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Method Article

Multilevel Oblique Lumbar Interbody Fusion in Degenerative Lumbar Disc Disease with Instability

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DOI:

10.3791/67543

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July 25th, 2025

 ,  ,  , 
1Division of Spine, Department of Orthopedic Surgery, Tan Tock Seng Hospital, National Healthcare Group, 2Yong Loo Lin School of Medicine, National University of Singapore, 3Rehabilitation Research Institute of Singapore, Lee Kong Chian School of Medicine, Nanyang Technological University

In This Article

Summary

This protocol presents the operative technique of multilevel Oblique Lumbar Interbody Fusion (OLIF) in a step-by-step manner, elaborating on the critical steps for achieving optimal outcomes.

Abstract

The surgical technique of L2- L5 Oblique Lumbar Interbody Fusion (OLIF), including the exposure of the surgical corridor, preparation of the disc space, and placement of the interbody cages, followed by pedicle screw fixation, is presented. To perform this technique, the patient is positioned in right lateral decubitus on a radiolucent table, and an oblique incision is made 3-5 cm anterior to the middle of the L3-L4 disc space. After dissecting the subcutaneous fat, the external oblique aponeurosis is cut along the line of the incision and the oblique muscles (external and internal), and the transversus abdominis muscles are split along the direction of the muscle fibers. Peritoneal fat is gently swept anteriorly until the psoas muscle is visualized. The psoas muscle is then retracted posteriorly to reveal the underlying disc space. A guide wire is inserted into the disc, followed by sequential dilators and placement of expandable retractors. After confirming the retractor position, annulotomy is performed, and the disc space is prepared using a combination of Cobb's elevator, curettes, and pituitary rongeurs, employing an orthogonal maneuver. Under the fluoroscopy guidance, serial trials are introduced, and an optimal-sized cage packed with bone graft substitutes is implanted into the disc space. The same steps are repeated at two adjacent levels (L2-L3, L4-L5), and the wound is closed in layers. The patient is turned into a prone position and pedicle screws are placed to complete the construct. The results of 30 patients who underwent this OLIF procedure were analyzed. The mean disc height was 7.47 ± 2.3 mm, which significantly increased to 10.9 ± 2.7 mm postoperatively (p < 0.0001). Similarly, the mean disc angle improved from 7.26° ± 6.2° to 9.81° ± 4.1° (p = 0.0065). At the final follow-up, both disc height and angle were maintained, along with satisfactory bony fusion, with no cases of pseudoarthrosis or implant failure.

Introduction

Degenerative disc disease is one of the most important causes of low back pain (LBP)1. Advanced degeneration of the discs results in instability of the motion segment and stenosis, leading to persistent low back pain (LBP) and neurological symptoms. Early stages of the disease are usually treated conservatively. However, patients refractory to conservative management or those with neurological worsening need surgical intervention. Fusion surgery is a well-established treatment option for managing these symptoms in the lumbar spine, of which interbody fusion has been proven to be biomechanically superior to posterior fusion2. Over the years, there have been various methods of interbody fusions, namely posterior, transforaminal, lateral, and anterior, each with its pros and cons3,4,5. In patients with multi-level disc degeneration and instability, when the posterior approach is used, there is a need for extensive muscle dissection and paraspinal muscle damage6. Similarly, access through the anterior approach would increase the overall morbidity of the procedure as it traverses through the peritoneum and other abdominal contents7. Hence, an ideal approach in such multi-level lumbar pathology should be to obtain the surgical goals with minimal morbidity and to improve the overall long-term surgical outcomes in these patients.

In addition to the posterior, transforaminal, and anterior approaches, the lateral approach to the lumbar spine is considered a valuable alternative that limits muscle, soft tissue, and neural injury. Lateral techniques include Extreme Lateral Interbody Fusion (XLIF) and Oblique Lumbar Interbody Fusion (OLIF), both convenient for multi-level lumbar pathologies. Oblique Lumbar Interbody Fusion (OLIF) was first described by Hynes et al. and quickly gained attention due to its minimally invasive access to the disc space8. It utilizes the plane anterior to the psoas muscle, called the oblique corridor, for accessing the disc space and is most suitable for lumbar levels L2 to L5. By using large footprint lordotic cages, optimal lordosis could be achieved with OLIF surgery. Moreover, compared to XLIF, the incidence of lumbar plexus injury is reportedly less, as OLIF utilizes the pre-psoas approach rather than the trans-psoas approach as in XLIF. We herein describe the technique of L2-L5 OLIF as performed at our center, where we have significant experience with the procedure, which is routinely conducted for patients with lumbar spine pathology.

