Abstract
Objective
This study aimed to evaluate the clinical efficacy of oblique lumbar interbody fusion (OLIF) combined with unilateral pedicle screw fixation (OLIF-UPS) performed in a single lateral position for degenerative lumbar diseases.
Methods
Clinical data of patients who underwent OLIF-UPS in a single lateral position were collected retrospectively. During the same period, patients who received OLIF combined with bilateral pedicle screw fixation (OLIF-BPS) requiring intraoperative position change were enrolled as the control group. Perioperative parameters, Visual Analogue Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified MacNab criteria were recorded to assess clinical outcomes. Radiographic parameters, including disc height (DH), lumbar lordosis (LL), cage subsidence rate, and interbody fusion rate, were compared between the two groups.
Results
The operative time in the OLIF-UPS group was significantly shorter than that in the OLIF-BPS group (p <0.001), whereas no significant differences were observed in intraoperative blood loss or postoperative hospital stay between the two groups (p >0.05). Postoperatively, VAS scores for back and leg pain and ODI scores were significantly improved in both groups compared with preoperative values (p <0.001), with a further improvement noted at 1 year postoperatively compared with 1 month postoperatively. Postoperative DH and LL were significantly increased in both groups relative to preoperative measurements (p <0.001). A slight reduction in DH and LL was observed at 1 year postoperatively compared with the immediate postoperative period, but this difference was not statistically significant (p >0.05). The interbody fusion rate was 92.2% in the OLIF-UPS group and 93.5% in the OLIF-BPS group. Both groups achieved favorable functional recovery and high patient satisfaction.
Conclusion
In patients with normal to near-normal bone density (T-score > -2.5), Grade I or no spondylolisthesis, no segmental instability, and BMI <30 kg/m2, single-position OLIF-UPS achieves short-term outcomes comparable to OLIF-BPS while significantly reducing operative time. Given the relatively short follow-up period, further long-term observation is warranted to verify its long-term clinical efficacy.
Keywords: Lumbar degenerative disease, Oblique lumbar interbody fusion, Unilateral pedicle screw fixation, Single lateral position, Clinical efficacy
Introduction
Oblique lumbar interbody fusion (OLIF) is performed retroperitoneally through an intermuscular approach, utilizing the natural space between the psoas major muscle and abdominal great vessels to establish an operative channel for lateral vertebral discectomy and interbody fusion [1]. Compared with traditional posterior lumbar interbody fusion, OLIF does not enter the spinal canal, avoiding bone structure destruction and nerve irritation. Implantation of a large-sized cage can achieve indirect decompression, improving spinal stability and interbody fusion rate [2, 3]; compared with anterior approaches, it causes less interference to abdominal great vessels and significantly reduces the risk of vascular injury [4], and has therefore gained rapid clinical adoption [5–7].
OLIF is often supplemented with fixation to enhance spinal stability, disperse cage stress, and thereby reduce the risk of cage subsidence [8–10]. Among them, the clinical effect of combining with posterior pedicle screw fixation has been verified [8, 11, 12], but this procedure requires changing to the prone position intraoperatively for screw placement, which increases the operative and anesthetic time and carries the risk of endotracheal tube displacement [13].
Some scholars have proposed that completing OLIF and posterior pedicle screw fixation in a single lateral position can improve surgical efficiency with good clinical efficacy [14–16], but screw placement on the side close to the operating table in the lateral position is technically challenging, and there is still a screw revision rate even with navigation assistance [8]. Previous studies have shown that the clinical effects of unilateral and bilateral pedicle screw fixation in interbody fusion are similar [17, 18]. Based on this, we chose single lateral position OLIF combined with unilateral pedicle screw fixation (OLIF-UPS) to improve surgical efficiency and optimize the operative workflow. Currently, there are few relevant reports on this procedure, and the sample size of existing studies is limited. Therefore, this study aims to evaluate the clinical efficacy and imaging results of single lateral position OLIF-UPS in the treatment of degenerative lumbar diseases.
Materials and methods
Patient selection
This retrospective study was approved by the Ethics Committee of the First People's Hospital of Yunnan Province. We reviewed the clinical data of patients with degenerative lumbar diseases who underwent either single-position OLIF-UPS or position-change OLIF combined with bilateral pedicle screw fixation (OLIF-BPS) between April 2021 and March 2024. All surgeries were performed by the same spinal surgery team.
Inclusion criteria were as follows: (1) diagnosis of lumbar spondylolisthesis, spinal stenosis, or lumbar disc herniation with failure of at least 3 months of conservative treatment, necessitating surgical intervention; (2) age ≥ 18 years with single- or double-level involvement; (3) BMD T-score > −3.0 as measured by dual-energy X-ray absorptiometry; (4) follow-up duration ≥ 12 months with complete clinical data.
