Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4–5

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Recently, authors have called into question the utility and complication index of the lateral lumbar interbody fusion procedure at the L4–5 level. Furthermore, the need for direct decompression has also been debated. Here, the authors report the clinical and radiographic outcomes of transpsoas lumbar interbody fusion, relying only on indirect decompression to treat patients with neurogenic claudication secondary to Grade 1 and 2 spondylolisthesis at the L4–5 level.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors conducted a retrospective evaluation of 18 consecutive patients with Grade 1 or 2 spondylolisthesis from a prospectively maintained database. All patients underwent a transpsoas approach, followed by posterior percutaneous instrumentation without decompression. The Oswestry Disability Index (ODI) and SF-12 were administered during the clinical evaluations. Radiographic evaluation was also performed. The mean follow-up was 6.2 months.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Fifteen patients with Grade 1 and 3 patients with Grade 2 spondylolisthesis were identified and underwent fusion at a total of 20 levels. The mean operative time was 165 minutes for the combined anterior and posterior phases of the operation. The estimated blood loss was 113 ml. The most common cage width in the anteroposterior dimension was 22 mm (78%). Anterior thigh dysesthesia was identified on detailed sensory evaluation in 6 of 18 patients (33%); all patients experienced resolution within 6 months postoperatively. No patient had lasting sensory loss or motor deficit. The average ODI score improved 26 points by the 6-month follow-up. At the 6-month follow-up, the SF-12 mean Physical and Mental Component Summary scores improved by 11.9% and 9.6%, respectively. No patient required additional decompression postoperatively.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This study offers clinical results to establish lateral lumbar interbody fusion as an effective technique for the treatment of Grade 1 or 2 degenerative spondylolisthesis at L4–5. The use of this surgical approach provides a minimally invasive solution that offers excellent arthrodesis rates as well as favorable clinical and radiological outcomes, with low rates of postoperative complications. However, adhering to the techniques of transpsoas lateral surgery, such as minimal table break, an initial look-and-see approach to the psoas, clear identification of the plexus, minimal cranial caudal expansion of the retractor, mobilization of any traversing sensory nerves, and total psoas dilation times less than 20 minutes, ensures the lowest possible complication profile for both visceral and neural injuries even in the narrow safe zones when accessing the L4–5 disc space in patients with degenerative spondylolisthesis.</jats:p></jats:sec>

Correction of Spondylolisthesis by Lateral Lumbar Interbody Fusion Compared with Transforaminal Lumbar Interbody Fusion at L4–5

“…The superiority of LLIF for spondylolisthesis reduction has been reported in several studies [5,10,15], and LLIF was also reported to be effective in the reduction of even grade II spondylolisthesis [30]. However, a previous study comparing it to TLIF reported that LLIF had no advantage in terms of spondylolisthesis reduction [15].…”

“…TLIF provides a good visualization of the neural elements through direct decompression of the posterior element [8,12]. LLIF approaches the intervertebral disc space through retroperitoneal transpsoas (DLIF/XLIF) or extrapsoas (OLIF) and indirectly decompresses the spinal canal and intervertebral foramen by inserting a cage with large footprint [5,10,23].…”

“…LLIF is a relatively new minimally invasive surgery (MIS) for the treatment of DS and has the advantage of being able to insert an interbody cage with a large foot-print without injury to posterior facets [6]. While recent findings on the treatment of DS with LLIF have been reported and comparative studies of LLIF with other therapies have been published, there remains controversy regarding whether LLIF is the optimal treatment for DS [5,10,15,18,22,23,25,30]. In addition, direct comparison studies between TLIF and MIS-LLIF were not only small in number but also insufficient for explaining the recent advances of MIS-LLIF [15,25].…”

Lateral and Oblique Lumbar Interbody Fusion—Current Concepts and a Review of Recent Literature

“…Persistent symptoms, again primarily thigh sensorimotor loss, were seen in 4-5% of patients with the difference in definition between transient and persistent somewhat arbitrary at a cut-off of 6 months [12]. A small series of 18 patients in which LLIF was used to treat spondylolisthesis patients found a third (33%) of the patients developed sensory deficit of the thigh but also that all had resolved within 6 months postoperatively [13]. Similarly, another small series from a different institution evaluating this same procedure and pathology found 3 in 16 (19%) patients developed transient sensory loss that resolved within 1 year.…”

Comparison of Outcomes between Indirect Decompression of Oblique Lumbar Interbody Fusion and MIS-TLIF in One Single-level Lumbar Spondylosis: a case control study

“…A variety of techniques of lumbar interbody fusion have been used to help alleviate pain from lumbar spine-related disease [1][2][3]. For the past few decades, the minimally invasive spinal surgical technique has emerged as an alternative approach to the more invasive open lumbar interbody fusion procedure [4][5][6].…”