Comparative effectiveness of oblique lumbar interbody fusion with anterior screw fixation versus percutaneous pedicle screw fixation for treating lumbar degenerative diseases: A systematic review and meta-analysis

Abstract

Purpose

Lumbar degenerative diseases impose a substantial health burden, prompting the exploration of advanced surgical approaches such as Oblique Lumbar Interbody Fusion (OLIF). This meta-analysis aims to evaluate the comparative efficacy of OLIF with anterior screw fixation (OLIF-AF) against OLIF with posterior pedicle fixation (OLIF-PF) in addressing these conditions.

Methods

A systematic search across multiple databases identified five studies meeting inclusion criteria, incorporating a total of 271 patients. Comparative analysis encompasses primary and secondary outcomes related to fusion rates, intraoperative parameters, patient-reported measures, and radiographic assessments.

Results

Primary outcome analysis demonstrated no statistically significant difference in total fusion rates between OLIF-AF and OLIF-PF. However, secondary outcomes revealed distinct advantages in OLIF-AF, showcasing lower intraoperative blood loss and reduced operative times compared to OLIF-PF. Nonetheless, patient-reported outcomes, encompassing measures such as pain scores and functional assessments, as well as radiographic parameters, exhibited no significant variations between the two techniques.

Conclusion

While OLIF-AF displayed favorable results in intraoperative parameters, such as reduced blood loss and shorter operative times, it did not significantly differ in patient-reported outcomes and radiographic assessments compared to OLIF-PF. Interpretation of findings must consider limitations in sample sizes and study heterogeneity. Future investigations with larger, more diverse cohorts and extended follow-ups are imperative to confirm these preliminary findings and comprehend the actual clinical impact of these OLIF techniques in managing lumbar degenerative diseas.

Keywords

Oblique lumbar interbody fusion lumbar degenerative diseases spine surgery anterior screw fixation percutaneous pedicle screw fixation

Introduction

Lumbar degenerative diseases (LDDs) inflict a substantial burden on healthcare systems worldwide. According to a survey released by the Centers for Disease Control in 2012, there were nearly 350 000 hospital admissions for patients suffering from low back pain in 2010.¹

Current treatment modalities primarily revolve around conservative and surgical treatments for treating lumbar degenerative diseases. Lumbar interbody fusion (LIF) stands as the foremost treatment option for a wide range of LDDs, not only offering immediate pain relief but also enhancing the quality of life by inducing lumbar lordosis and alleviating neural compression.²

Among the various surgical techniques, posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) are two common techniques widely employed. However, while TLIF shows a high intervertebral fusion rate, it comes with the potential for spinal canal damage, nerve root injury, and tension band complications.³ In contrast, oblique lumbar interbody fusion (OLIF), a relatively minimally invasive approach for spinal fusion through psoas muscle and the abdominal aorta space,⁴ prevents posterior structure destruction, postoperative pain, and lumbar muscle fatigue with no damage to the proximal nerve trunk of the lumbar muscles.⁵ According to reports, OLIF surgery not only has a quick recovery time and little intraoperative blood loss but also demonstrates a low incidence of complications and reduced cost.⁶ The inclusion of posterior fixation in OLIF significantly enhances interbody fusion stability, minimizing the likelihood of surgical complications like fusion device settling and displacement, thereby reducing revision rates.⁷ Furthermore, OLIF with posterior fixation preserves the immediate indirect decompression effect of cage insertion, augments segmental stability, and diminishes the prospect of cage subsidence.^7,8

When addressing single-segment lumbar degenerative disease, studies comparing OLIF with anterolateral screw fixation (OLIF-AF) and OLIF with posterior pedicle fixation (OLIF-PF) demonstrated similar outcomes in terms of Oswestry Disability Index (ODI) score, imaging findings, and complication rates as OLIF-PF.⁹ Yet, according to recent research,^9–11 the OLIF and OLIF-AF groups performed better than the OLIF-PF group in terms of shorter operation times and less intraoperative blood loss.

