This study was supported by the Okayama Spine Group.

This study was approved by the ethics committee at Okayama Rosai Hospital (No. 201-3).
1. Patient examination
<ol>
	<li>History taking
	<ol>
		<li>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.</li>
		<li>Ask the patient to describe the radiating leg pain, its location, and aggravating and reliev...

<ol>
	<li>Tawfik, S., Phan, K., Mobbs, R. J., Rao, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+incidence+of+pars+interarticularis+defects+in+athletes.">The incidence of pars interarticularis defects in athletes.</a> Global Spine Journal. 10 (1), 89-101 (2020).</li><li>Sonne-Holm, S., Jacobsen, S., Rovsing, H. C., Monrad, H., Gebuhr, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lumbar+spondylolysis:+A+life+long+dynamic+condition?+A+cross+sectional+survey+of+4.151+adults.">Lumbar spondylolysis: A life long dynamic condition? A cross sectional survey of 4.151 adults.</a> European Spine Journal. 16 (6), 821-828 (2007).</li><li>McAfee, P. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+indications+for+interbody+fusion+cages+in+the+treatment+of+spondylolisthesis:+Analysis+of+120+cases.">The indications for interbody fusion cages in the treatment of spondylolisthesis: Analysis of 120 cases.</a> Spine. 30 (6), 60-65 (2005).</li><li>Parajon, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+transforaminal+lumbar+interbody+fusion:+Meta-analysis+of+the+fusion+rates.+What+is+the+optimal+graft+material.">Minimally invasive transforaminal lumbar interbody fusion: Meta-analysis of the fusion rates. What is the optimal graft material.</a> Neurosurgery. 81 (6), 958-971 (2017).</li><li>Lowe, T. G., Tahernia, A. D., O'Brien, M. F., Smith, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Unilateral+transforaminal+posterior+lumbar+interbody+fusion+(TLIF):+Indications,+technique,+and+2-year+results.">Unilateral transforaminal posterior lumbar interbody fusion (TLIF): Indications, technique, and 2-year results.</a> Journal of Spinal Disorders and Techniques. 15 (1), 31-38 (2002).</li><li>Mayer, H. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+microsurgical+technique+for+minimally+invasive+anterior+lumbar+interbody+fusion.">A new microsurgical technique for minimally invasive anterior lumbar interbody fusion.</a> Spine. 22 (6), 691-699 (1997).</li><li>Hodgson, A. R., Stock, F. E., Fang, H. S. Y., Ong, G. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anterior+spinal+fusion+the+operative+approach+and+pathological+findings+in+412+patients+with+Pott's+disease+of+the+spine.">Anterior spinal fusion the operative approach and pathological findings in 412 patients with Pott's disease of the spine.</a> The British Journal of Surgery. 48, 172-178 (1960).</li><li>Woods, K., Billy, J. B., Hynes, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technical+description+of+oblique+lateral+interbody+fusion+at+L1-L5+(OLIF25)+and+at+L5-S1+(OLIF51)+and+evaluation+of+complication+and+fusion+rates.">Technical description of oblique lateral interbody fusion at L1-L5 (OLIF25) and at L5-S1 (OLIF51) and evaluation of complication and fusion rates.</a> The Spine Journal. 17 (4), 545-553 (2017).</li><li>Tan, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+simultaneous+single-position+oblique+lumbar+interbody+fusion+and+percutaneous+pedicle+screw+fixation+with+posterior+lumbar+interbody+fusion+using+O-arm+navigated+technique+for+lumbar+degenerative+diseases.">Comparison of simultaneous single-position oblique lumbar interbody fusion and percutaneous pedicle screw fixation with posterior lumbar interbody fusion using O-arm navigated technique for lumbar degenerative diseases.