Becker's Spine Review

41 Executive Briefing Sponsored by: The oblique lateral interbody fusion is among the most innovative spine surgery approaches. It allows surgeons to achieve the same outcomes as open procedures with less tissue disruption and an accelerated patient recovery time. Becker's was able to sit down with four leading spine surgeons to learn more about how they incorporated OLIF into their practice and where they see the procedure heading in the future. The surgeons participating in the roundtable include: • John Williams, MD, of SpineONE in Fort Wayne, Indiana • Luis Duarte, MD, of Shannon Clinic in San Angelo, Texas • John Peloza, MD, of Center for Spine Care in Dallas, Texas • Kornelis Poelstra, MD, of OrthoNorCal in Los Gatos, California Dr. Williams began the discussion by outlining the benefits of OLIF compared to other fusion techniques. "When you approach the anterior spine obliquely, you're no longer retracting the lumbar plexus in the way that we do when we do transpsoas surgery," said Dr. Williams. "You essentially eliminate plexus injury, limb numbness, quadriceps weakness and other issues we have with transpsoas surgery." Patients are placed in the lateral decubitus position to allow gravity to drain away the peritoneal contents; surgeons don't have to retract them. OLIF is associated with fewer instances of postoperative complications including ureteral injuries, retrograde ejaculation and peritoneal injuries. "The genius of this procedure is that it's really a modified ALIF that's done through the lateral approach, and in which gravity does a lot of the retraction for you," said Dr. Duarte. "It's extremely valuable because you can do it right side up or left side up, whatever your most comfortable level is, and it eliminates a lot of issues with the lateral procedures or ALIF just because the tissue retraction is almost absent." Camber Spine's SPIRA®-O, which has an arch design for the oblique position, multiplies arches throughout the internal architecture so there are multiple points of contact with the endplate. The stress is distributed evenly across the implant and the implant's material nano-signals to the cells to make bone. "The key is to make sure you know where the orientation of the implant's position is so you don't put it into the canal or into the foramen," said Dr. Peloza. "There's all these different stops and visual ways to do that with the Camber instrumentation." "Do you use one incision or multiple incisions for multiple levels?" Surgeons can either perform an OLIF procedure with a single, larger incision or two smaller incisions. Dr. Peloza uses the single incision approach, making a 2.5 to 3 centimeter incision in the skin for a more tubular retraction; new retractors require a bit larger incision, but he found it has little neural tissue manipulation and remains cosmetically attractive for the patient. Dr. Poelstra, also typically performs the procedure with one incision to relieve compression. "With this approach, it's almost like we have the illusion that we're going through posteriorly," he said. "Initially when people started to do interbody surgery they get clips and then somebody realized that if we go a bit more lateral and we start doing TLIFs we have a beautiful window and there is no requirement for nerve retraction to get into the interbody space in the back. It's an evolution now that we're doing it in the front." On the other hand, Dr. Williams makes two smaller incisions for the procedure, especially when he first teaches the technique to other surgeons. Dr. Duarte typically uses one incision for procedures at L1 to L5 and then two incisions for L4-5 and L5- S1. "The reason for that is the angle at L5-S1 in some patients is very pointed toward the floor and L4-L5 is more horizontal," he said. "It's very hard to do that through a single incision." "Can you decompress the spinal canal from the OLIF approach like an ACDF?" Dr. Poelstra performed around a thousand direct lateral spine surgeries to correct deformities before he discovered the OLIF procedure and realized the direct lateral approach disrupted patients more than was necessary. Surgeons can decompress the spinal canal with OLIF, which is similar to anterior cervical decompression. "I believed before that anterior column reconstruction and posterior tension band recreation was the way to go. But the problem was always that you could not get enough of an opening of the interior column from the direct lateral approach," Dr. Poelstra said. "The OLIF allows you to carefully come around, open up the front, restore that sagittal balance where the patient needs to go and through that soft tissue plane that we take, we hurt the patient so much less than we used to." Dr. Williams said standing anterior to the patient and performing a complete discectomy is his most successful approach. He is able to set his retractor and light source to look into the back of the disc space and then use fluoroscopy guidance to remove the disc space with an angled curette. As the surgeon moves up towards the diaphragm, it becomes more difficult to see back into the spinal canal, but at L5-S1 the procedure is identical to the ACDF; it's close to identical at L4-5 as well. "As my practice has evolved and changed through the years, I really loved the direct lateral transpsoas surgery," Dr. Williams The next evolution for minimally invasive spine: OLIF in the ASC

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