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Canwell Medical helps OLIF Technology promotion
In 1997, Mayer was the pioneering figure who first introduced the anterior lumbar interbody fusion technique. Which involved using the abdominal vascular sheath and the anterior space of the psoas major. Subsequently, Professor Hynes made significant advancements and innovations to this technique. Leading to the development of a specialized fusion instrument and a matching channel system for lumbar oblique lateral interbody fusion (OLIF) by 2012. These OLIF technology advancements were registered by Medtronic. The OLIF25 and OLIF51 trademarks were established to revive and expand upon this technology.
Compared to traditional lateral fusion products, OLIF technology offers the advantage of minimal invasiveness. Reduced trauma, less bleeding, and faster postoperative recovery. Additionally, the OLIF technology ensures the safety of the lumbar plexus. Which makes it an important surgical procedure for lumbar interbody fusion. As a result of its numerous benefits, OLIF technology has gained significant popularity and clinical application.
An Expert Perspective
On July 25, 2014, OLIF technology officially entered mainland China. With the completion of its first domestic operation in Shanghai Changzheng Hospital. However, the initial development of OLIF technology in the country encountered several obstacles. Medtronic’s statistics show, that the number of OLIF surgeries in China between 2014 and 2016 was only slightly more than 450 cases. This can be attributed to several reasons.
Firstly, most domestic scholars are more familiar with lumbar posterior surgery. Leading to their limited understanding of the concept of lumbar anterior surgery and lack of familiarity with the anatomy. Additionally, there are technical bottlenecks in the development of OLIF technology. Secondly, since OLIF technology has just entered China, there is a lack of clarity regarding its indications and applications. As a result, most spine surgeons adopt a cautious approach. Thirdly, OLIF involves a small incision and limited exposure range. The operation manual stipulates the use of fingers to insert the guide pin and establish the channel. As such, there is a steep learning curve involved in mastering the technique. Fourthly, anatomical parameters for the Chinese population differ from those of the Western population. It brings additional uncertainty regarding the technical risk of OLIF.
High Incidence of Complications
Through retrospective analysis, it was discovered that during the initial application stage. OLIF had a higher incidence of neurological and vascular injury complications than XLIF (33.3% vs. 10%). Fujibayashi conducted a survey on 71 medical centers in Japan and analyzed 2998 lateral fusion surgery cases. Including 1995 cases of XLIF and 1003 cases of OLIF. The results showed that the incidence of OLIF surgery complications was as high as 45.4%, much higher than the 27.6% of XLIF. However, after performing more than 100 operations, the incidence of OLIF complications decreased to 3.5%, significantly lower than the 12.1% of XLIF. Similarly, many domestic scholars performed OLIF surgery with apprehension during the early stages, resulting in several serious complications.
In conclusion, the steep learning curve involved in mastering the OLIF technique and the high incidence of complications during the initial application stage have made many spine surgeons hesitant to use OLIF technology in China’s severe medical environment. Therefore, promoting the use of OLIF technology in China remains a challenge.
Technical Improvements and Anatomical Considerations in OLIF Treatment
As lumbar lateral fusion gains recognition. Domestic scholars have conducted extensive research on the anterior lumbar anatomy of Chinese individuals, providing an anatomical basis for the development of OLIF technology. Anatomical studies by Davis, Molin⁃ares et al, Xu Haichao, and Wang Hongli and colleagues have revealed significant differences in anatomical parameters between Chinese and Western populations.
Important data from anatomical studies conducted by scholars are as follows:
Davis found that the distance between the anterior border of the psoas major and the aorta or iliac artery was 18.60 mm at L2-3, 19.25 mm at L3-4, and 15.00 mm at L4-5.
Molin⁃ares et al found that the distance of the OLIF physiological channel is 16.04mm at L2-3, 14.21mm at L3-4, and 10.28mm at L4-5 through MRI study.
