What are the optimal disc height changes for successful indirect decompression with OLIF? 
Analysis of pre- and postoperative parameter changes up to 1 year

doi:10.21203/rs.3.rs-4929751/v1

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What are the optimal disc height changes for successful indirect decompression with OLIF? Analysis of pre- and postoperative parameter changes up to 1 year

https://doi.org/10.21203/rs.3.rs-4929751/v1

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Study design: Retrospective study.

Objective: To evaluate the associated factors for successful indirect decompression by assessing the changes in disc height and spinal canal width.

Methods: This study included 63 patients and 104 involved surgical levels. The efficacy of OLIF for lumbar spinal stenosis on spinal canal and foramen before and after surgery was analyzed up to 1 year. Radiologic parameters were anterior disc height (ADH), posterior disc height (PDH), lumbar lordotic angle (LL), segmental lordotic angle (SL), foraminal height (FH), cross-sectional area (CSA) of the spinal canal, cross-sectional foraminal area (CSF), and subsidence (SD).

Results: Comparing pre- and postoperative values, the mean CSA and CSF were significantly increased (p < 0.001). FH increased from 15.23 ± 3.48 mm to 18.78 ± 2.93 mm and was stable for up to 1 year (p < 0.0001). The VAS leg and ODI scores significantly improved after surgery (P < 0.05). Changes of immediate postoperative and 1-year FH were significantly related to 1 year ADH, PDH, and VAS leg changes (P < 0.05). The group showing 1-year FH improvement (positive(+) group) demonstrated significantly larger immediate postoperative ADH and PDH changes compared with the FH negative(-) group (6.46 mm vs. 4.52 mm, p = 0.038; 3.59 vs. 2.40, P < 0.001, respectively). The CSF positive(+) group also showed significantly higher immediate postoperative ADH and PDH changes (6.24 mm vs. 4.55 mm, p = 0.043; 3.00 vs. 1.57, P = 0.010, respectively).

Conclusions

OLIF provided satisfactory indirect decompression up to 1 year. Considering the increase of foraminal height, we recommend more than 3.0 mm of immediate postoperative PDH increase, avoiding over-distraction of disc space.

Health sciences/Rheumatology/Musculoskeletal system

Health sciences/Medical research/Outcomes research

Oblique lumbar interbody fusion (OLIF) is a minimally invasive surgical technique for lumbar spine diseases with minimal trauma and quick recovery compared with conventional posterior lumbar interbody fusion surgery. The key advantages of OLIF are indirect neural decompression of the spinal canal and prevention of iatrogenic dural tear or nerve root injury. [1–3] In OLIF surgery, insertion of a cage into the intervertebral disc space can restore disc height and indirectly distract the posterior element of the vertebral column, providing expansion of the spinal canal and foramen. In addition, several studies have reported permanent regression of the thickened ligamentum flavum after surgery. [4–8] Park et al. reported that intraoperatively modifiable factors of improvement of anterior disc height (ADH), posterior disc height (PDH), and restoration of segmental lordosis (SL) are related to distraction of posterior vertebral elements.[9] However, target or optimal changes of modifiable parameters for successful indirect decompression have not been analyzed. Changes of disc height is closely related to foraminal height and symptom improvement; however, over-distraction of disc space may induce subsidence and failure of indirect decompression. The purpose of this study was to evaluate the preoperative and postoperative changes of parameters to determine the optimal values to achieve successful indirect decompression for up to 1 year.

Subjects

We included 63 patients who underwent OLIF by a single surgeon between 2018 and 2022 was evaluated. We included patients who were diagnosed with lumbar stenosis, underwent less than two-level surgery, and underwent indirect decompression. We excluded the patients who underwent open decompression at the same level. All surgeries were performed with oblique lateral approach, followed by percutaneous posterior pedicle screw fixations. This study was approved by the Institutional Review Board of Korea University Ansan Hospital (IRB No. 2022AS0307). Informed consent was exempted by Institutional Review Board. All methods were performed in accordance with the relevant guidelines and regulations.