We chose to conduct a systematic review and meta-analysis comparing the surgical and clinical outcomes of OLIF with anterior screw fixation and OLIF with posterior pedicle fixation, as OLIF-AF is a relatively new technique and the first recorded study we could find in 2020.¹²

Methods

Protocol registration

The protocol of the present review was registered and allocated the identification number CRD42024496478 in the PROSPERO database, hosted by the National Institute for Health Research, University of York, Center for Reviews and Dissemination.

Search strategy

Search databases, such as PubMed, Cochrane CENTRAL, ScienceDirect, and Google Scholar, were searched from inception to July 2023 for all articles according to the search strategy. The key terms ‘oblique interbody fusion,’ ‘OLIF,’ ‘OLIF with anterolateral screw fixation,' ‘OLIF with percutaneous pedicle fixation,’ ‘lumbar degenerative disease,’ and ‘spondylolisthesis’ were combined with the Boolean operators ‘AND,’ ‘NOT,’ and ‘OR’ to search relevant literature in all databases. The literature did not adhere to any specified limits regarding sample size, language, or age of participants. The detailed search strategy including full electronic search strategy for all databases is given in the supplementary file.

Data extraction

The reviewers independently screened the titles, abstracts, and, if necessary, the full texts of the obtained articles to ensure that both inclusion and exclusion criteria were met. A data extraction sheet was formulated to summarize details, facilitating the final comparisons between both surgical methods. This sheet included information regarding the authors, number of patients, ODI, VAS score, subsidence assessment, radiological outcomes, perioperative outcomes, complications, and follow-up time of the included studies. Any disagreements were resolved through discussion with all authors.

Inclusion and exclusion criteria

Retrospective cohorts and a case control study were included if the following criteria were met: (1) anterolateral and percutaneous pedicle screw fixation procedures were compared; (2) adequate clinical and radiographic outcomes were collected (including at least one of the following: length of hospital stay, operative time, intraoperative blood loss, visual analog scale (VAS), and Oswestry disability index (ODI), fusion rate, subsidence, complications, disc height, disc angle, and lumbar lordosis); and (3) subjects were diagnosed with lumbar degenerative disc disease, spondylolisthesis; (4) a followup duration of at least 12 months was reported; (5) studies were published in English or Chinese full-text.

The exclusion criteria were: (1) combined anterior and posterior surgery; (2) lumbar tumors; (3) conditions such as lumbar trauma, infection, or metabolic disease; (4) previous lumbar surgery; and (5) an average follow-up time of <6 months (6) incomplete medical records; (7) reviews, case reports, letters, and conference papers, etc.

Quality assessment

Two independent authors evaluated the methodological quality of the included studies using the NOS (Newcastle Ottawa Scale). The primary domains of NOS included the selection of patients, comparability, and assessment of results. With the exception of comparability, which could attain a maximum of two points, the remaining criteria were given one point each, resulting in a score range of 0 to nine points. A higher total score indicated higher study quality. A score of <6 was considered to be of lower quality, whereas a score of >6 was considered to be of high quality and was subsequently included in our meta-analysis.

Data synthesis

The information gathered was pooled together for a meta-analysis using Review Manager (RevMan) Version 5.4, with two authors (L.F. and R.F.) carrying out this process. Forest plots were generated to assess both binary and continuous data, along with 95% confidence intervals (CI). Any p-value below 0.05 was deemed statistically significant. In order to account for variations in intervention effects across different studies, Der-Simonian and Laird random-effects meta-analyses were employed for all outcomes, which helped in addressing the heterogeneity observed among the studies. We assessed statistical heterogeneity using Higgins I2 statistics, categorizing it as mild (25%-50%), moderate (50%-75%), or severe (>75%).

Results

Search results

In total, 2221 records were searched using PubMed, Google Scholar, and the Cochrane Central Register of Controlled Trials. After screening titles and abstracts, 124 manuscripts were identified as being eligible for our analysis. Full articles were retrieved. Ultimately, five studies^13–17 met the predefined inclusion criteria and were included in our systematic review and meta-analysis. A flowchart of the retrieval process is shown in Figure 1.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram for identification of studies included in the meta-analysis.

