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J Minim Invasive Spine Surg Tech > Volume 10(Suppl 1); 2025 > Article
Ma, Lee, and Park: Minimally Invasive Strategy for Uniportal Full-Endoscopic Transforaminal Lumbar Interbody Fusion Using a Large Cage Utilized in Oblique Lumbar Interbody Fusion

Abstract

A spine endoscope can be used for lumbar interbody fusion, and endoscopic spinal surgery has various advantages over conventional open surgery. With just one small incision, uniportal full-endoscopic surgery can be the most minimally invasive approach. This technique can minimize intraoperative tissue damage, but the working space is very narrow, making it challenging to insert a large cage and posing a dilemma for an additional large skin incision. The anterior approach for lumbar interbody fusion, particularly oblique lumbar interbody fusion (OLIF), has advantages, such as a wider fusion bed and a large supportive cage, potentially increasing the fusion rate and reducing the risk of cage subsidence. Furthermore, OLIF cages can provide robust support to the apophyseal ring of the vertebral body. An elliptical skin incision is performed to expand the usable area for inserting a large cage and pedicle screw. We aimed to introduce a minimally invasive technique for inserting a large OLIF cage during uniportal full-endoscopic transforaminal lumbar interbody fusion through a single small incision measuring 1.8–2 cm, which could facilitate minimal tissue damage and maximal fusion rate by combining the advantages of endoscope and anterior fusion surgery.

INTRODUCTION

Uniportal endoscopic lumbar surgery is employed to treat various lumbar spinal conditions, including foraminal stenosis and disc herniation. With only a small incision, it could be the most minimally invasive surgery. Recently, uniportal endoscopic fusion has been used for a wider range of lumbar spinal diseases, including spondylolisthesis and instability [1,2]. However, a small skin incision makes insertion of a large cage challenging. Although another incision can be added, inserting a large cage could be still difficult due to the limited working space [3,4]. To maintain a small incision while inserting a large cage, screws, and rod through one incision, a novel incision technique is required.
Oblique lumbar interbody fusion (OLIF) uses a large cage, which can support the strongest part of the vertebral body, the apophyseal ring. Using a wide fusion bed, it can reduce the possibility of cage subsidence and increase the fusion rate [5,6]. Additionally, it allows the use of various sufficient cage angles. However, OLIF has disadvantages, such as injury to the bowel, psoas muscle, vessels, and sympathetic chain. OLIF also provides only indirect decompression to the pathology [7].
We introduce a minimally invasive technique for uniportal full-endoscopic transforaminal lumbar interbody fusion (TLIF), utilizing the same large cage used in OLIF. This technique can provide direct decompression, a wide fusion bed, and strong cage support while maintaining one small incision, which could reduce hospital stays and postoperative back and leg pain. Additionally, it avoids the need for an abdominal approach and reduces the risk of related complications.

ILLUSTRATIVE CASES

1. Case 1: Grade 2 Isthmic Spondylolisthesis

A 62-year-old male patient experienced left leg pain, foot drop, and claudication for 10 years. Imaging revealed L4–5 grade 2 isthmic spondylolisthesis with central and bilateral foraminal stenoses (Figure 1AC). The patient underwent a uniportal full-endoscopic TLIF at L4–5. A large cage used for OLIF, measuring 45 mm × 18 mm × 10 mm (length × width × height) and having a 6° angle, was inserted. The cage and screw were inserted through an elliptical-shaped incision (Figure 1D). Postoperative imaging confirmed the cage was well-positioned, and the thecal sac and left foramen were well decompressed (Figures 1E and F). The patient experienced significant pain relief, with Numeric Rating Scale (NRS) scores dropping from 6 to 1 (back) and 8 to 1 (leg). He was discharged on postoperative day 4. Two linear incisions measuring 1.8 cm each were used bilaterally (Figure 1G).

2. Case 2: Multilevel

A 70-year-old female patient experienced low back pain for 10 years and bilateral leg pain for 1 year. Radiograph showed L3–5 degenerative anterolisthesis with angular instability (Figure 2A). The patient underwent a uniportal full-endoscopic TLIF at L3–5. A large cage used for OLIF, measuring 45 mm × 18 mm × 10 mm and having a 6° angle, was inserted at L4–5. A relatively small X-TLIF cage, measuring 40 mm × 15 mm × 9 mm and having a 6° angle, was inserted at L3–4 due to the smaller Kambin’s triangle at this level. Postoperative radiograph showed that the cages were well inserted, which resembled an OLIF surgery (Figure 2B). Four elliptical incisions were visible in the image taken before skin closure. We observed that the position of the incision used for both cages, and the screw was slightly different from the incision used only for the screw (Figure 2C). Postoperatively, the patient's NRS scores improved significantly, with back pain decreasing from 7 to 2 and leg pain from 8 to 1. The patient was discharged on postoperative day 3, with 4 small linear scars, each about 2 cm in length, visible at a follow-up visit (Figure 2D).