Radiological and clinical parameters

Plain radiographs and CT were evaluated pre- and postoperatively up to 1 year. In addition, pre- and postoperative (1 week) MRI was performed for all patients. We defined ADH as the distance between the superior and the inferior endplate at the anterior vertebral edge. PDH was calculated as the length between the superior to the inferior endplate at the posterior vertebral edge. LL was the angle between the upper endplates of L1 and upper part of S1 vertebrae. FH was the length from the lower pedicle border of the upper level vertebra to the superior border of the lower level. We defined SL as the angle between the superior endplate of the upper and the inferior endplate of the lower vertebrae. Subsidence was defined as a greater than 2mm height decrease from immediately postoperative to 1-year postoperative radiographs. The CSA of the spinal canal and the CSF of the left and right intervertebral foramen was measured on T2 axial and sagittal MRI (Fig. 1). Clinical parameters including pre- and postoperative visual analogue score (VAS) and Oswestry Disability Index (ODI) were evaluated up to 1 year.

Statistical analysis

Radiographic measurements were performed by two orthopedic spine surgeons (first and second authors). Preoperative and postoperative parameters were compared using a paired t-test. The relationships of parameters were analyzed using the Pearson’s correlation coefficient. To determine significant disc height changes compared with postoperative foraminal height increase, ROC analysis was applied. All statistical analyses were performed using SAS software (version 9.3; SAS Institute, Cary, NC, USA).

Table 1 summarizes the basic information of the 63 patients included in the study. The mean age of the 21 males and 42 females was 69.52 ± 7.92 years. Among the 104 surgical levels, 46.15% (n = 48) involved L3–4. Among the 63 patients, 18 underwent one-level OLIF surgery and 45 underwent two-level OLIF surgery.

Table 1

Characteristics of the study group
Demographics
Age	69.52 ± 7.92
	M:F = 21:42
Disease type
Deg.stenosis*	44 (63.5%)
ASD**	9 (14.29%)
Deg.Listhesis***	10 (15.87%)
Fusion levels (N = 104)
L2–3	23 (22.12%)
L3–4	48 (46.15%)
L4–5	33 (31.73%)
Fused segments
1 level	18 (28.57%)
2 level	45 (71.43%)
Complication
Subsidence⁺	19 (18.27%)
Transient sensory change	6 (9.52%)
Pneumonia	1 (1.59%)
Deg.stenosis: Degenerative stenosis ASD: Adjacent segment disease Deg.listhesis: Degenerative spondylolisthesis ⁺Subsidence: Greater than 2 mm height decrease

Pre- and postoperative changes up to 1 year

The results showed that OLIF combined with percutaneous pedicle screw fixation effectively restored disc height and increased the cross-sectional area of the spinal canal (Table 2). FH increased from 15.23 ± 3.48 mm to 18.78 ± 2.93 mm and was stable up to 1 year (p < 0.0001). ADH and PDH also significantly increased and were stable up to 1 year (p < 0.0001). Comparing pre- and postoperative MRI values, mean CSA increased from 71.61 ± 47.48 mm² to 92.81 ± 58.64 mm² and mean left CSF increased from 46.57 ± 14.75 mm² to 70.27 ± 19.46 mm² (p < 0.05). The leg VAS and ODI scores significantly improved after surgery, and the improvement was preserved up to 1 year (P < 0.05).

