The recent study [1] entitled “Simultaneous Single-Position Lateral Lumbar Interbody Fusion Surgery and Unilateral Percutaneous Pedicle Screw Fixation for Spondylolisthesis” is worth interest in many aspects. This study is the first to compare “lateral lumbar interbody fusion (LLIF)+unilateral minimally invasive (MIS) screws” versus “MIS-transforaminal lumbar interbody fusion (TLIF)” in a single institution experience. In addition, the presentation of surgical methodology is excellent. I appreciate the authors’ efforts and their recommendations.
Since their introduction, interbody fusion techniques gained popularity and are now regarded as the first choice for several indications such as spondylolisthesis, degenerative pathologies, trauma and infection. The technique evolving rapidly, recent studies feature robotic approaches [2]. Reviews and meta-analyses prove that TLIF, posterior lumbar interbody fusion, anterior lumbar interbody fusion MI-TLIF, oblique lumbar interbody fusion/anterior to psoas, and LLIF are all effective with comparable outcomes [3,4]. Yet, the diversity of techniques and nuances inhibits access to unbiased data and higher levels of evidence. Studies that focus on a single variable such as “adjacent segment disease” or “fusion rate” promise clearer insight on selection of interbody technique [5].
As discussed well in the paper, the foremost benefits of LLIF are the utility of larger interbody cages compared to posterior approach and the ease of end plate preparation. This certainly contributes to the favorable fusion rates and better disc height. In comparison, MIS-TLIF procedure yields limited vision of the endplate and curettage is more challenging. For LLIF, the authors encourage addition of unilateral posterior pedicle screws to prevent cage migration and improve biomechanics. This provides a 3-quarter stabilization if not a full 360°. Thanks to these factors, a 92% of fusion at 12 months is achieved. The untouched contralateral facet can be a weak spot in the case of spondylolisthesis (an interest for biomechanical testing). One typical downside for lateral approach is the shortage of autograft harvest. The authors suggested allografts enriched with bone marrow to achieve better fusion.
Considering the very low rate of complications and the short operative duration, we can estimate the surgeon(s) is highly experienced in LLIF-lateral single screw-rod and unilateral percutaneous pedicle screw fixation (LSUP) approach. To prevent positive bias, specific complications have to be reminded. These include sympathectomy, vascular damage, ureteral injury [6]. The local anatomy has to be carefully examined before surgery. On the other hand, obvious advantages of lateral approach include protection of posterior lumbar muscles and facet joints, spared dural sac and nerve roots, direct visualization of disc space. These factors favor selection of the LLIF approach.
We do not have the chance to compare the results of the study, due to the lack of similar reports. One study has strong resemblance though. Koike et al. [7] compared oblique lateral interbody fusion with percutaneous posterior fixation in lateral position (OLIF-LPF) and MIS-TLIF for single-level degenerative spondylolisthesis. In a total of 92 cases, OLIF-LPF group proved superior to MIS-TLIF with lesser surgical duration and better disc height at follow-up.
In conclusion, this article provides valuable insight despite its limitations. The promising LLIF-LSUP technique needs further evaluation with larger cohorts and prospective trials. Long-term outcomes, effect on adjacent segment disease and the indication criteria must be validated.
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