Exclusion criteria were: (1) severe spinal stenosis, lumbar disc herniation requiring nerve root exploration, or lumbar spondylolisthesis greater than Grade II; (2) BMD T-score ≤ −3.0; (3) BMI < 18.5 kg/m2 or ≥ 30.0 kg/m2; (4) lumbar fracture, infection, tumor, or previous abdominal or lumbar surgery.
Indications for OLIF-UPS versus OLIF-BPS
The choice between OLIF-UPS and OLIF-BPS followed a standardized institutional protocol based on preoperative parameters.
Indications for OLIF-UPS – All of the following criteria must be met: (1) BMD T-score > −2.5; (2) Meyerding Grade I spondylolisthesis (or no spondylolisthesis); (3) No segmental instability on preoperative flexion-extension radiographs (translation < 3 mm AND angular motion < 10°); (4) BMI < 30 kg/m2 (as per the exclusion criteria).
For patients meeting all of the above criteria, either unilateral or bilateral fixation was feasible. OLIF-UPS was generally preferred to reduce operative time and avoid intraoperative repositioning, but bilateral fixation remained an acceptable alternative at the surgeon’s discretion.
Indications for OLIF-BPS – The following situations mandated or allowed bilateral fixation: (1) Mandatory (OLIF-BPS required): −3.0 < BMD T-score ≤ −2.5, or Grade II spondylolisthesis, or segmental instability (translation ≥ 3 mm or angular motion ≥ 10°); (2) Optional (surgeon’s choice): The patient meets all OLIF-UPS criteria, but the surgeon opts for bilateral fixation based on personal or other clinical considerations.
Based on the above criteria, a total of 208 patients were included, comprising 115 in the OLIF-UPS group and 93 in the OLIF-BPS group (Figure 1). No significant differences in baseline characteristics were observed between the two groups (all P > 0.05, Table 1).
Fig. 1 .
Flowchart of patient selection and surgical decision-making
Table 1.
General characteristics of patients
| Characteristic | OLIF-UPS (n=115) | OLIF-BPS (n=93) | P |
|---|---|---|---|
| Age | 60.2 ± 10.2 | 58.3 ± 9.1 | 0.153 |
| Gender | |||
| Male | 49 | 41 | 0.831 |
| Female | 66 | 52 | |
| BMI | 24.9 ± 4.1 | 25.2 ± 3.9 | 0.593 |
| BMD | −1.4 ± 0.9 | −1.6 ± 1.0 | 0.162 |
| Hypertension | |||
| Yes | 29 | 25 | 0.785 |
| No | 86 | 68 | |
| Diabetes | |||
| Yes | 16 | 14 | 0.816 |
| No | 99 | 79 | |
| Preoperative diagnosis | |||
| Lumbar spinal stenosis | 57 | 44 | 0.933 |
| Degenerative spondylolisthesis | 33 | 27 | |
| Lumbar disc herniation | 25 | 22 | |
| Number of levels | |||
| 1 | 84 | 70 | 0.716 |
| 2 | 31 | 23 | |
Data collection and evaluation
Data collected included demographic characteristics and perioperative parameters (blood loss, operative time, length of postoperative hospital stay, and complications) for both groups. Low back pain and leg pain were evaluated using the Visual Analogue Scale (VAS), while lumbar function was assessed with the Oswestry Disability Index (ODI). Patient satisfaction was measured at the 1-year follow-up using the modified MacNab criteria [19]. Radiological outcomes included disc height (DH), lumbar lordosis (LL), cage subsidence, and interbody fusion status. DH, LL, and cage subsidence were assessed using lateral lumbar radiographs [20]. Interbody fusion was evaluated by computed tomography (CT) and graded according to the Bridwell classification system [21]; grades I and II were defined as successful fusion, while grades III and IV were considered nonunion.
Operative techniques
All patients underwent general anesthesia with a left-sided approach. For the OLIF-UPS group, C-arm fluoroscopy was used to localize and mark the target segments; disinfection covered the OLIF field and posterior pedicle screw area. A left anterolateral retroperitoneal approach was used to expose the target intervertebral space, followed by guide pin insertion, dilating sleeve placement, disc resection, endplate preparation, and implantation of a Peek Cage (Zhejiang Kehui Medical Devices Co., Ltd., China) prefilled with hydroxyapatite artificial bone (Allgens Medical Science & Technology Co., Ltd., China). Without repositioning, the surgeon inserted pedicle screws via a left paravertebral muscle incision (Figure 2). For the OLIF-BPS group, OLIF was performed in lateral decubitus position, followed by repositioning to the prone position, re-disinfection, and bilateral manual pedicle screw insertion via Wiltse approach. No drainage tubes were used in either group.
