Case Report on Contralateral Neural Complications following OLIF

Summary

We report a rare case of contralateral L4 nerve root compression following oblique lumbar interbody fusion (OLIF). Imaging confirmed the impingement was caused by cage malposition and a fractured osteophyte. Urgent transforaminal lumbar interbody fusion (TLIF) revision successfully decompressed the nerve, resulting in complete neurological recovery.

Abstract

Oblique Lumbar Interbody Fusion (OLIF) is widely used minimally invasive techniques for lumbar degenerative diseases. While neurological complications are recognized, they predominantly affect the ipsilateral lumbar plexus. Contralateral L4 nerve root compression is an exceptionally rare and often overlooked complication, with limited understanding of its biomechanical mechanisms and sparse radiological evidence linking symptoms to specific causes. A 61-year-old female underwent L3/4 and L4/5 OLIF via a left retroperitoneal approach for degenerative spondylolisthesis and spinal stenosis. Postoperatively, she developed right lower extremity pain and quadriceps weakness. Imaging revealed a malpositioned interbody cage and a fractured L4 osteophyte fragment compressing the contralateral L4 nerve root. Revision surgery via a transforaminal lumbar interbody fusion (TLIF) approach successfully removed the fragment and decompressed the nerve, leading to complete symptom resolution at 5-month follow-up. This case provides direct radiological and intraoperative confirmation of contralateral L4 nerve root compression due to cage malposition and osteophyte fracture—a rarely documented mechanism. Contributing factors likely included asymmetric cage placement and potential patient positioning inaccuracies. The report underscores the importance of precise surgical techniques, including rigorous fluoroscopic verification, optimal patient positioning, and consideration of intraoperative navigation to prevent such complications. Prompt postoperative imaging and timely intervention are crucial for managing unexpected neurological deficits. This case demonstrates that timely revision surgery successfully resolved the contralateral neurological deficits, resulting in complete functional recovery at 5-month follow-up. Enhanced awareness and adherence to preventive strategies can significantly reduce the incidence of this serious, yet preventable, complication in lateral access lumbar surgery.

Introduction

Oblique Lumbar Interbody Fusion (OLIF) is a recognized minimally invasive approach for the management of lumbar degenerative diseases¹. The advantages of this approach, such as decreased intraoperative blood loss, preservation of posterior musculature, and expedited recovery, have led to its increasing popularity^2,3,4. Neurological complications continue to be a significant concern linked to this approach^5,6. Most reported cases involve the ipsilateral lumbar plexus and are generally transient,....

Protocol

1. Preoperative preparation

1. The patient was admitted 1 day prior to surgery for preoperative assessment and preparation. Obtain laboratory studies, including complete blood count, coagulation profile, and basic metabolic panel. Confirm all values are within normal limits. Instruct the patient to fast for 8 h before the procedure. Prophylactic antibiotics (cefazolin 2 g intravenously) were administered 30 min prior to skin incision.

2. Intraoperative management

1. Patient positioning and setup
   1. Induce general anesthesia via endotracheal intubation. The patient was posit....

Results

Following the correct execution of the revision decompression procedure, the patient experienced complete resolution of contralateral neurological symptoms. Immediate postoperative assessment revealed a significant reduction in right anterior thigh pain. Motor strength in the right quadriceps improved from 3/5 preoperatively to 4/5 at hospital discharge and continued to improve to 5/5 (normal) by the 6-week follow-up visit.

Postoperative CT imaging obtained after revision surgery demonstrated .......

Discussion

OLIF is a recognized minimally invasive technique for addressing lumbar degenerative diseases, providing notable benefits including decreased blood loss, maintenance of posterior musculature, and expedited recovery^1,4. The benefits arise from the procedure's lateral approach, which preserves the anterior longitudinal ligament and minimizes soft tissue damage, thereby decreasing postoperative pain and length of hospital stay. Most neurological complications ty.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Absorbable sutures	Ethicon (Johnson & Johnson)	VCP316H	Wound closure (muscle and fascial layers)
Bone graft material	Medtronic	93-5000	Filled in interbody cage
C-arm fluoroscopy system	Siemens Healthineers	Cios Alpha	Intraoperative imaging
Cefazolin	Shandong Luokang Pharmaceutical	H20023691	Prophylactic antibiotic
Computed Tomography (CT) scanner	GE Healthcare	Revolution CT	Pre- and postoperative imaging
Interbody cage system	Shanghai San You Medical Device	CoRoent	OLIF interbody fusion
Magnetic Resonance Imaging (MRI) scanner	Siemens Healthineers	MAGNETOM Vida	Pre- and postoperative imaging
Pedicle screw system	Shanghai San You Medical Device	Adena-Zina System	Posterior fixation
Retractor system	Medtronic	963-001	Psoas retraction and exposure
Spinal surgical instruments (curettes, rongeurs, shavers, retractor)	Shanghai San You Medical Device	CoRoent	Discectomy and decompression
Surgical Scalpel Blade	Swann-Morton, Sheffield, UK	Size #10 (Carbon steel)	Skin incision and soft tissue dissection
Vancomycin Hydrochloride for Injection, USP (1 g/vial)	Hospira, Inc. (Pfizer)	NDC 0409-6531-02	Reconstituted in 500 mL of normal saline (2 mg/mL) for intraoperative retroperitoneal irrigation to prevent surgical site infection.
X-ray imaging system	Philips Healthcare	DigitalDiagnost C90	Pre- and postoperative plain radiographs