C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

Summary

C-arm-free oblique lumbar interbody fusion at the L5-S1 level (OLIF51) and simultaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This technique does not expose the surgeon or operating staff to radiation hazards.

Abstract

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 level (OLIF51) is technically difficult because of the anatomical structures. We present a novel simultaneous technique of OLIF51 with percutaneous pedicle screw fixation without fluoroscopy. The patient is placed in a right lateral decubitus position. A percutaneous reference pin is inserted into the right sacroiliac joint. An O-arm scan is performed, and 3D reconstructed images are transmitted to the spinal navigation system. A 4 cm oblique skin incision is made under navigation guidance along the pelvis. The internal/external and transverse abdominal muscles are divided along the muscle fibers, protecting the iliohypogastric and ilioinguinal nerves. Using a retroperitoneal approach, the left common iliac vessels are identified. Special muscle retractors with illumination are used to expose the L5-S1 intervertebral disc. After disc preparation with navigated instruments, the disc space is distracted with navigated trials. Autogenous bone and demineralized bone material are then inserted into the cage hole. The OLIF51 cage is inserted into the disc space with the help of a mallet. Simultaneously, percutaneous pedicle screws are inserted by another surgeon without changing the lateral decubitus position of the patient.

In conclusion, C-arm-free OLIF51 and simultaneous percutaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This novel technique reduces surgical time and radiation hazards.

Introduction

Spondylosis is regarded as a stress fracture¹ and occurs in about 5% of the young adult population². The most common level of occurrence is at the L5 level due to the unique shearing force applied at the L5-S1 area. The main symptoms of spondylosis and spondylolisthesis are low back pain, leg pain, and numbness. If conservative treatment proves ineffective, surgical treatment is recommended³. Transforaminal lumbar interbody fusion (TLIF) is an effective and established technique⁴, but the nonunion rate of this procedure is relatively higher at the L5-S1 level

Protocol

This study was approved by the ethics committee at Okayama Rosai Hospital (No. 201-3).

1. Patient examination

1. History taking
   1. Evaluate a patient with a suspected herniated disc or stenosis by taking their history. Usually, the patient presents with a history of prodromal low back pain. The patient may correlate their symptoms with an episode of trauma.
   2. Ask the patient to describe the radiating leg pain, its location, and aggravating and reliev.......

Discussion

Recently, the lateral lumbar approach for interbody fusion has been gaining popularity due to its minimal invasiveness⁹. Among these approaches, the direct lateral psoas splitting approach has several disadvantages, such as lumbar nerve plexus injury and psoas muscle weakness¹⁰. To reduce these complications, prepsoas or OLIF was introduced by Davis et al. in 2014¹¹. However, it is difficult to operate at the L5-S1 disc due to its anatomical features.......

Materials

Name	Company	Catalog Number	Comments
Adjustable hinged operating carbon table	Mizuho OSI	6988A-PV-ACP	OSI Axis Jackson table
CD Horizon Solera Voyager	Medtronic	6.4317E+11	Percutaneous pedicle screw system
Navigated Cobb elevator	Medtronic	NAV2066
Navigated combo tool	Medtronic	NAV2068
Navigated curette	Medtronic	NAV2069
Navigated high speed bur	Medtronic	EM200N	Stelth
Navigated passive pointer	Medtronic	960-559
Navigated pedicle probe	Medtronic	9734680
Navigated shaver	Medtronic	NAV2071
NIM Eclipse system	Medtronic	ECLC	Neuromonitouring
O-arm	Medtronic	224ABBZX00042000	Intraoperative CT
Radiolucent open spine cramp	Medtronic	9731780
Self-retaining retractor	Medtronic	29B2X10008MDT151
Sovereign Spinal System	Medtronic	6.4317E+11	OLIF51 cage
Spine small passive frame	Medtronic	9730605
Stealth station navigation system Spine 7R	Medtronic	9733990	Navigation
U-NavLock Gray	Medtronic	9734590
U-NavLock Green	Medtronic	9734734
U-NavLock Orange	Medtronic	9734683
U-NavLock Violet	Medtronic	9734682