Fig. 2.
After completing the OLIF procedure, the patient’s position was maintained and the operating table was elevated. Pedicle screws were inserted via the left intermuscular space approach
Statistical analysis
Statistical analyses were performed using SPSS 24.0 software (SPSS Inc., Chicago, IL, USA). Continuous variables, including age, operative time, estimated blood loss, postoperative hospital stay, VAS scores, ODI scores, DH, and LL, were assessed for normality. Normally distributed data are presented as mean ± standard deviation. Intragroup comparisons across time points were performed using repeated-measures analysis of variance (ANOVA), with Bonferroni correction for post hoc multiple comparisons. Between-group comparisons were analyzed using the independent-samples t-test. Categorical variables, such as gender, surgical segments, and preoperative diagnosis, were presented as n (%) and compared using the chi-square test. A two-sided P < 0.05 was considered statistically significant.
Results
Compared with the OLIF-BPS group, the operation time of the OLIF-UPS group was significantly shorter (84.4 ± 14.4 min vs. 159.5 ± 30.0 min, p <0.001; Table 2). However, there were no significant differences in intraoperative blood loss (79.5 ± 23.1 ml vs. 83.3 ± 35.2 ml) and postoperative hospital stay (2.7 ± 1.0 d vs. 2.7 ± 1.3 d) between the two groups (all p > 0.05; Table 2).
Table 2.
Comparison of perioperative condition between two groups
| Variable | OLIF-UPS (n=115) | OLIF-BPS (n=93) | P |
|---|---|---|---|
| Operative time (min) | 84.4 ± 14.4 | 159.5 ± 30.0 | < 0.001* |
| Blood loss (ml) | 79.5 ± 23.1 | 83.3 ± 35.2 | 0.381 |
| Postoperative stay (d) | 2.7 ± 1.0 | 2.7 ± 1.3 | 0.473 |
* indicates highly significant (p < 0.001)
Both groups showed significant improvements in back VAS, leg VAS, and ODI scores postoperatively (all p < 0.001; Table 3). In the OLIF-UPS group, further improvements were noted at 1 year compared with 1 month after surgery, with leg VAS and ODI showing significant differences (all p < 0.05; Table 3). The OLIF-BPS group also exhibited improvements in back VAS, leg VAS, and ODI at 1 year, with ODI showing a statistically significant difference (p < 0.001; Table 3). There were no significant between-group differences in VAS or ODI at any time point (all p > 0.05; Table 3). Based on the modified MacNab criteria, both groups achieved favorable functional recovery and high patient satisfaction at 1 year postoperatively (p > 0.05; Table 3).
Table 3.
Comparison of clinical results between two groups
| Variable | OLIF-UPS (n=115) | OLIF-BPS (n=93) | P |
|---|---|---|---|
| Low back pain VAS | |||
| Preoperatively | 6.1 ± 1.8 | 6.3 ± 1.7 | 0.633 |
| 1 month postoperatively | 2.3 ± 1.7 | 2.2 ± 1.7 | 0.644 |
| 1 year postoperatively | 1.8 ± 1.3 | 1.9 ± 1.1 | 0.824 |
| Leg pain VAS | |||
| Preoperatively | 6.2 ± 1.6 | 6.1 ± 1.9 | 0.916 |
| 1 month postoperatively | 2.3 ± 1.4 | 2.1 ± 1.6 | 0.463 |
| 1 year postoperatively | 1.7 ± 1.2# | 1.8 ± 1.3 | 0.515 |
| ODI | |||
| Preoperatively | 59.3 ± 9.4 | 61.7 ± 9.9 | 0.088 |
| 1 month postoperatively | 30.0 ± 12.8 | 32.9 ± 10.8 | 0.087 |
| 1 year postoperatively | 16.0 ± 6.0# | 15.7 ± 6.4# | 0.696 |
| Modified MacNab Criteria | |||
| Excellent | 82 | 65 | 0.924 |
| Good | 26 | 23 | |
| Fair | 7 | 5 | |
| Poor | 0 | 0 | |
# indicates a significant difference vs. 1 month postoperatively
Both groups showed significant improvements in DH and LL after surgery (all p < 0.001; Table 4). Mild losses of DH and LL were observed at 1 year compared with immediate postoperative values, but the differences were not statistically significant (all p > 0.05; Table 4). No significant between-group differences in DH or LL were detected at any time point (all p > 0.05; Table 4). According to the Bridwell classification, 9 cases in the OLIF-UPS group and 6 cases in the OLIF-BPS group were rated as grade III (uncertain fusion), characterized by bone rarefaction within the cage and radiolucent lines at the upper and lower interfaces. All other patients achieved grade I or II fusion. The fusion success rates were 92.2% and 93.5% in the two groups, respectively (p > 0.05; Table 4).