Case Presentation
The procedure described herein is the OLIF surgery for a 55-year-old female who presented with complaints of chronic LBP with right gluteal pain and bilateral lower limb radicular pain. She had symptoms of neurogenic claudication with a walking distance of less than 500 m. Despite conservative management for over 3 months, there was no improvement in her symptoms. On evaluation, her motor power was normal (Medical Research Council [MRC] grade: 5/5) in all four limbs, but she exhibited bilateral altered sensation in both the L4 and L5 dermatomes. Radiographs of the lumbar spine revealed degenerative lumbar scoliosis with its apex at L2-L3 level (Figure 1A,B). Magnetic resonance (MR) imaging revealed multi-level lumbar disc degeneration, L2-L5 stenosis, and L3-L4 spondylolisthesis (Figure 1C-G). As the patient had difficulty in activities of daily living and no improvement with conservative management, L2-L5 OLIF (stage I) with robotic guided minimally invasive (MIS) posterior pedicle screw instrumentation (stage II) was performed. The patient considerations and technical description of multi-level OLIF are described below.

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Protocol

This study was conducted in accordance with the ethical standards set forth in the 1964 Declaration of Helsinki and was approved by the Domain Specific Review Board, National Healthcare Group, Singapore.

1. Pre-operative considerations

  1. Patient selection
    1. Assess the feasibility of the procedure using radiographs and MRI scans.
    2. Check for a high iliac crest (in the Anterior-Posterior radiograph) that could make performing OLIF at the L4-L5 level challenging, especially for surgeons in the early stages of their surgical practice.
    3. In patients with degenerative lumbar scoliosis, check for the convex and concave side of the deformity.
    4. Ensure the presence of an adequate surgical corridor between the vascular structures and the psoas muscle in an axial MRI scan.
    5. Look for the size of the psoas musculature in axial MRI scan, as a bulky psoas might be challenging to retract, especially for early adopters of this technique. Consider using muscle relaxants and/or a more anterior incision in these cases.
    6. Ensure that the patient is fit for surgery as assessed by an anesthesiologist and eligible for the surgical procedure.
  2. Patient preparation
    1. Clean and drape the patient as per the standard pre-surgical guidelines set forth by the hospital.
    2. Administer intravenous antibiotics about half an hour before the surgical incision to reduce the risk of post-operative infection.
  3. Equipment
    1. Ensure the availability of a radiolucent operating table, a high-quality fluoroscopy machine with a trained technician, neuro-monitoring leads with a well-equipped device, and an electrophysiologist during the surgery.
      ​NOTE: A surgical headlight (preferably with magnifying lenses) is recommended, as the workflow involves a narrow surgical corridor.
    2. Ensure the availability of the following instruments and implants: appropriately sized hand-held retractors, tubular retractors, cage sizing trials, intervertebral OLIF cages, allografts, bone graft substitutes (e.g., Demineralized Bone Matrix [DBM], Bone Morphogenetic Protein [BMP]), and all necessary consumables including suture materials (refer to the Table of Materials).

2. Surgical preparation

  1. Anesthesia
    1. Assess the patient's surgical risk by grading according to the American Society of Anesthesiologists (ASA) classification of Physical Health.
    2. Ensure the placement of the required intravenous cannulas in the peripheral veins as needed, with the option of placing a central venous line if peripheral access is difficult.
    3. Prepare the entire anesthesia setup, including the electrocardiogram, arterial pressure monitor, pulse oximetry, capnography, urinary volume monitoring, and body temperature monitoring, for use throughout the procedure.
    4. Discuss with the anesthesiologist the anesthesia of choice, with general anesthesia (GA) being ideal, administered following endotracheal tube (ET tube) intubation for the surgery.
    5. Do not provide neuromuscular blockade during the procedure.
  2. Patient position
    1. Place the patient in the right lateral decubitus position near the posterior edge of the operating table (Figure 2A).
    2. Place an axillary roll below the right lateral chest wall and position a soft pillow between the arms and legs.
    3. Place the lower limbs in extension to ensure that the psoas muscle is in less tension.
    4. Strap the patient to the operating table in the lateral position at the shoulders, legs, and iliac crest level (Figure 2B).
  3. Surgical site marking
    1. Bring the C-arm for True AP and lateral fluoroscopy images.
    2. In the True AP view, center the C-arm around the spinous process with pedicles symmetrically visible bilaterally.
    3. In the True Lateral view, place the C-arm perpendicular to the floor with a clear visualization of endplates as a single line.
    4. In case of lumbar degenerative scoliosis, adjust the C-arm at each level to obtain True AP and lateral views.
    5. Once fluoroscopy images are obtained, mark the skin incision corresponding to the levels to be operated on using lateral C-arm image guidance (Figure 3A).
    6. In the lateral view, mark the anterior, middle, and posterior borders of the surgical disc levels.
    7. Mark the incision site approximately 3-5 cm anterior to the middle of the disc space at the L2-L5 levels, though this may vary depending on the levels, psoas morphology, and patient body habitus. For larger patients with a bulky psoas, mark the incision 4-5 cm anterior at the L4-L5 level. For L2-L3, avoid marking too anteriorly, as the ribs may obstruct exposure with a more anterior incision (Figure 3B).
    8. Mark the incision in an oblique fashion, as it allows for extending anteriorly, which is beneficial in the rare event that abdominal or vascular surgery becomes necessary.
    9. Mark the iliac crest for anatomical reference.