</a> Journal of Clinical Medicine. 10 (21), 4938 (2021).</li><li>Phillips, F. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adult+degenerative+scoliosis+treated+with+XLIF:+Clinical+and+radiographical+results+of+a+prospective+multicenter+study+with+24-month+follow-up.">Adult degenerative scoliosis treated with XLIF: Clinical and radiographical results of a prospective multicenter study with 24-month follow-up.</a> Spine. 38 (21), 1853-1861 (2013).</li><li>Davis, T. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Retroperitoneal+oblique+corridor+to+the+L2-S1+intervertebral+discs+in+the+lateral+position:+An+anatomic+study.">Retroperitoneal oblique corridor to the L2-S1 intervertebral discs in the lateral position: An anatomic study.</a> Journal of Neurosurgery: Spine. 21 (5), 78 (2014).</li><li>Houten, J. K., Alexandre, L. C., Nasser, R., Wollowick, A. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nerve+injury+during+the+transpsoas+approach+for+lumbar+fusion.">Nerve injury during the transpsoas approach for lumbar fusion.</a> Journal of Neurosurgery: Spine. 15 (3), 280-284 (2011).</li><li>Tanaka, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=C-arm+free+simultaneous+OLIF51+and+percutaneous+pedicle+screw+fixation+in+a+single+lateral+position:+A+technical+note.">C-arm free simultaneous OLIF51 and percutaneous pedicle screw fixation in a single lateral position: A technical note.</a> Interdisciplinary Neurosurgery. 27, 101428 (2022).</li><li>Hadelsberg, U. P., Harel, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hazards+of+ionizing+radiation+and+its+impact+on+spine+surgery.">Hazards of ionizing radiation and its impact on spine surgery.</a> World Neurosurgery. 92, 353-359 (2016).</li><li>Kim, T. T., Drazin, D., Shweikeh, F., Pashman, R., Johnson, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+and+radiographic+outcomes+of+minimally+invasive+percutaneous+pedicle+screw+placement+with+intraoperative+CT+(O-arm)+image+guidance+navigation.">Clinical and radiographic outcomes of minimally invasive percutaneous pedicle screw placement with intraoperative CT (O-arm) image guidance navigation.</a> Neurosurgical Focus. 36 (3), 1 (2014).</li><li>Kakarla, U. K., Little, A. S., Chang, S. W., Sonntag, V. K., Theodore, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Placement+of+percutaneous+thoracic+pedicle+screws+using+neuronavigation.">Placement of percutaneous thoracic pedicle screws using neuronavigation.</a> World Neurosurgery. 74 (6), 606-610 (2010).</li><li>Nagamatsu, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+of+3D+lumbosacral+vascular+anatomy+for+OLIF51+by+non-enhanced+MRI+and+CT+medical+image+fusion+technique.">Assessment of 3D lumbosacral vascular anatomy for OLIF51 by non-enhanced MRI and CT medical image fusion technique.</a> Diagnostics. 11 (10), 1744 (2021).</li><li>Tanaka, M., Fujiwara, Y., Uotani, K., Maste, P., Yamauchi, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=C-arm-free+circumferential+minimally+invasive+surgery+for+adult+spinal+deformity:+Technical+note.">C-arm-free circumferential minimally invasive surgery for adult spinal deformity: Technical note.</a> World Neurosurgery. 143, 235-246 (2020).</li></ol>