Table 4.
Comparison of imaging results between two groups
| Variable | OLIF-UPS (n=115) | OLIF-BPS (n=93) | P |
|---|---|---|---|
| Disc height (mm) | |||
| Preoperatively | 7.1 ± 3.2 | 6.9 ± 2.9 | 0.726 |
| Immediately postoperatively | 12.3 ± 2.0 | 12.1 ± 2.1 | 0.451 |
| 1 year postoperatively | 11.7 ± 2.0 | 11.4 ± 2.1 | 0.361 |
| Lumbar lordosis (°) | |||
| Preoperatively | 35.1 ± 6.0 | 34.2 ± 5.5 | 0.282 |
| Immediately postoperatively | 44.1 ± 6.8 | 42.7 ± 5.1 | 0.101 |
| 1 year postoperatively | 42.5 ± 5.8 | 41.4 ± 5.4 | 0.130 |
| Cage subsidence rate, n (%) | 23.5 (27/115) | 20.4 (19/93) | 0.598 |
| Fusion rate, n (%) | 92.2 (106/115) | 93.5 (87/93) | 0.703 |
No major surgical complications occurred in either group. In the OLIF-UPS group, three patients (2.6%) sustained endplate injury and six (5.2%) had nerve injury, presenting as iliopsoas weakness (4 patients) or aggravated leg pain (2 patients). In the OLIF-BPS group, four patients (4.3%) sustained endplate injury and five (5.4%) had nerve injury, manifesting as iliopsoas weakness (2 patients) or aggravated leg pain (3 patients). All symptoms resolved within one week after symptomatic treatment. No surgical site infection or delayed wound healing was observed. During follow-up, no cage loosening or instrumentation failure was detected, and all patients exhibited significantly improved quality of life. A representative case is presented in Figure 3.
Fig. 3.
A 56-year-old female patient with lumbar spondylolisthesis treated with OLIF-UPS. A, B Preoperative DR demonstrates grade I anterolisthesis of the L4 vertebral body; C, D Preoperative MRI reveals spinal canal stenosis at the L4-5 level; E, F Follow-up DR on the third day postoperatively shows well-positioned cage and pedicle screws; G, H One-year postoperative follow-up DR indicates maintained screw positioning with mild cage subsidence; I-L One-year postoperative CT scans demonstrated mild cage subsidence with successful interbody fusion and no signs of instrumentation loosening
Discussion
In recent years, OLIF has gained widespread clinical adoption due to its advantages of minimal invasiveness and rapid recovery [5–7]. However, standalone OLIF is associated with risks of endplate fracture, cage subsidence, and uncertain stability [22, 23]. A retrospective analysis by Hu et al. of 119 patients who underwent standalone OLIF reported a cage subsidence rate as high as 40.3% [24]. A meta-analysis by Jiang et al. demonstrated that supplemental fixation significantly improved fusion rates and reduced cage subsidence and reoperation rates compared to standalone OLIF [25]. In the present study, both single-position OLIF-UPS and repositioning-required OLIF-BPS achieved high fusion rates and low subsidence. Patients in both groups exhibited significant symptomatic improvement and enhanced quality of life.
Clinically, approach-related complications such as nerve injury and endplate injury were observed in both groups. The incidence of nerve injury was 5.2% in the OLIF-UPS group and 5.4% in the OLIF-BPS group, both lower than the rates of 10.0% for unilateral and 13.95% for bilateral fixation reported by Wang et al [26]. Notably, all nerve injuries were transient and recovered early without permanent neurological deficit, and no immediate cage subsidence occurred in patients with intraoperative endplate injury. No significant intergroup differences were identified in intraoperative blood loss or postoperative hospital stay. Both groups achieved significant and comparable improvements in VAS and ODI scores postoperatively, with high patient satisfaction based on the modified MacNab criteria, suggesting equivalent clinical efficacy. Given that OLIF-UPS avoids intraoperative repositioning and yields significantly shorter operative and anesthesia times, it presents distinct clinical advantages.