3. Case 3: Relatively Longer Cage

A 57-year-old male patient presented with right leg pain and ankle dorsiflexion weakness. Imaging revealed L4–5 anterolisthesis and right foraminal stenosis (Figures 3A and B). The patient underwent a uniportal full-endoscopic TLIF at L4–5. A large cage used for OLIF, measuring 50 mm × 18 mm × 10 mm and having 6° angle, was inserted. In the intraoperative C-arm anterior-posterior (AP) view, before rotating the cage from an oblique to a transverse position, the anterior tip of the cage was positioned at the opposite vertebral margin. In the lateral view, the posterior tip of the cage was located anterior to the caudal vertebral posterior line but posterior to the cranial vertebral posterior line (Figure 3C). After rotating the cage to a transverse position, it was confirmed to be well-positioned, like an OLIF procedure (Figure 3D). Postoperative magnetic resonance imaging (MRI) showed successful decompression of the thecal sac and right foramen, with the OLIF cage well-positioned (Figure 3E).
The patient experienced significant pain relief, with NRS scores improving from 6 to 1 (back) and 8 to 1 (leg). He was discharged on postoperative day 4.
This study was approved by the Institutional Review Board of Wooridul Spine Hospital (approval number: 2024-04-WSH-003), and the requirement for patient consent was waived due to the retrospective nature of the study and the complete anonymization of patient identifiers.

SURGICAL TECHNIQUE

1. Position and Anesthesia

All surgeries were performed under general anesthesia, and the patient was lying prone on a Wilson frame with a radiolucent table, in a uniportal full-endoscopic fashion.

2. Skin Incision to Disc Space

A 1-cm length skin incision was made 4.5 cm lateral to the midline on the x-ray AP view and designed to be parallel to the disc level in the lateral view.
This approach facilitated disc preparation and eased the insertion angle of a large cage across the contralateral side, while also offering the added benefit of preserving the important stabilization muscle, the multifidus. Insert obturator on the facet joint and oblique type working cannular was inserted via obturator. An endoscope was introduced through a working cannular. We used a 125-mm working length, dual irrigation channels, 15° optical angle, and 10-mm outer diameter with 6-mm working channel endoscope (iLESSYS Delta, Joimax, Inc., Irvine, CA, USA). Total facetectomy was performed. Subsequently, the inferior articular facet and superior articular facet (SAP) were completely removed and harvested for bone graft. The SAP must be resected totally to the lateral end to insert a large cage (Figure 4A). After exposure of the traversing and exiting roots, they must be sufficiently released to make them movable during disc preparation or cage insertion.

3. Discectomy and Endplate Preparation

To insert a large cage, sufficient preparation of the disc space on both the ipsilateral and contralateral sides is necessary. If the disc space preparation on the contralateral side is insufficient, extending the cage to the contralateral side and inserting a long cage becomes impossible. If the disc space preparation on the ipsilateral side is not enough, it becomes difficult to position the cage at the optimal angle when laying it transversely. For disc space preparation on the contralateral side, the bevel of the working cannula was directed laterally to ensure clear visibility of the disc space, whereas the back of the working cannula protected the traversing root. Preparation on the contralateral side becomes easier as you move toward the disc midline, but care must be taken as nerve retraction can become severe. Because the skin incision is 4.5 cm away from the midline, even if the back of the working cannula is at the midline, the surgery can proceed without severe nerve retraction because the thecal sac is only slightly lifted obliquely, not fully retracted to the midline (Figure 4B). During disc preparation on the ipsilateral side, the back of the working cannula protected the exiting root, and discectomy was performed on the ipsilateral and contralateral sides until complete removal of the cartilaginous endplate from the subchondral bone. The use of an endoscope for endplate preparation provides direct visualization, minimizing potential damage to the endplate.

4. Additional Incision Strategy for Large Cage and Screw Insertion

Inserting a large cage requires a large incision. However, an effective incision that allows the insertion of a large cage while remaining small is required to preserve the advantages of a uniportal endoscope. Traditional incisions are linear and 1-dimensional, but considering that the cross-section of a cage is planar and 2-dimensional, we designed a wide incision in both longitudinal and transverse directions to accommodate a large cage and facilitate screw insertion without unnecessarily long incisions. An elliptical incision with a 3:1 ratio of longitudinal to transverse dimensions allows for a large cross-sectional area intraoperatively, whereas it heals as a minimal-length linear incision postoperatively (Figure 4C) [8,9]. The reason for the longitudinal dimension being 3 times is due to the longer length required for screw insertion. In our cases, a longitudinal incision length of 1.8–2 cm per level was used to cover up to screw insertion.

