and suction drainage for 2 weeks

MI-TLIF indicates minimally invasive transforaminal lumbar interbody fusion; OLIF, oblique lateral interbody fusion.

Table 3. Literatures Review of the Clinical and Radiologic Outcomes of OLIF Compared With MI-TLIF
Study	Properties (Mean Follow up)	Subjects (Patient No)	Results
Lin et al, 2018	A matched-pair retrospective study (29 months for OLIF; 40 months for MI-TLIF)	Low-grade spondylolisthesis or lumbar spinal stenosis of L4-L5 (25 in MI-TLIF; 25 in OLIF)	Similar changes in VAS, ODI, forminal height, SLA, LLA, CSAS, and complication rate; less blood loss and shorter operative time in OLIF versus MI-TLIF; OLIF was superior to MI-TLIF in restoring DH and CASF; Fusion rate at 6 months: 80% in OLIF and 52% in MI-TLIF
Sheng et al, 2020	A retrospective study (12 months for OLIF and MI-TLIF)	DS (38 in MIS-OLIF; 55 in MIS-TLIF)	Similar changes in VAS, ODI, disc angle and L1-S1 lordosis; shorter procedures and hospital stay and less blood loss in OLIF versus MI-TLIF; changes of DH and foramina dimension were greater in MIS-OLIF versus MI-TLIF.
Li et al, 2018	A systematic review (10.4 months for OLIF; 25.4 months for MI-TLIF)	DS, spinal stenosis, degenerated kyphoscoliosis and discogenic low back pain (2009 in OLIF; 1488 in MI-TLIF)	Similar changes in DH, SLA, LLA, length of hospital stay, VAS, ODI, fusion rates; less operative blood loss and operative time in OLIF versus MI-TLIF; the incidence of intraoperative and postoperative complications was 9.5% and 19.9% for OLIF and 3.5% and 8.5% for MI-TLIF.
Koike et al, 2021	A retrospective study (18.1 months for OLIF-LPF; 22.5 months for MI-TLIF)	Single-level DS (38 in OLIF-LPF; 48 in MIS-TLIF)	Similar changes in operation time, EBL, CRP level 5 days postoperatively, VAS and slipping length; DH changes and JOABPEQ domains improvements was greater in OLIF-LPF versus MI-TLIF;
Kotani et al, 2020	A retrospective study (31 months for OLIF-LPF; 57 months for MI-TLIF)	L3 or L4 DS (92 in OLIF-LPF; 50 in MI-TLIF)	Similar changes in operation time, EBL, the percent slip reduction, fusion rate, and symptomatic ASD; JOABPEQ effectiveness rate and VAS of leg pain improvements were higher in OLIF-LPF versus MI-TLIF; the less correction loss of posterior DH in OLIF-LPF versus MI-TLIF

LLA indicates lumbar lordosis angle; ODI, Oswestry Disability Index; MI-TLIF, minimally invasive transforaminal lumbar interbody fusion; OLIF, oblique lateral interbody fusion; SLA, segmental lordosis angle; VAS, visual analog scale.