Radiographically, both groups demonstrated significant postoperative improvements in DH and LL, which remained stable at 1-year follow-up with no intergroup differences, indicating that OLIF combined with unilateral or bilateral pedicle screw fixation can effectively maintain spinal stability. Restoration of intervertebral height helps enlarge the spinal canal and foraminal volume, a key mechanism of indirect decompression for relieving low back and leg pain and improving functional disability. Cage subsidence rates were 23.5% in the OLIF-UPS group and 20.4% in the OLIF-BPS group, mostly grade 0 without clinical symptoms, which may be associated with supplementary fixation. With uniform hydroxyapatite bone grafting, the synergistic effect of a stable mechanical environment and appropriate graft material improved fusion efficiency [27]. The cage subsidence rate was significantly lower than that reported for standalone OLIF [24] and consistent with OLIF plus posterior fixation [28]. Fusion rates were also comparable to those reported by Wang et al. [26] for unilateral (91%) and bilateral (93.03%) fixation. No cage migration or implant loosening was observed during follow-up.
The single-position OLIF-UPS technique offers distinct advantages and limitations. Its major strength is a significant reduction in operative and anesthesia time compared to OLIF-BPS, streamlining the workflow and eliminating risks associated with intraoperative repositioning under anesthesia. Fewer implants may also reduce cost and theoretical infection risk. However, pedicle screw insertion in the lateral position requires a learning curve due to altered surgical ergonomics; surgeons typically adapt after 3–5 cases. Additionally, posterior screw placement in this position often requires assistance from two assistants rather than one, possibly due to gravitational effects on exposure. Although clinical outcomes were similar, OLIF-UPS may provide less biomechanical stability than OLIF-BPS, as supported by previous studies [29, 30].
The comparable outcomes between groups do not imply that unilateral and bilateral fixations are interchangeable in all patients. Rather, our results support a stratified approach: OLIF‑UPS is reserved for patients with T‑score > −2.5, Grade I or no spondylolisthesis, no instability (translation <3 mm, angulation <10°), and BMI <30 kg/m2 – a cohort in whom unilateral fixation suffices. Bilateral fixation is mandatory for those with osteoporosis (−3.0 < T‑score ≤ −2.5), overt instability, or Grade II spondylolisthesis, and remains an option even for eligible patients at the surgeon’s discretion. This retrospectively derived algorithm requires prospective validation, but it provides a clinically actionable framework beyond a mere technical comparison.
This study has several limitations. As a retrospective cohort study, it carries inherent potential selection bias. Because patients with multilevel disease were excluded, the applicability of OLIF-UPS for multilevel lesions remains to be further clarified. In addition, the relatively short follow-up duration means that longer-term studies are required to verify the long-term clinical efficacy and radiographic stability of both procedures.
Conclusion
In patients with normal to near-normal bone density (T-score > −2.5), Grade I or no spondylolisthesis, no segmental instability, and BMI <30 kg/m2, single-position OLIF-UPS achieves short-term outcomes comparable to OLIF-BPS while significantly reducing operative time. Given the relatively short follow-up period, further long-term observation is warranted to verify its long-term clinical efficacy.
Acknowledgements
Not applicable.
Abbreviations
- OLIF
Oblique lateral lumbar interbody fusion
- OLIF-UPS
OLIF combined with unilateral pedicle screw
- OLIF-BPS
OLIF combined with bilateral pedicle screw fixation
- VAS
Visual Analogue Scale
- ODI
Oswestry Disability Index
- DH
Disc height
- LL
Lumbar lordosis
Authors’ contributions
YHZ and SL conceived the study. YHZ wrote the manuscript. WCL, YCL, JL, and HZ collected the data. YHZ and WCL analyzed the results. WCL, HZ, JL, and SL provided technical support. All authors reviewed the manuscript.
Funding
Yunnan Province "Xingdian Talent Support Plan" (XDYC-YLXZ-2022-0015); Spinal Cord Disease Clinical Medical Center of Yunnan Province (ZX2022000101⁃2024JSKFKT⁃22); Kunming Medical University Applied Basic Research Joint Project (202301AY070001⁃293); Yunnan Provincial Health Commission Medical Reserve Talent Training Program (H-2024032).
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The experimental protocol was developed according to the Declaration of Helsinki ethical guidelines and approved by the Ethics Committee of the First People’s Hospital of Yunnan Province. Written informed consent was obtained from the participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yonghui Zhao and Weicheng Lin contributed equally to this work and are co-first authors.
Contributor Information
Jie Liu, Email: pacemakerliu@126.com.
Sheng Lu, Email: lusheng@kust.edu.cn.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.