The authors declare that there are no conflicts of interest.

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...

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 level5. Furthermore, with TLIF, it is difficult to create adequate lordosis compared to oblique lumbar interbody fusion (OLIF) or anterior lumbar interbody fusion (ALIF)6.
Indirect decompressions such as ALIF or OLIF are currently common methods for treating lumbar stenosis7. However, the conventional ALIF technique causes a large amount of muscle damage. Oblique lateral interbody fusion at the L5-S1 level (OLIF51) was first reported in 20178. Posterior instrument augmentation is usually necessary to ensure solid fusion, but the conventional OLIF technique uses a C-arm, and the patient position is changed from lateral to prone. To overcome these problems, we report herein a novel technique of C-arm-free simultaneous OLIF51 and percutaneous pedicle screws (PPSs) in a single lateral position. 
We introduce the case of a 75-year-old woman with symptomatic L5 spondylolisthesis (grade 2).

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Adjustable hinged operating carbon table</td>
			<td>Mizuho OSI</td>
			<td>6988A-PV-ACP</td>
			<td>OSI Axis Jackson table</td>
		</tr>
		<tr>
			<td>CD Horizon Solera Voyager</td>
			<td>Medtronic</td>
			<td>6.4317E+11</td>
			<td>Percutaneous pedicle screw system</td>
		</tr>
		<tr>
			<td>Navigated Cobb elevator</td>
			<td>Medtronic</td>
			<td>NAV2066</td>
			<td></td>
		</tr>
		<tr>
			<td>Navigated combo tool</td>
			<td>Medtronic</td>
			<td>NAV2068</td>
			<td></td>
		</tr>
		<tr>
			<td>Navigated curette</td>
			<td>Medtronic</td>
			<td>NAV2069</td>
			<td></td>
		</tr>
		<tr>
			<td>Navigated high speed bur</td>
			<td>Medtronic</td>
			<td>EM200N</td>
			<td>Stelth</td>
		</tr>
		<tr>
			<td>Navigated passive pointer</td>
			<td>Medtronic</td>
			<td>960-559</td>
			<td></td>
		</tr>
		<tr>
			<td>Navigated pedicle probe</td>
			<td>Medtronic</td>
			<td>9734680</td>
			<td></td>
		</tr>
		<tr>
			<td>Navigated shaver</td>
			<td>Medtronic</td>
			<td>NAV2071</td>
			<td></td>
		</tr>
		<tr>
			<td>NIM Eclipse system</td>
			<td>Medtronic</td>
			<td>ECLC</td>
			<td>Neuromonitouring</td>
		</tr>
		<tr>
			<td>O-arm</td>
			<td>Medtronic</td>
			<td>224ABBZX00042000</td>
			<td>Intraoperative CT</td>
		</tr>
		<tr>
			<td>Radiolucent open spine cramp</td>
			<td>Medtronic</td>
			<td>9731780</td>
			<td></td>
		</tr>
		<tr>
			<td>Self-retaining retractor</td>
			<td>Medtronic</td>
			<td>29B2X10008MDT151</td>
			<td></td>
		</tr>
		<tr>
			<td>Sovereign Spinal System</td>
			<td>Medtronic</td>
			<td>6.4317E+11</td>
			<td>OLIF51 cage</td>
		</tr>
		<tr>
			<td>Spine small passive frame</td>
			<td>Medtronic</td>
			<td>9730605</td>
			<td></td>
		</tr>
		<tr>
			<td>Stealth station navigation system Spine 7R</td>
			<td>Medtronic</td>
			<td>9733990</td>
			<td>Navigation</td>
		</tr>
		<tr>
			<td>U-NavLock Gray</td>
			<td>Medtronic</td>
			<td>9734590</td>
			<td></td>
		</tr>
		<tr>
			<td>U-NavLock Green</td>
			<td>Medtronic</td>
			<td>9734734</td>
			<td></td>
		</tr>
		<tr>
			<td>U-NavLock Orange</td>
			<td>Medtronic</td>
			<td>9734683</td>
			<td></td>
		</tr>
		<tr>
			<td>U-NavLock Violet</td>
			<td>Medtronic</td>
			<td>9734682</td>
			<td></td>
		</tr>
	</tbody>
</table>

c-arm-free simultaneous olif51 and percutaneous pedicle screw fixation in a single lateral position

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.

Fourteen cases (average age: 71.5 years) were treated using this new technique. They were compared to 40 cases (average age: 74.0 years) of L5-S1 TLIF. L5-S1 lordosis angle and disc height were measured in both groups. The OLIF51 group obtained a better L5-S1 lordosis than the TLIF 51 group (Figure 15).
<img alt="Figure 15" class="xfigimg" src="/files/ftp_upload/63572/63572fig15.jpg" /> 
<stron...

Watch this Scientific Journal Video about C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position at JoVE.com

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

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.

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 ...