5. Cage Choice

Not all cases can accommodate a large cage, and choosing the indication carefully is crucial. If an 18-mm wide OLIF cage is tilted by 45°, a 25-mm width safe zone is required (Figure 4D). Considering the width of the safe zone, it is advisable that on the MRI axial view at the surgical index level, the distance between the traversing and exiting roots should be at least 2 cm, and preferably not less than 1.8 cm, to ensure the safe insertion of an 18 mm wide OLIF cage (Figure 4E).

6. Cage Insertion and Transverse Lying

A half-open working tube also serving as a medial protector (Figure 5A) was inserted, then the traversing root was observed directly and protected using the back of the working tube. The tube was securely anchored to the margins of the cranial and caudal bones of the disc space to prevent any movement, ensuring that the traversing root is protected medially and undamaged during cage insertion. The lateral protector (Figure 5B) is slid along the groove of the medial protector until its tip is positioned within the disc space. The cage can be safely inserted with both medial and lateral protectors in place within the disc space (Figure 5C). Subsequently, the trial is used to determine the appropriate cage size and predict the proper placement of the cage before insertion, after safely positioning the protectors. When the trial is inserted obliquely, the cage can be stably inserted if the anterior tip of the trial touches the contralateral apophyseal ring in the x-ray AP view and is located at the anterior 1/3 of the vertebral body in the lateral view (Figure 5D). Subsequently, the selected size cage is inserted obliquely until the posterior tip of the cage is positioned ventral to the vertebral posterior line (Figure 5E). If the posterior tip of the cage is already in front of the vertebral posterior line, at that time, the cage being already inside the disc space, the exiting root can be considered safe when laying the cage down transversely. At this stage, switching to the original working tube and perfectly protecting the traversing root using the dorsal part of the working tube under endoscopic view (Figure 5F). Afterward, a pusher is used to lay the cage transversely (Figure 5G). However, the posterior tip of the cage may be positioned posterior to vertebral posterior line in cases where the vertebral body is small relative to the length of the cage. Moreover, in patients with severe spondylolisthesis inserting a long cage, the posterior margin of the cage may be ventral to the caudal vertebral body's posterior line but posterior to the cranial vertebral body's posterior line (Figure 5H). In such cases, protecting the exiting root instead of the traversing root becomes necessary, when laying the cage transversely (Figure 5I).

7. Screw Insertion via One Small Incision

The screw was inserted through one incision. A percutaneous screw system (QUATTRO-GADGET, MANTIZ, Inc., Daegu, Korea) was used. Regardless of whether it was multilevel or single level, the screw insertion at the most caudal level was characteristic. The most caudal screw is inserted to minimize space when combining the screw extender and rod holder, and the cap is placed without the rod and not fully tightened, turning it one and a half to 2 turns. Subsequently, the screw extender was removed (Figure 6A). The cranial screw was inserted as usual, and the rod was inserted up to the caudal screw by using the screw extender of the cranial screw, where the cap was turned one and a half to 2 turns. Tightening the cap of the caudal screw completely completes the procedure while maintaining a small incision (Figure 6B). This process can be similarly applied to multilevel surgeries. In multilevel surgeries, the process begins with inserting the most caudal screw. Subsequently, the cap is placed on this screw and tightened one and a half to 2 turns. Afterward, the cranial screws were inserted in the usual manner (Figure 6C). Using the screw extenders utilized for the cranial screws, the rod is guided up to the screw head of the most caudal level, where the cap has been placed and lightly pretightened (Figure 6D). Finally, the cap on the most caudal screw is securely tightened, effectively reducing both the number and length of incisions required (Figure 6E).

8. Drain and Closure

The drain was inserted into the surgical site, and a subcutaneous tunnel was created to exit the drain at different skin locations from the incision. The skin was closed using 2 subcutaneous stitches and skin glue, ensuring that the elliptical incision did not extend longitudinally but was closed to a length of 1.8–2 cm.