Study and patient characteristics

The detailed baseline characteristics of the included studies are presented in Table 1. All studies included are retrospective cohorts or retrospective case studies. The years of publication ranged from 2022 to 2023. They have all been conducted in China. The sample size ranges from 25 to 71, making up a total of 271 patients for our analysis (96 in the anterior fixation group and 125 in the posterior fixation group).

Table 1.

Characteristics and design of the included studies.

Study		Guo et al., 2022	Wu et al., 2022	Zhang X et al., 2023	Zhang X et al., 2022	Zhang XY et al., 2023
Study design		Retrospective	Retrospective	Retrospective	Retrospective	Retrospective
Location		China	Taiwan	China	China	China
Sample size (n)	Total	51	25	71	53	71
	OLIF-AF	24	9	19	25	19
	OLIF-PF	27	16	27	28	27
Follow-up		1 week, 3 months, 1 year	1 week, 3 months, 6 months, 1 year	1 year, 2 years, >3 years	1 week, 3 months, 1 year, 2 years	1 week, 1 year
Male (%) I/C		45.8/44.4	22.2/31.3	5.3/55.6	48/68	NA
Age (mean) I/C		57.2/59.7	67.8/68.3	66.9/62.8	43.3/47.4	NA
Mean BMI (kg/m2) I/C		22.7/24.1	NA	NA	28.4/26.7	24.9/24.7
Smoker (%) I/C		NA	NA	5/22	NA	NA
Diabetes (%) I/C		NA	33.3/12.5	10.5/18.5	NA	NA
Osteoporosis (%) I/C		NA	33.3/43.7	NA	NA	NA
Chronic Kidney disease (%) I/C		NA	11.1/0.0	NA	NA	NA
Hyperlipidemia (%) I/C		NA	44.4/12.5	NA	NA	NA
Hypertension (%) I/C		NA	33.3/50.0	NA	NA	NA
Method of fusion assessment		computed tomography (CT)	CT	CT	CT	CT
Criteria for clinical fusion		Bridwell interbody fusion scoring system	Bridwell interbody fusion scoring system	NA	NA	NA
Cage used		NA	NA	NA	Clydesdale spinal system, Medtronic, Memphis, TN,USA) 12 mm in height, 50 mm in length and 18 mm in width, classed as 6° lordotic, made of polyether ether ketone and 3.27 cc graft volume was inserted and filled with demineralized allogeneic bone matrix
Outcomes reported		Total fusion rate Operative time intraoperative blood loss Hospitalization Cage subsidence Follow-up VAS of low back follow up-ODI% Follow-up- anterior disc height Follow-up-PDH Follow-up-foraminal height	Levels fused Total fusion rate Operative time Intraoperative blood loss Hospitalization days Cage Subsidence Post lumbar lordosis (degree) Post- anterior disc height (cm) Follow-up- anterior disc height (cm) Post-PDH (cm) Follow-up-PDH (cm) Post-foraminal height (cm) Follow-up-foraminal height (cm)	Delta VAS of low bac Total fusion rate Operative time (min) Intraoperative blood loss Hospitalization (day) Revision cage-associated infection Cage migration Cage Subsidence Pedicle screw breakage Post-VAS of low back Follow-up VAS of low back Post-VAS of leg Follow-up VAS of leg Delta VAS of leg Post-ODI (%) follow up-ODI (%) Post lumbar lordosis (degree) Follow up lumbar lordosis (degree) Post- anterior disc height (cm) Follow-up- anterior disc height (cm) Post-PDH (cm) Follow-up-PDH (cm) Follow-up-foraminal height (cm) Post-CSAF (cm2)	Post-VAS of low back Follow-up VAS of low back Post-ODI (%) follow up-ODI (%) Post lumbar lordosis (degree) Follow up lumbar lordosis (degree) Post-foraminal height (cm) Follow-up-foraminal height (cm) Post surgery intervertebral space height Follow up intervertebral space height	Total fusion rate operational time Intraoperative blood loss Hospitalization (day) Cage Subsidence Post-VAS of low back Follow-up VAS of low back Post-ODI (%) follow up-ODI (%)

Risk of bias and publication bias assessment

The quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS) (Supplementary Appendix, Figure 1).