Table 2

Mean postoperative changes up to 1 year
	Before surgery	After surgery	At 1 year	P
Plain radiographs
LL (°)	25.62 ± 16.76	29.38 ± 13.35	28.54 ± 10.67	< 0.001
SL (°)	7.10 ± 9.51	9.08 ± 8.04	8.73 ± 7.00	< 0.001
ADH (mm)	7.77 ± 3.77	13.37 ± 3.38	11.47 ± 2.52	< 0.001
PDH (mm)	4.61 ± 1.80	7.68 ± 2.04	6.67 ± 2.00	< 0.001
FH (mm)	15.23 ± 3.48	18.78 ± 2.93	17.40 ± 2.50	< 0.001
MRI measurement
CSA (mm²)	71.61 ± 47.48	92.81 ± 58.64		< 0.001
CSF Lt (mm²)	46.57 ± 14.75	70.27 ± 19.46		< 0.001
CSF Rt (mm²)	36.69 ± 13.77	57.37 ± 17.74		< 0.001
Clinical scores
VAS leg	7.47 ± 1.62	4.22 ± 2.36	4.67 ± 1.16	0.020
ODI	25.32 ± 9.16	21.42 ± 10.38	17.3 ± 8.08	< 0.001
LL: Lumbar lordosis SL: Sacral slope ADH: Anterior disc height PDH: Posterior disc height FH: Foraminal height CSA: Cross-sectional area of the thecal sac CSF: Cross-sectional foraminal area VAS: Visual analogue scale ODI: Oswestry disability index

Relationships between parameters

Table 3 summarizes the relationships between parameters. Immediate postoperative CSA and CSF changes significantly correlated with 1 year PDH changes (r = 0.221, p = 0.040; and r = 0.162, p = 0.016, respectively). Changes of immediate postoperative and 1 year FH were significantly related to 1 year ADH and PDH changes (P < 0.05). We found a significant relationship between FH changes immediately postoperative and at 1 year with 1-year VAS leg changes (r = 0.151, p = 0.043; and r = 0.096, p = 0.045, respectively).

Table 3

Correlation analysis of parameters
	ADH changes	PDH changes	Leg VAS changes (1 year)
CSA changes	0.129 (p = 0.202)	0.221 (p = 0.040)	0.091 (p = 0.474)
CSF Lt changes	0.109 (p = 0.280)	0.162 (p = 0.016)	0.065 (p = 0.609)
CSF Rt changes	0.061 (p = 0.615)	0.303 (p = 0.011)	0.022 (p = 0.863)
FH changes	0.245 (p = 0.012)	0.291 (p = 0.003)	0.151 (p = 0.043)
FH changes (1 year)	0.273 (p = 0.010)	0.269 (p = 0.011)	0.096 (p = 0.045)
ADH: Anterior disc height PDH: Posterior disc height CSA: Cross-sectional area of the thecal sac, CSF: Cross-sectional foraminal area VAS: Visual analogue scale FH: Foraminal height

Optimal height changes for successful indirect decompression

Table 4 shows the comparison of the ADH and PDH changes according to degree of indirect decompression up to 1 year. We performed ROC analysis to determine cut off values of parameters that indicate degree of indirect decompression. Immediate postoperative ADH and PDH changes were reliable predictors of indirect decompression according to ROC analysis (AUC = 0.654; 0.684, respectively). The 1-year FH improvement positive(+) group, defined as those with greater than 2.21 mm of height increase compared with preoperative value, showed significantly higher ADH and PDH changes (6.46 mm vs. 4.52 mm, p = 0.038; 3.59 vs. 2.40, P < 0.001, respectively). Patients were divided according to CSF values into positive(+) and negative(-) groups (cut-off, 20.12 mm²); significant differences of immediate postoperative ADH and PDH changes were observed (6.24 mm vs. 4.55 mm, p = 0.043; 3.00 vs. 1.57, P = 0.010, respectively). However, the CSA positive(+) and negative(-) groups (cut-off 21.02 mm²) did not show significant differences of parameters (P > 0.05). The 1-year subsidence positive(+) group (> 2 mm) showed significant differences in immediate PDH increase (4.77 vs. 2.56, P < 0.001, respectively). Figure 2 shows pre- and postoperative radiographs of a patient in the 1-year FH positive(+) group.