9. Difficult Points, Pitfalls, and Rescue Techniques

To position the cage optimally, the SAP must be completely removed to ensure that there are no bone obstructions during cage insertion, preventing the cage from deviating in an undesired direction. Thorough preparation of both the ipsilateral and contralateral disc spaces is essential. The traversing and exiting roots should be fully mobilized so they can move freely, preventing localized kinking or pressure during cage insertion, and minimizing pressure on the nerves to facilitate a smooth procedure. While the indications for this technique may be expanded in the future, it is advisable to proceed only when the distance between the traversing and exiting roots in the disc space is at least 1.8 cm, considering the safe width required when the cage is tilted. If the distance between the roots is less than 1.8 cm, a smaller cage should be considered, or an alternative approach may be necessary.

DISCUSSION

Anterior lumbar interbody fusion (ALIF), OLIF, and direct lateral interbody fusion (DLIF) allow the insertion of large, stable, and angled cages without navigating around nerves, unlike TLIF. The use of cages with a broad area helps distribute stress more evenly, reducing the likelihood of cage subsidence. Angled cages assist in maintaining lumbar lordosis, preserving a more physiological lumbar state [10]. Additionally, OLIF and DLIF allow the cage to rest on the apophyseal ring, further decreasing the risk of subsidence. However, complications, such as injury to the bowel, ureter, vessels, psoas muscle, and sympathetic chain should be managed. Uniportal endoscopic TLIF minimizes the damage to normal structures, reducing postoperative back pain and facilitating rapid recovery. The minimal incision size also facilitates rapid postoperative wound management and early discharge. Nevertheless, the narrow corridor has posed a limitation for large cage insertion, which is critical for successful fusion. Enhanced visualization through the endoscope has improved the understanding of Kambin triangle and enabled meticulous and clean endplate preparation. Using a paraspinal approach, 4.5–5 cm lateral from the midline, the endoscope’s slender and long characteristics allow for the preparation of the contralateral apophyseal ring and the use of long cages spanning the contralateral side. Clean endplate preparation under endoscopic guidance can enhance the fusion rate. Unlike ALIF cages, OLIF cages are long and cylindrical and can navigate Kambin triangle without nerve damage with proper indication. When positioned transversely, these cages can distribute pressure symmetrically and bilaterally engage the apophyseal ring, reducing subsidence risk. Symmetrical positioning also takes advantage of the cage’s AP angle to aid in creating lumbar lordosis. Furthermore, the paraspinal approach preserves the insertion point of the multifidus muscle, which is crucial for stabilization, and allows screw insertion through the same incision used for the cage [11]. Moreover, traditional linear incisions increase in length with the expansion of the surgical field due to the requirement of a 2-dimensional area by instruments, such as the endoscopic working tube, cage, and screw insertion device. However, an elliptical incision with a longitudinal-to-transverse ratio of 3:1 can reduce incision length while utilizing skin elasticity for linear closure, enabling surgery with minimal incision length. It can also reduce the tension applied to the skin when large instruments are inserted. The longer longitudinal length provides sufficient space for the screw extender and rod holder. The cage width presents the greatest surgical challenge, as it must pass between the exiting and traversing roots. Although the vertebral body size determines the length and the disc space determines the height, a wider cage complicates navigation through these roots. Thus, adequately dissecting the traversing and exiting roots is crucial to make them movable, ensuring safe retraction during cage insertion. An optimally initiated small incision minimizes damage to all tissues involved in the surgery, reducing bleeding, infection risk, postoperative pain, and the need for additional medication, thereby speeding recovery and shortening hospital stays, as well as achieving aesthetic satisfaction for the patient. Consequently, the number and length of incisions should be minimized, with advanced screw insertion techniques required to maintain the advantage of a very small single incision offered by the uniportal endoscope. Although the incision marks the start of the surgery, optimal planning and execution through the final stages can reduce the number and length of incisions. And fusion is the ultimate goal of endoscopic fusion surgery, efforts must focus not only on minimizing the number and length of incisions but also on the insertion of large, stable cages.

CONCLUSION

Uniportal endoscopic TLIF can provide the smallest possible incision for the least invasive decompression while allowing the use of large and stable cages used in OLIF. This approach enables us to take advantage of both surgeries.

NOTES

Conflict of Interest

The authors have nothing to disclose.