A total of 11 outcomes were reported in our final analysis. The forest plots of meta-analysis are given in the Figure 2 [2.1-2.17].

Figure 2.

Individual and pooled analyses demonstrate the efficacy of OLIF-AF compared to OLIF-PF. The risk ratio (RR) and the 95% confidence intervals (CI) are depicted using a logarithmic scale, with the box size scaling in accordance with the sample size. The diamond symbolizes the combined or overall effect.

Primary outcome

Four of the five studies reported a total fusion rate following OLIF surgery.^13,14,16,17 However, the analysis revealed no significant difference between the groups (87.66% vs 94.29%; RR: 0.93; 95% CI: 0.85–1.03; p = 0.15; I2 = 0%). No heterogeneity was detected.

Secondary outcomes

Intraoperative blood loss, reported as an outcome by three studies, was significantly lower in the OLIF-AF group as compared to the OLIF-PF group (SMD, −23.40; 95% CI: −26.73–-20.06; p = 0.00,001; I2-96%). Three studies reported the operative time, which was significantly lower in the OLIF-AF group (SMD, −73.42; 95% CI: −85.10--61.73; p = 0.00,001; I2 = 0%). There was no significant difference in hospitalization between both groups (SMD, −0.28; 95% CI: −1.03 - 0.48; p = 0.47; I2 = 27%). Similarly, cage subsidence between the OLIF-AF and OLIF-PF groups revealed no statistically significant results. However, the OLIF-PF group exhibited slightly lower rates of subsidence than the OLIF-AF group (39.70% vs 29.67%; RR: 1.36; 95% CI: 0.89–2.08; p = 0.15; I2 = 0%).

Visual analogue scale (VAS)

No significant difference was observed for post-operative VAS (SMD, 0.00; 95% CI: −1.27–1.28; p = 0.01; I2 = 99%). The follow-up VAS of the lower back, reported by four studies, showed improvement, although not significant, in the OLIF-AF group (SMD, −6.33; 95% CI: −20.33–7.68; p = 0.38; I2 = 100%).

Oswestry disability index (ODI)

The post-operative ODI difference, reported by three studies, between the two groups was also insignificant (SMD, 1.27; 95% CI: −1.31 - 3.84; p = 0.33; I2- 77%). Similarly, the follow up ODI reported by four studies was also not significantly different between the experimental and control groups (SMD, −1.15; 95% CI: −4.63 - 2.33; p = 0.52; I2- 96%).

Lumbar lordosis (LL)

Three studies reported the post-operative (SMD, −0.44; 95% CI: −3.37 - 2.48; p = 0.77; I2- 0%) and follow up lumbar lordosis data (SMD, 1.08; 95% CI: −1.31 - 3.47; p = 0.38; I2- 0%). There was no significant difference between the OLIF-AF and OLIF-PF groups for either of these outcomes.

Anterior disc height (ADH)

While post-operative ADH was reported by two studies with no significant difference (SMD, −0.04; 95% CI: −0.16 - 0.08; p = 0.53; I2- 0%), follow up ADH was reported by three studies, also with no significant difference. (SMD, −0.09; 95% CI: −0.23 - 0.05; p = 0.20; I2- 0%).

Posterior disc height (PDH)

Two studies reported post-operative PDH with an insignificant difference (SMD, −0.11; 95% CI: −0.22 - 0.00; p = 0.04; I2- 0%). The three studies reporting follow up PDH also had insignificant results (SMD, −0.29; 95% CI: −0.84 - 0.27; p = 0.31; I2- 43%).