Xu Haichao measured the distance between the left edge of the abdominal aorta (left common iliac artery) and the right edge of the left psoas muscle through CT scans and found that it was 15.90mm at L1-2 and 14.82mm at L2-3, L3-4 is 17.57mm, L4-5 is 11.16mm.
Wang Hongli and others found that the distance between the front edge of the left psoas major and the abdominal aorta was 13.77mm at L2-3, 11.38mm at L3-4, and 8.90mm at L4-5 through the autopsy study of Chinese people.
It was found that the left sympathetic trunk distance between L2-3 and the abdominal aorta is 11.14mm, L3-4 is 9.11mm, and L4-5 is 6.40mmi
Innovate of AIP exposure technique
However, the width of the OLIF fusion device introduced in China is significantly larger than the distance between the vascular sheath or sympathetic trunk and the front edge of the psoas major in normal individuals. This presents higher requirements for accurate placement of the guide wire and channel to prevent damage to important structures. The use of the needle placement method to push the peritoneum with fingers. As described in the OLIF technical manual, also carries risks of injury to blood vessels, ureters, and abdominal viscera.
To address these difficulties and improve the operability and safety of OLIF surgery. Run Run Shaw’s team affiliated with Zhejiang University School of Medicine proposed an anteroinferior psoas (AIP) exposure technique. This technique includes three innovative points: (1) a sideways surgical incision is made about 2cm forward from the central point of the intervertebral space. (2) exposure is performed under direct viewing with the assistance of a long right-angle retractor system with a light source. (3) the anterior and inferior approach of the psoas major muscle is utilized.
The AIP technique is suitable for the anatomical characteristics of Chinese individuals and has been adopted in the latest version of the Medtronic OLIF operating manual. It has simplified OLIF surgery, making it safe, clear, and operable. The OLIF technic has truly taken root and flourished in Mainland China.
Standardize Training and Promote it Nationwide
Oblique lateral lumbar interbody fusion (OLIF) technology was introduced in China as a new surgical option for spine surgery. Since its introduction, standardized training and nationwide promotion have been crucial to ensuring its effective and safe use. This technology has been rapidly gaining popularity. Now widely recognized by the relevant domestic fields, with its potential being further explored.
Standardize Training and Promotion:
Several major domestic spine centers began to hold training courses on OLIF technology. Anatomy, operation application, and surgical demonstration and promoted and applied OLIF-related technical specifications, skills, and clinical indications across the country.
From 2014 to 2016, OLIF technology-related training and study classes were mainly carried out in several well-known domestic hospitals that carried out OLIF surgery earlier. The total number of training sessions was about 10, and the total number of participants in the training was less than 300.
Since 2017, OLIF technical training and study classes have been gradually popularized in prefecture-level hospitals. With an average annual training or study class of more than 30 times, and the average number of participants in training reached more than 1,000 people per year.
Run Run Shaw Hospital affiliated with Zhejiang University School of Medicine. They alone hold OLIF training courses and surgical demonstrations 4 times a year. With more than 5,000 participants each time (including watching live surgical demonstrations online).
All major spine centers in China that carry out OLIF technology accept peers from all over the country (including Taiwan, Hong Kong, and other regions) for further study.
OLIF technology has directly promoted the in-depth popularization of the concept and technology of lateral fusion in the domestic orthopedic field.
Professor Hai Yong led the establishment of the Chinese Lateral Approach Surgery Research Group. They held a corresponding academic conference every year, playing a very positive role in promoting the promotion and application of lateral fusion technology in China.
Academic Papers and Guidelines:
Through the Wanfang database, a total of 69 OLIF-related journal papers were found, among which 2014 to 2014 There were 14 articles in 2016 and 55 articles from 2017 to 2019.
In the 16th issue of 2017, the Chinese Journal of Orthopedics conducted an in-depth discussion on the anatomy, imaging, clinical application, and complications of OLIF technology in the form of a special issue.