3. Surgery

  1. Surgical exposure
    1. Perform a baseline neuromonitoring recording, and incise the skin along the skin marking, and dissect the subcutaneous tissue using finger dissection.
    2. Cut the external oblique fascia in line with the skin incision using electrocautery. Then, split open the oblique muscles (external/ internal) and transversus abdominis muscle along the direction of their respective muscle fibers (Figure 4A-C).
    3. Retract these muscles in layers to expose the retroperitoneal fat (Figure 5A). Continue further finger dissection or dissect with the use of hand-held retractors.
    4. Sweep the peritoneum anteriorly and caudally using blunt dissection to expose the anterior margin to the psoas muscle (Figure 5B). Once all the fat is cleared from the psoas gently palpate the psoas muscle and then retract it posteriorly using hand-held retractors.
    5. Visualize the L3-L4 disc underneath the muscle (Figure 5C). Place a long guide wire in the disc space and sequential dilators over it (Figure 5D).
  2. Retractor placement and disc preparation
    1. Replace the dilators and guide wire by placing the expandable retractor blades over them (Figure 6A).
    2. Fix the retractor to the operating table using a rigid articulating arm and adjustable hinges. Confirm the position of the retractor blades at the appropriate disc space using AP and lateral fluoroscopy (Figure 6B, C).
      NOTE: In the AP view, note the location of the blades in relation to the disc level. In the lateral fluoroscopy image, check the relative position of the posterior edge of the blades in the disc space. Position the blades obliquely relative to the patient to prevent interference when instruments pass through the surgical corridor. Additionally, align the retractor blades parallel to the targeted disc space.
    3. Perform an annulotomy with a long-handled knife.
      NOTE: The posterior boundary of the annulotomy is determined by the position of the retractor blade's posterior edge relative to the rear margin of the disc.
    4. Remove any lateral osteophytes in the disc margins using a Kerrison rongeur.
    5. Introduce a Cobb's elevator and gently move along the endplate perpendicular to the patient (orthogonal maneuver) (Figure 7A,B). Use a straight Cobb's elevator for the upper end plate and a curved elevator for the lower endplate preparation without violating the bony endplates. Advance the Cobb's elevator to breech the contralateral annulus without exerting too much force.
      NOTE: Perform this step only under anteroposterior fluoroscopy guidance (Figure 8A).
    6. Remove all disc material with a pituitary rongeur (Figure 8B) and curette the cartilaginous endplates carefully to avoid violating the underlying bony endplates (Figure 8C). Throughout the disc preparation process, assess the anterior and posterior borders of the disc space.
  3. Cage insertion and closure
    1. After preparing the disc space and endplates, introduce serial sizers under fluoroscopy guidance, and note the optimal size for the disc level (Figure 9A,B).
    2. Insert an appropriately sized OLIF cage filled with allograft/DBM and BMP into the disc space using cage introducers (Figure 10A-D). In cases with significant collapse of the disc space, introduce the cage using sliders to avoid damaging the endplate.
      NOTE: The cage should be introduced in an 'orthogonal' fashion under fluoroscopy guidance. Place the cage along the long axis of the disc space spanning along the rim of the vertebral endplate.
    3. Take fluoroscopic images to confirm central placement of the cage before moving the retractors to the next level (Figure 11A).
    4. Repeat the same steps, from docking the guide wire to cage placement, at the other planned surgical levels, as demonstrated for the L4-L5 and L2-L3 disc levels (Figure 11B-E).
    5. Remove the retractors and obtain final fluoroscopic images to check the placement of all cages in both AP and lateral views.
    6. Assess neural integrity by motor stimulation using the neuromonitoring setup.
    7. Achieve thorough hemostasis using bipolar electrocautery and a hemostat matrix, as deemed necessary.
    8. Place a drain with a soft inner tube over the lateral aspect of the vertebral bodies and perform wound closure.
      NOTE: This is done for all cases operated for three or more levels.
    9. Close the wound in layers, starting with the external oblique fascia, subcutaneous fat, dermal layer, and finally, the skin. Consider the second stage of surgery immediately following the placement of cages, keeping the overall surgical duration, blood loss, and other factors in mind. For the second stage of surgery, position the patient prone for the placement of pedicle screws by any modality of convenience.
      NOTE: In this patient, pedicle screws were placed using robotic assistance. As our technique strictly adheres to established guidelines for screw placement, the sequence of steps narrating screw placement is not explained here.