Funding/Support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Contribution

Conceptualization: HJM; Data curation: HJM; Formal Analysis: HJM; Funding acquisition: HJM; Methodology: HJM; Project administration: HJM, SHL, CHP; Visualization: HJM, SHL, CHP; Writing – original draft: HJM, CHP; Writing – review & editing: HJM, SHL

Figure 1.
Preoperative and postoperative images of a 62-year-old male patient with grade 2 lytic listhesis. (A) A radiograph shows L4–5 grade 2 spondylolisthesis. (B) Magnetic resonance imaging (MRI) shows a central, bilateral lateral recess, and foraminal stenoses. (C) Computed tomography shows bilateral lysis. (D) An elliptical-shaped incision, slightly stretched because of a photo taken after the insertion of the cage and screw. (E) Postoperative x-ray shows the same result as in oblique lumbar interbody fusion surgery. (F) Postoperative MRI shows a well-decompressed thecal sac and left foramen. (G) The elliptical incision healed into a 1.8-cm linear wound, and a skin bond is still present on the left side wound. Rt., right; Lt., left; AP, anterior-posterior; Lat., lateral.
jmisst-2024-01634f1.jpg
Figure 2.
Preoperative and postoperative images of a 70-year-old female patient with multilevel instability. (A) A radiograph shows L3–5 degenerative anterolisthesis with angular instability. (B) Postoperative x-ray shows the same result as in oblique lumbar interbody fusion surgery. (C) Four elliptical incisions are visible on the image taken just before skin closure. Position of the incision used for the cage and screw is different from the incision used only for the screw. (D) The elliptical incision healed into 4 linear wounds, measuring between 1.8 and 2 cm. AP, anterior-posterior; Lat., lateral.
jmisst-2024-01634f2.jpg
Figure 3.
Images of a 57-year-old male patient with a relatively long cage in use. (A) Radiograph shows L4–5 anterolisthesis. (B) Magnetic resonance imaging (MRI) shows right foraminal stenosis. (C) The posterior tip of the cage is positioned anterior to the caudal vertebral posterior line but posterior to the cranial vertebral posterior line. (D) After rotating the cage, the intraoperative C-arm image is the same as that in oblique lumbar interbody fusion (OLIF) surgery. (E) MRI shows a well-decompressed thecal sac and right foramen and a well-positioned OLIF cage. AP, anterior-posterior; Lat., lateral.
jmisst-2024-01634f3.jpg
Figure 4.
Considerations from skin incision to cage choice. (A) An endoscopic view shows the traversing root, exiting root, totally resected superior articular facet (SAP), and disc space. (B) When approaching 4.5 cm laterally from the midline, the opposite side past the center of the thecal sac can be accessed by slightly lifting it, without retracting to the midline. The red arrow indicates the approach route. (C) An elliptical incision with a 3:1 ratio of the longitudinal to transverse dimensions allows a large cross-sectional area. The red solid and dashed lines indicate the elliptical incision and healed linear wound, respectively. The blue trapezoid indicates the cross-section of the oblique lumbar interbody fusion (OLIF) cage. (D) An 18-mm wide OLIF cage is tilted by 45°, and a safe zone of 25-mm width is required. (E) The distance between the traversing and exiting roots—2 cm, or at least 1.8 cm, is required to safely insert an 18-mm wide OLIF cage.
jmisst-2024-01634f4.jpg
Figure 5.
Cage insertion and transverse lying. (A) A half-open working tube serves as a medial protector protecting the traversing root. (B) The lateral protector slides down the groove of the medial protector until reaching the disc space. (C) The medial and lateral protectors are positioned within the disc space. (D) The obliquely inserted trial touches the contralateral apophyseal ring in the anteroposterior x-ray view and the anterior 1/3 of the vertebral body in the lateral x-ray view. (E) The obliquely inserted cage. The posterior tip of the cage is positioned ventral to the vertebral posterior line. (F) From left to right, the working tube is used to protect the traversing root fully. (G) A pusher is used to lay the cage transversely. (H) When the anterior margin of the 50-mm-long cage is positioned at the opposite apophyseal ring in the anteroposterior view, the posterior margin is ventral to the caudal vertebral body's posterior line but posterior to the cranial vertebral body's posterior line in the lateral view. (I) When positioning the 50-mm-long cage transversely, the exiting root must be protected instead of the traversing root. AP, anterior-posterior; Lat., lateral.
jmisst-2024-01634f5.jpg
Figure 6.
Screw insertion strategy via one small incision. (A) After inserting the caudal screw, the cap is lightly placed, and the screw extender is removed. (B) The cranial screw procedure is performed as usual, and the cranial screw extender is used to insert the rod into the caudal screw. (C) The same process is followed for multilevel cases. The most caudal screw is slightly capped before removing the screw extender, whereas the cranial screw extenders are left attached as usual. (D) Using the 2 cranial screw extenders, the rod is inserted into the most caudal screw, which is slightly capped. (E) The antitorque is held at the screw one level above the most caudal screw, the torque-limited handle is assembled on the caudal screw cap, and final locking is performed. AP, anterior-posterior; Lat., lateral.
jmisst-2024-01634f6.jpg

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