Foraminal height (FH)

The three studies reporting postoperative FH also found no significant differences (SMD, 0.25; 95% CI: −0.55 - 1.05; p = 0.54; I2- 54%). Lastly, the reported follow up FH had no significant difference either (SMD, −0.32; 95% CI: −0.95 - 0.30; p = 0.31; I2- 39%).

Discussion

To the best of our knowledge, this is the first meta-analysis to compare the efficacy of OLIF-AF versus OLIF-PF in patients undergoing spinal surgery for lumbar degenerative diseases. This study highlights the non-inferiority of OLIF-PF to OLIF-AF in terms of intraoperative blood loss and operative time required.

The OLIF technology has attracted attention from surgeons due to its advantages in reducing trauma, improving safety, and restoring lumbar lordosis. OLIF-PF is widely used and can reconstruct spinal stability, restore the normal spinal sequence, and improve intervertebral fusion rates.¹⁸ However, the combined procedure requires an intraoperative change of patient position, significantly increasing the operative time and amount of intraoperative bleeding.¹⁹ To reduce these problems, OLIF-AF has been proposed instead for treating lumbar degenerative diseases. Because the cage used in OLIF is larger and spans the bilateral epiphyseal ring, the stability of the fixation interface is significantly enhanced, so that the effective fixation strength can be achieved with lateral screw-assisted fixation of the vertebral body.^20,21

The primary outcome of the total fusion rate following OLIF surgery reveals a comparable fusion success rate between OLIF-AF and OLIF-PF. However, further research is warranted to explore the potential long-term impacts of this similarity in fusion rates and its implications for patient outcomes. Understanding the subtle nuances that contribute to fusion dynamics could pave the way for personalized surgical approaches in the future.

Regarding secondary outcomes, intraoperative parameters presented distinct differences between OLIF-AF and OLIF-PF, notably lower blood loss and reduced operative time in the OLIF-AF group, pointing to a potential advantage of anterior screw fixation in minimizing operative blood loss and reducing surgical time. Although OLIF is superior to TLIF in terms of intraoperative blood loss and operative time,²¹ OLIF-AF has shown more promising results when compared to OLIF-PF, which can be attributed to several factors. The anterolateral approach in OLIF allows a more direct pathway to the disc space through the abdominal retroperitoneal region, potentially reducing extensive muscle dissection and blood vessel manipulation, leading to minimized blood loss. Simultaneously, the anterior method might involve fewer complex steps, contributing to the shorter operative duration. This approach could result in reduced disturbance to surrounding muscles, leading to decreased bleeding and faster closure, as well as less soft tissue trauma and minimal injury to ligaments and bony structures.⁵ However, these inferences are speculative and require further detailed investigation through prospective studies or biomechanical analyses to precisely ascertain the causative elements behind the observed differences in surgical outcomes.

Subsidence during the follow-up, as reported by four of the included studies, revealed a slightly lower rate in the OLIF-PF group compared to the OLIF-AF group. Zhang, Guo, and Zhang et al. reported that OLIF PF was superior to OLIF-AF in avoiding cage subsidence, but the study by Wu MT et al. showed that OLIF- AF result in a lower incidence of subsidence.¹⁶ This implies that posterior fixation may have an edge in reducing cage subsidence over the anterior screw fixation. Higher rates of incidence of cage subsidence are associated with both OLIF-SA and OLIF-LF as compared to OLIF-PF. For patients with osteoporosis and obesity, OLIF PF in contrast to OLIF-SA emerges as a preferable choice, exhibiting greater efficacy in reducing the cage subsidence, enhancing the early fusion rate and alleviating patient pain in a short term. However, factors such as significant intraoperative blood loss and cost of the procedure, may necessitate consideration of OLIF-AF and OLIF-SA surgical methods, nevertheless additional investigation is necessary to validate these findings. These studies collectively suggest that while OLIF-PF might offer better structural support in terms of disc height and foraminal height, OLIF-AF has advantages in surgical efficiency and reduced complications, with no significant difference in long-term stability.

