Far Lateral Lumbar Spine Fusions | Oblique Lateral Interbody Fusion (OLIF)

An Overview of Far Lateral Lumbar Spine Fusions: Oblique Lateral Interbody Fusion (OLIF) & Extreme Lateral Interbody Fusion (XLIF)

The XLIF was the first procedure to be developed to approach the vertebral body from the side which avoids the anterior approach and all the potential morbidity of going straight through the front of the belly wall. The XLIF procedures works reasonably well but does require the psoas muscle to be split (cut) to reach the side of the vertebra and the disc. The psoas muscle contains all the exiting nerve roots from L1-S1 including the femoral and sciatic nerves. These are essentially all the nerves that service both legs. These XLIF procedures required entering the muscle belly and cause retraction of the muscle containing these nerve roots which puts these nerves at risk.

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This image demonstrates the spinal nerves located within the psoas muscle (nerves noted on the left, psoas on the right).

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(Please keep reading below for more information on this treatment.)

The OLIF procedure was developed to prevent the need to split the psoas muscle and prevent injury to the imbedded nerve roots. This is accomplished by the “oblique” approach (the “O” in OLIF) instead of the direct lateral approach. The OLIF procedure is very good for patients with a significant deformity where one vertebra is angulated or collapsed on another and is a powerful tool to realign the spine compared to a purely posterior approach.

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This is an axial view of the area of the lumbar spine. The small arrow points to the XLIF approach and the large arrow points to the OLIF approach.

The approach is made through a small incision (normally 3 inches or less) on the side of the belly about where your arm would set when it hangs down from your side when standing. A small amount of abdominal wall muscle is incised and the pathway to the spine is found between the peritoneal sac (the sack containing the bowels) and the front of the psoas muscle. The psoas muscle is left fully intact but a small portion of the psoas insertion at its attachment to the vertebral body is pushed slightly back for access to the disc space. Since the important spinal nerve roots imbedded in the psoas muscle are not retracted or compressed, there is significant reduction of compression injury to these nerves (which was much more common in the XLIF approach).

This side of the disc space is opened and various “spreader tools” are used to redevelop the original disc space height. The disc is then “cleaned out” to remove cartilage and nucleus. A cage (really just a spacer) filled with bone substitutes is then inserted to hold the space open and induce fusion with its contents.

The cage is made out of PEEK (polyether ether ketone), a plastic material that is inert and non-reactive to human tissues. This cage acts as a spacer to hold the vertebra apart and in appropriate position. The cage is filled with BMP and DMP (bone morphogenic protein and demineralized bone matrix), two substances that induce new bone formation. For this part of the surgery, patient’s bone graft does not need to be taken.

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Pivox cage filled with BMP and DBM

XLIF or OLIF cages have to be stabilized by posterior instrumentation (pedicle screws) to make sure the cage does not “slip” out of position before the vertebra heals together. Screws can be placed by various posterior procedures.

The OLIF is designed to distract the vertebral bodies apart. This separation can indirectly reduce the compression of the neural elements in the canal or foramen but this is not guaranteed to fully free the nerve roots. This is called “indirect decompression”.

During the procedure, nerve monitoring is necessary to make sure there is no irritation or injury to the exiting nerve roots that can occur with the placement of the retractor or that too much distraction is not employed as this can on occasion cause a nerve root stretch or compression injury.

Example

These are X-rays before and after of a patient who had a long laminectomy for lower back pain that did not give him relief. This is because his pain was generated from disc degeneration and not canal narrowing (stenosis). The laminectomy makes a TLIF at all levels very difficult so OLIFs were employed at L2-3, L3-4 and L4-5 where a TLIF was utilized at L5-S1.

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Lateral preop X-ray. Arrows point to collapsed discs (multilevel isolated disc resorption-IDR) Note the discs are severely narrowed and the lordosis is about 30 degrees.

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AP preop X-ray. Note scoliosis and arrow which points to prior laminectomy. (Note the missing spinous processes-laminectomy did not help his pain).

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Here is the post-op X-ray correcting the scoliosis and kyphosis. Note the upper vertebra have OLIF cages and the lowest level (L5-S1) has a TLIF cage.

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X-ray post-op demonstrating the correction of the curve. OLIF cages above and TLIF at the bottom. Large arrows indicate OLIF, small arrow points to TLIF.

For more resources on far lateral lumbar spine fusions, such as a oblique lateral interbody fusion (OLIF) or extreme lateral interbody fusion (XLIF), please contact the office of Dr. Donald Corenman, spine surgeon and back pain specialist in the Vail, Aspen, Denver and Grand Junction, Colorado area.

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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Far Lateral Lumbar Spine Fusions: Oblique Lumbar Interbody Fusion (OLIF) & Extreme Lateral Interbody Fusion (XLIF)

An Overview of Far Lateral Lumbar Spine Fusions: Oblique Lateral Interbody Fusion (OLIF) & Extreme Lateral Interbody Fusion (XLIF)

Are you a candidate for a OLIF or XLIF procedure?

Related Content

About the Author: Donald Corenman, MD, DC

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