Table 4

Comparison of parameters between groups
	ADH increase (mm)	PDH increase (mm)	Leg VAS change
FH1 year(+)	6.46 ± 6.17	3.59 ± 1.71	4.12 ± 1.71
FH1 year(-)	4.52 ± 3.60	2.40 ± 1.49	2.56 ± 0.71
p	p = 0.038	p < 0.001	p < 0.001
CSF(+)	6.24 ± 6.13	3.00 ± 1.63	3.65 ± 1.71
CSF(-)	4.55 ± 2.22	1.57 ± 1.60	2.12 ± 1.71
p	p = 0.043	p = 0.010	p = 0.103
CSA(+)	6.26 ± 6.67	3.39 ± 1.44	3.64 ± 1.71
CSA(-)	5.46 ± 3.25	3.21 ± 2.02	3.19 ± 1.71
p	p = 0.374	p = 0.584	p = 0.234
Subsidence(+)	5.91 ± 2.93	4.77 ± 1.54	2.14 ± 1.99
Subsidence(-)	5.50 ± 3.14	2.56 ± 1.42	3.96 ± 2.34
p	p = 0.553	p < 0.001	p = 0.011
ADH increase: Immediate postoperative anterior disc height increase PDH increase: Immediate postoperative posterior disc height increase CSA: Cross-sectional area of the thecal sac CSF: Cross-sectional foraminal area VAS: Visual analogue scale FH1 year(+): Greater than 2.21 mm of change in foraminal height group CSF(+): Greater than 20.12 mm² of change in CSF group CSA(+): Greater than 21.02 mm² of change in CSA group Subsidence(+): Greater than 2.00 mm of change in subsidence group

OLIF surgery is believed to be efficacious for treatment of mechanical low back pain resulting from disc degeneration, segmental instability, or degenerative scoliosis. OLIF surgery is also considered for leg pain with neurogenic claudication accompanied by mild spinal canal stenosis.(10) Previous studies on OLIF have primarily included single retrospective analysis of oblique lumbar interbody fusion (OLIF) treatment for lumbar spinal stenosis (LSS), comparative studies between OLIF and other surgical methods, and diagnostic analysis through CT or MRI measurements of the dura mater.(11–14) In this study, values of the parameters at 1 year after the operation demonstrated varying degrees of increase or decrease compared with the immediate postoperative values, but all were significantly different from baseline. VAS for leg pain improved within 1 week following OLIF surgery, and this was preserved up to 1 year. In addition, with the radiologic improvement of CSA and CSF as well the immediate improvement of radicular symptoms, we suggest that OLIF surgery may offer an advantage in the treatment of radicular pain as well as neurogenic claudication due to spinal canal stenosis. By removing the intervertebral disc in the surgical segment and performing bone grafting and fusion in that segment, followed by implanting an appropriately sized cage to fully restore the intervertebral space in the surgical area, the displaced facet joint is indirectly returned to its normal anatomical position, increasing the foraminal and spinal canal spaces. However, additional direct decompression of bony stenosis and severe ligamentum flavum thickening was needed in some cases. A recent retrospective review of 45 patients (101 levels) reported that bony stenosis at the lateral recess is a predictor of failure of indirect decompression. Although indirect decompression using OLIF can stretch the soft tissue elements that compress the neural element, there may be a limitation of indirect decompression in relieving bony stenosis.(15) However, symptoms can be resolved with a small amount of canal or foramen expansion with indirect decompression, as we reported in our study; thus, most cases including those with a severe degree of canal and foramen stenosis are good candidates for OLIF surgery (16, 17).

The success of indirect decompression through OLIF surgery depends on many factors. Previous studies on indirect decompression of OLIF reported significant increases in CSA, CSF, and FH postoperatively, which is consistent with the results of the current study (18–24). In OLIF surgery, a large cage can distract the interbody disc space as well as the posterior vertebral element, including the facet joint, restoring the disc and foraminal heights. Even though regression of the ligamentum flavum has been reported to have a significant role in CSA expansion over long-term follow-up, our results indicate that indirect decompression can also be successfully accomplished immediately with significant improvement in spatial radiological parameters. We found significant increments in ADH, PDH, FH, CSA, and CSF in immediate postoperative radiographs, and these were preserved up to 1 year. This result indicates that OLIF is sufficient to provide good mid-term radiological outcomes in patients with degenerative lumbar stenosis. In addition, the improvement of PDH correlated with improvement of CSF and FH. Immediate postoperative CSA and CSF changes were also significantly correlated with 1 year PDH change (r = 0.221, p = 0.040; and r = 0.162, p = 0.016, respectively). Changes of immediate postoperative and 1 year FH were significantly related to 1 year ADH and PDH changes, indicating an effect of indirect decompression on subsidence. Based on these findings, we conclude that sufficient indirect decompression after OLIF surgery can be accomplished in patients with intervertebral disc space narrowing, which can be fully opened and restored by insertion of a large cage. Adversely, direct decompression may be needed for young patients with preserved disc height and severe central canal stenosis. The indications of OLIF are important and significantly affect the success of indirect decompression.