Run Run Shaw Hospital took the lead in organizing more than 30 experts in the field of spine surgery nationwide. They are committed to the promotion of OLIF technology and formulated the “Lumbar Spine Clinical Application Guidelines for Oblique Lateral Intervertebral Fusion”. Which is published in this issue, playing a positive role in the standardized application of OLIF technology in China.
Application of OLIF Technology:
As of the end of 2019, only Medtronic OLIF25 has performed more than 6,000 surgeries in China.
With the popularization of OLIF in large hospitals, this technology has also been well-developed in some grassroots hospitals. The total number of operations reached more than 450 cases.
Correspondingly, domestic medical device manufacturers, such as Zhejiang Canwell Medical Devices Co., Ltd. Beijing Fuel Technology Development Co., Ltd., have developed and produced devices related to lumbar lateral fusion surgery, which have been applied nationwide.
With standardized training and promotion, OLIF technology has rapidly developed and gained popularity in China. The technology has been widely recognized by relevant domestic fields, and its potential is being further explored. With the continuous efforts of researchers and practitioners, OLIF technology is expected to continue.
Accumulation of experience and flourish
As more OLIF surgery cases are performed by domestic spine surgeons. Of course, their understanding and mastery of the technology have deepened, facilitated by a culture of mutual learning, exchange, and experience sharing. OLIF technology’s minimally invasive advantages, technical feasibility, and safety have enabled it to become widely accepted for the treatment of a variety of spinal conditions in China, including:
- Discogenic low back pain
- Lumbar segmental instability
- Spondylolisthesis of grade II and below
- Non-rigid lumbar degenerative scoliosis
- Mild to moderate degenerative lumbar spinal stenosis syndrome, including lumbar disc herniation
As experience with OLIF technology has accumulated, it has been further expanded and applied. For example, the approach and concept of OLIF technology have been successfully applied to single-segment lumbar infectious diseases. This results in fewer complications, less surgical trauma, and faster recovery compared to traditional surgery.
Furthermore, some scholars have combined direct decompression of the spinal canal with endoscopic or microscopic techniques during OLIF. Achieving satisfactory results in the short-term follow-up. Other scholars have attempted to apply the lateral vertebral body fixation technique to OLIF surgery, eliminating the need for posterior internal fixation and allowing intervertebral fusion and internal fixation to be completed in one operation.
Domestic scholars have also reported that OLIF25 technology has been expanded and applied to T12L1, L1-2, and L5S1 segments during conference exchanges, with good results.
However, it is essential to note that while these expanded applications have achieved good curative effects, surgical indications and risk awareness should be strictly followed. Blindly following trends and arbitrarily expanding the scope of OLIF technology’s application should be avoided.
Although it has achieved results, efforts are still needed
Firstly, it is important to recognize that OLIF technology is still an emerging technology. It has only been used for a relatively short period of time in clinical cases. Additionally, there is a lack of multi-center randomized controlled studies in the world, and further long-term efficacy needs to be demonstrated.
Furthermore, the fusion material used in OLIF technology is currently limited to allogeneic bone or artificial bone. The fusion rate and time require further follow-up observation. To address this issue, the development of an integrated fusion device with sufficient biomechanical stability to supplement the defect of posterior internal fixation in OLIF surgery is crucial for the future development of OLIF technology.
To fully cover the entire lumbar segment with OLIF and reduce the risk of large vessel injury. Caused by the expansion of OLIF25 technology to the L5S1 segment, the introduction of the Medtronic OLIF51 device that is more suitable for the L5S1 segment is necessary. Additionally, attention must be given to the anatomical differences between Chinese and Western populations. When matching fusion cages and endplates, as well as preventing the sinking of fusion cages.
Conclusion
In summary, while OLIF technology has made significant progress in the past six years, there are still numerous challenges that must be addressed. Domestic colleagues must continue to work hard to promote the further development and reasonable application of OLIF technology. The integration of more Chinese elements to create a road of OLIF technology with Chinese characteristics.