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Results

In the above-described patient, the overall surgical time for the first stage was 2 h, with an estimated blood loss of less than 100 mL (Table 1). The second stage of surgery was completed quickly, as robotic guidance facilitated the screw placement, making it a minimally invasive procedure. Supine and standing whole spine radiographs were taken, and the positions of the cage and screws were found to be satisfactory. Following the procedure, mobilization was initiated the next day. As it was a minimally ...

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Discussion

OLIF surgery has become popular over the last decade in managing various lumbar spinal pathologies like instability, stenosis, and adult deformities9. It achieves indirect decompression of the spinal canal, provides a broader surface area for interbody fusion, widens the neural foramen, and corrects the spinal alignment10. All these surgical goals could be efficiently enabled using the minimally invasive (pre-psoas) approach with OLIF. Compared to other fusion techniques su...

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Disclosures

The authors have nothing to disclose

Acknowledgements

The authors sincerely thank all the operating room staff, nurses, and technicians at Tan Tock Seng Hospital for their assistance with all OLIF cases and for helping us demonstrate this OLIF case for JoVE.

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
Add-on arm with universal jointMedtronic10042177The metal arm to attach the expandable retractors to the clamp
Bayoneted Penfield #4Medtronic9569650To mobilize residual soft tissue from the disc for clear visualization of the annulus
C-arm fluroscopySiemensTo provide intra-operative radiographs during the surgical procedure
Cascadia Lateral 22*50*10 mm/ 8ºStryker6101-2225010LL8-G2The OLIF interbody cage inserted in the disc space. 8º refers to the lordotic angle
Cascadia Lateral 22*50*8 mm/ 8ºStryker6101-2225008LL8-G2The OLIF interbody cage inserted in the disc space. 8º refers to the lordotic angle
Cup curette, Size 5, AngledMedtronic3280017To prepare the vertebral endplates
Dissection blade, 17 cmMedtronic10045377Blade with long handle to cut the annulus of the disc
Elastic Adhesive cotton crepe 10 cm * 4.5 mConvi931 624To strap the patient in position to the operating table, 10 cm * 4.5 m refers to the size
Foley catheter 14 FrBard123614CESilicone Elastomer coated catheter for bladder drainage during surgery, 14 Fr refers to the size
Guide wire, blunt, 450 mmMedtronic75700450To puncture the annulus for level confirmation and placement of tubular dilators
Infuse Bone graftMedtronicP000058Recombinant human bone morphogenic protein-2 that is placed in the interbody cage to aid in fusion
METRX, Dilator 10.6 mmMedtronic9561421Sequential dilators to place the retractors, 10.6 refers to the size
METRX, Dilator 16 mmMedtronic9561422Sequential dilators to place the retractors, 16 refers to the size
METRX, Dilator 20.8 mmMedtronic9561424Sequential dilators to place the retractors, 20.8 refers to the size
METRX, Dilator 5.3 mmMedtronic9560420Sequential dilators to place the retractors, 5.3 refers to the size
Monocryl plus, 3-0EthiconMCP427HPoliglecaprone antibacterial coated suture material, 3-0 refers to the size
NIM-Eclipse E4MedtronicFor intra-operative neuromonitoring
Paddle shaver, 10 mmMedtronic2941610To clear the end plates and to size the disc height
Paddle shaver, 12 mmMedtronic2941612To clear the end plates and to size the disc height
Paddle shaver, 8 mmMedtronic2941608To clear the end plates and to size the disc height
Pituitary rongeur, 6 * 14, straightMedtronic3280001To remove the disc material during disc space preparation, 6*4 refers to size
Quick Connect Handle, Light sourceMedtronic10042129QLTo establish better illumination through the tubular retractors to the disc
Quick Connect to shaft clamp adapterMedtronic10042165To attach the retractor blades to the retractor assembly
Rail ClampMedtronic10041903ACLTo attach the metal arm to the operating table
Retractor assemblyMedtronic10042138QTo attach the rounded blades to the mounted operating arm
Round caudad blade, 11 cmMedtronic10045451Distal rounded blade to accommodate the tubular dilators
Round cephalad blade, 11 cmMedtronic10045431Proximal rounded blade to accommodate the tubular dilators
Slap hammerMedtronic9074002To push the sizers and cage into the disc space
Straight Cobb, 10 mmMedtronic2942035To detach the disc attachment and incise the contralateral annulus
Surgical blade, 10Swann-Morton201To make the skin incision, 10 refers to size
Vicryl plus, 1EthiconVCP486HPolyglactin braided absorbable suture, antibacterial suture, 1 refers to the size
Vicryl, 2-0EthiconJ589HPolyglactin undyed braided absorbable suture, 2-0 refers to the size

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