To achieve successful indirect decompression, it is important to restore posterior disc height while avoiding over-distraction, which may induce postoperative subsidence.(9) In our study, the 1-year FH improvement positive(+) group showed significantly higher immediate postoperative PDH changes (3.59 vs. 2.40, P < 0.001). The CSF positive(+) group also showed significantly higher immediate postoperative ADH and PDH changes (6.24 mm vs. 4.55 mm, p = 0.043; 3.00 vs. 1.57, P = 0.010, respectively). Considering the improvement of foraminal height and symptoms, better outcome was expected with a greater than 3.0–3.6 mm immediate postoperative PDH increase; an increase less than 1.6–2.4 mm implies a worse outcome. Zeng et al. reported a retrospective analysis of 235 cases of perioperative complications after OLIF. Among these, 22 cases of endplate damage showed a probability of 9.36% and 18 cases of cage subsidence and displacement was a probability of 7.66%, resulting in a combined probability of 17.02%.(25) Similarly, Abe et al. found that the most common perioperative complication in their retrospective study of 155 OLIF cases was endplate fracture/subsidence, with a probability of 18.7%.(26) Similarly, the present study observed 18% of cases to have significant subsidence (> 2 mm), with a significantly higher immediate PDH increase (4.77 vs. 2.56, P < 0.001). This indicates the importance of subsidence consideration in OLIF surgery, for which symptoms can be resolved with a small amount of canal or foramen expansion without over-distraction of the disc space. In addition, cages positioned in the middle of the inferior vertebral body had a greater effect on improvement of FH.(9) Therefore, the factors that significantly affect the improvement of CSF and FH are posterior disc height restoration and a more posterior location of the cage. These results support our hypothesis that the effect of indirect decompression through OLIF surgery might occur through distraction of the middle and posterior vertebral column. These results provide a strong rationale to place the cage in the middle or posteriorly to increase the amount of posterior disc height restoration and the amount of facet distraction for better outcomes after OLIF surgery.

Our study has some limitations. First, this is a small retrospective study that included patients with a wide range of ages. This makes it difficult to accurately reflect the radiologic outcome with respect of the degree of degenerative change. Additionally, the small sample size may limit the reliability of the results. Furthermore, the follow-up observation was limited to 1 year, and longer-term tracking could offer more compelling evidence. Even though we found significant improvement in CSA, CSF, and foraminal height postoperatively, we did not evaluate 1 year postoperative MRI findings, which are as significant as other radiologic outcomes. Further research is required to clarify the minimal clinically important difference in each radiologic parameter for both successful radiological and clinical outcomes following OLIF surgery.

OLIF provided satisfactory indirect decompression with significant improvement of radiological parameters and symptoms up to 1 year. To achieve successful indirect decompression, restoration of PDH is important, considering improvement of foraminal height and symptoms. Thus, we recommend more than 3.0 mm of PDH increase, avoiding over-distraction, for successful indirect decompression.

Funding

Disclosures: No funds were received in support of this work.

Author Contribution

JYH, YJH and JHP wrote the main manuscript.JHP, JWS, JWP designed the study.DHS supervised the main manuscript.

Acknowledgement

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Data Availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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No competing interests reported.

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What are the optimal disc height changes for successful indirect decompression with OLIF? Analysis of pre- and postoperative parameter changes up to 1 year

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