Spondylosis is regarded as stress fracture and occurs in about 5%of young population. The most common level of occurrence is the L5 level due to the unique shearing force applied at L5-S1 area. The main symptom of spondylosis and spondylolisthesis are low back pain, leg pain, and numbness.If conservative treatment proves ineffective surgical treatment is recommended. Transforaminal Lumbar Interbody Fusion, TLIF is an effective and established technique but the non-union rate of this procedure is relatively higher at the L5-S1 level. Furthermore TLIF is difficult to create a decreased lordosis compared to Oblique Lumbar Interbody Fusion, ORIF or Anterior Lumbar Interbody Fusion, ALIF.Interior decompression such as ALIF or ORIF are currently common method for treating lumbar stenosis. However, a compressional method cause a large amount of muscle damage. OLIF at 5-S1 level, OLIF-51 was first reported in 2017.Posterior Ligament Augmentation is usually necessary to ensure solid fusion but the conventional OLIF technique use C-arm and the patient position is changed from lateral to prone. To overcome these problems we propose a novel technique of C-arm free simultaneous OLIF-51 implanting pedicle screw fixation in a single lateral position. In this video, we introduce a case of a 75 year old woman with symptomatic L5 spondylolisthesis.This study was approved by the Essex committee at Okayama Rosai Hospital. This is a protocol of C-arm free simultaneous OLIF-51 and percutaneous pedicle screw fixation. Check the preoperative image.Functional radiograms helps us to evaluate spinal instability. MRI give us the information of neural dish. CT scan are important to check boney structure.Vascular window which is made of common iliac vessels at L5-S1 disk level is clearly demonstrated by CT MRI fusion image. This procedure is performed under general anesthesia. Operation table should be full carbon table to perform CT scan by O-arm.This is Pro axis which is adjustable full carbon table. Patient is pressed in light lateral decubitus position with tape. If possible the neuro monitoring is recommended to prevent neurological complication during OLIF.We use NIM neuro monitoring system. Navigation reference frame is pressed percutaneously into sacroiliac joint. Then O-arm is set and intraoperative CT scan is performed.4 centimeter upper skin incision along the peri is made then alongside with skin incision the abdominal muscles were divided and dissected. After exposing pro left common iliac vessels are identified and left gradualy by a blue self retaining retractor with elimination. The navigated probe is used to check the L5-S1 disk space.A green grade is to retract right side common iliac vessels. A light blue grade is to retract bifurcation of common iliac vessels. Now you can see L5-S1 disc very clearly.The annulus is cut with a knife and discectomy is performed using pituitary forceps. With the navigated pointer you can confirm the anatomy in a 3D way without C-arm. This is ligature.This is a navigated combo tool to make enterprise smooth. This is navigated shaver. This is navigated trial.For OLIF-51 cage size is from 10 to 16 millimeter and robotic cage angle are 8, 12, 18 degrees. A cage is inserted with a mallet. After the cage is inserted a supplemental screw is inserted.Another surgeon performs percutaneous pedicle screw fixation simultaneously. These are postoperative radiograms. There were 14 cases of this new technique.To compare with 40 cases of TLIF-51 preoperative L5-S1 angle of OLIF-51 and TLIF-51 were 11.4 degrees and 10.1 degrees respectively. These were not significant difference. However, post operative L5-S1 angle of OLIF-51 and TLIF-51 were 21.3 degrees and 12 one point degrees respectively.These result were statistically different. Also postoperative L5-S1 disk height of OLIF-51 group was higher than that of TLIF-51 group. Critical steps for our method.First, preoperatively preparation of the location of common iliac vessels is very important because the vascular window, less than 20 millimeter lead presents a contraindication for OLIF-51.Second. The difference frame pin should be firmly inserted in the left SI joint percutaneously. If the difference frame is moved the accuracy of this procedure, wasn't risking screw or cage malposition, Third, navigated instrument including a pointer, pedicle probe, shaver should be used effectively As an alternative a C-arm technique is also available for this simultaneous method and certain limitation to this technique must be considered.Relatively expensive equipment, such as O-arm and navigation system is necessary. With a steep learning curve for this technique. Further studies in the form of case series are necessary to ensure this technique remains effective for managing ischemic spondylolisthesis.In summary C-arm free OLIF-51 and simultaneous percutaneous pedicle screw fixation performed in a single lateral position under navigation guidance. This novel technique reduces surgical time and radiation hazards to surgeon and operating staff. Thank you for your attention.

c-arm-free-simultaneous-olif51-percutaneous-pedicle-screw-fixation

Research

JoVE Journal

Medicine

3.6K Görüntüleme.  Okayama Rosai Hospital. Spondiloz stres kırığı olarak kabul edilir ve genç nüfusun yaklaşık %5'inde görülür. En yaygın oluşum seviyesi, L5-S1 bölgesinde uygulanan benzersiz kesme kuvveti nedeniyle L5 seviyesidir. Spondiloz ve spondilolistezin ana semptomu bel ağrısı, bacak ağrısı ve uyuşukluktur.Konservatif tedavinin etkisiz olduğu kanıtlanırsa cerrahi tedavi önerilir. Transforaminal Lomber İnterbody Füzyon, TLIF etkili ve yerleşik bir tekniktir, ancak bu prosedürün birleşmeme o...