Minor findings, including hospitalization duration, cage subsidence, and patient-reported outcomes such as Visual Analogue Scale, Oswestry Disability Index, lumbar lordosis, and disc and foraminal heights, displayed no statistically significant differences between the two fixation groups. The studies reviewed indicate that both OLIF-AF and OLIF-PF are effective methods for treating degenerative lumbar diseases, but they exhibit different profiles in terms of surgical outcomes and early clinical benefits. Wang et al. (2022) found that OLIF stand-alone has advantages in terms of shorter surgery duration, less blood loss, and reduced muscle damage compared to OLIF-PF, though long-term outcomes were similar between the groups. Wu et al. (2022) reported that single-stage OLIF with anterior screw fixation resulted in shorter operation times, reduced hospital stays, and fewer complications compared to two-stage OLIF-PF. Another study found no significant difference in VAS and ODI scores at long-term follow-up between OLIF-AF and OLIF-PF, but OLIF-SA was favored for lower intraoperative blood loss and shorter surgical times (Zhang et al., 2023). Lastly, Wu et al. (2023) highlighted that while OLIF and TLIF showed similar clinical outcomes, OLIF had advantages in terms of less blood loss and better early postoperative disc height restoration. It is important to note that multi-segment fusion stability, such as reported by Zhang et al. (2023) and Wu et al. (2022) might prove to be more significant.

While trends towards improvement were observed in the OLIF-AF group, the lack of statistical significance warrants further exploration to comprehend the clinical relevance of these trends.

To further illuminate the outcomes and address gaps in the existing literature, future research might consider a larger sample size, encompassing diverse patient populations. Long-term prospective studies examining patient-reported outcomes, functional recovery, and complications could shed light on the clinical significance of the observed trends. Additionally, detailed investigations into the biomechanical aspects and their implications on post-operative recovery might provide a more comprehensive understanding of the differences between OLIF-AF and OLIF-PF.

Limitations

It is important to acknowledge the limitations of this study. First, the sample size of the included studies may have affected the statistical power of the analysis. Second, almost all the studies were carried out in a single geographical region and centers that is China, which may restrict the generalizability of the findings to broader and more diverse patient populations. Thus, differences in patient demographics, underlying spinal etiologies, and comorbidities may have influenced outcomes. Third, the inclusion of observational studies with short follow-up durations in this meta-analysis may have contributed to heterogeneity in the results. Although the risk of bias was assessed using an appropriate statistical methodology, observational studies inherently carry a higher risk of bias than controlled randomized trials. Finally, a few of our outcomes reported high heterogeneity, thus limiting their real-world clinical significance.

A comparison between OLIF-AF and OLIF-PF is essential to understanding the potential advantages and limitations of each OLIF technique. Long-term follow-up and assessment of clinical outcomes, including fusion rates and hospitalization data, would provide more comprehensive insights into the overall effectiveness of these methods for spinal surgery.

Conclusion

In summary, our meta-analysis comparing OLIF-AF and OLIF-PF for lumbar degenerative diseases revealed similar fusion rates. OLIF-AF demonstrated advantages in intraoperative parameters, but patient-reported outcomes did not significantly differ between the techniques. While OLIF-AF shows promise, larger, more diverse studies are needed to confirm these findings and better understand their clinical impact.

Supplemental Material

Supplemental Material - Comparative effectiveness of oblique lumbar interbody fusion with anterior screw fixation versus percutaneous pedicle screw fixation for treating lumbar degenerative diseases: A systematic review and meta-analysis

Supplemental Material for Comparative effectiveness of oblique lumbar interbody fusion with anterior screw fixation versus percutaneous pedicle screw fixation for treating lumbar degenerative diseases: A systematic review and meta-analysis by Laveeza Fatima, Sameer S Tebha, Rabeya Farid, Aemen Kamran, Sravan KR Edamakanti and Mohammad F Farrukh in Journal of Orthopaedic Surgery

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Aemen Kamran

Supplemental Material

Supplemental material for this article is available online.

Appendix

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