Comparison of navigation-assisted single position oblique lumbar interbody fusion and minimally invasive surgical transforaminal lumbar interbody fusion in L4 degenerative lumbar spondylolisthesis: A retrospective analysis

doi:10.21203/rs.3.rs-2276895/v1

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Comparison of navigation-assisted single position oblique lumbar interbody fusion and minimally invasive surgical transforaminal lumbar interbody fusion in L4 degenerative lumbar spondylolisthesis: A retrospective analysis

https://doi.org/10.21203/rs.3.rs-2276895/v1

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Background: Minimally invasive surgical oblique lumbar interbody fusion (MIS-OLIF) is an innovative anterolateral, retroperitoneal, and anterior psoas approach for L4 degenerative lumbar spondylolisthesis (DLS). A single-position technique and the utilize of the navigation system improves surgical outcomes.

Methods: This study retrospectively analyzed successive patients treated with navigation-assisted single position oblique lumbar interbody fusion (NASP-OLIF) or minimally invasive surgical transforaminal lumbar interbody fusion (MIS-TLIF) for L4 DLS. According to the surgical procedures, participants were divided into NASP-OLIF and MIS-TLIF groups. Operative duration times, intraoperative blood loss, postoperative first floor activity time, total screw placement time, per screw time, cage height, visual analog scale (VAS), Oswestry disability index (ODI), slipping distance (SD), segmental lordosis (SL), intervertebral foraminal area (IFA), intervertebral disc height (IDH), and spinal canal cross-sectional area(CSA) were compared between groups.

Results: Among 53 patients (NASP-OLIF: 25 vs MIS-TLIF: 28) treated for L4 DLS between September 2017 and June 2020. There were 212 pedicle screws insertion (NASP-OLIF: 100 vs MIS-TLIF: 112). In the NASP-OLIF group, according to the Gertzbein-Robbins scale, screws were as follow: grade A with 90 screws, grade B with 6 screws, grade C with 3 screws, grade D with 1 screw, Grade E with no screw.There were no neurovascular injury. The satisfactory rate of screw insertion was 96%. The NASP-OLIF group showed significantly shorter the operative duration times, lessened intraoperative blood loss, higher cage height and shorter postoperative first floor activity time, and shorter total screw and per-screw placement times (P<0.05). On postoperative and last follow-ups,IDH and IFA were significantly improved in the NASP-OLIF group (P<0.05); VAS of leg pain (VASL), VAS of low back pain (VASB), and ODI were significantly decreased in the NASP-OLIF group (P<0.05). SL, SD, or CSA was no remarkably differences between groups (P>0.05).

Conclusions: NASP-OLIF was superior to MIS-TLIF in the aspect of the reduction of trauma and faster recovery. However, the two surgical techniques were comparable in many other aspects.

OLIF

Navigation

Single position

O-arm

Percutaneous pedicle screw

The radiographically typical feature of degenerative lumbar spondylolisthesis (DLS) is forwardly slipped upper vertebral body with respect to the lower vertebral body, which typically occurs in the L4 vertebral segment. According to current knowledge, spinal stenosis is the primary symptom and often requires surgical treatment [1]. Studies have shown that patients with DLS who are treated surgically show significantly reduced pain and improved function compared to their conservatively-treated counterparts [2]. The objectives of surgical treatment for DLS include nerve decompression, slipping reduction, and segmental fixation [3]. At present, many fusion procedures have been reported in DLS, one being the MIS-TLIF. This surgical procedures offers superiority to traditional open surgery and has become a common procedure in DLS. Another option is oblique lumbar interbody fusion (OLIF) which offers the advantages of reduced invasiveness and quickened recovery. The surgical fixation methods used in OLIF include posterior pedicle screw fixation, lateral vertebral screw or steel plate fixation, and standalone fixation. Of these, posterior pedicle screw fixation provides the best mechanical performance [4–5]. However, After the intervertebral disc depression is performed in the lateral position during OLIF, the patient must change the position in the prone position to perform inserting the pedicle screws. This process of adjusting surgical position may lead to the risks of fusion cage displacement, posterior peritoneal injury, anesthesia accidents, and others, and operation time may be prolonged [6–7]. Alternatively, OLIF performed in the single lateral position can shorten operative time and reduce prone position-related complications. In addition, many studies have described the advantages of O-arm navigation-assisted percutaneous pedicle screws (PPS) including high accuracy, less radiation, shorter operation time, and fewer complications [8–10]. Our center began using OLIF with O-arm navigation-assisted single lateral position PPS fixation for L4 DLS in 2017, and we have since named this new technique navigation-assisted single position oblique lumbar interbody fusion (NASP-OLIF). We proposed to compare the surgical effects of NASP-OLIF and MIS-TLIF and explore the advantages of NASP-OLIF for the treatment of L4 DLS in this study.

Study design

The medical ethics committee of Huazhong University of Science and Technology Union Shenzhen Hospital approved this study. In order to compare the surgical effects of NASP-OLIF and MIS-TLIF and explore the advantages of NASP-OLIF for the treatment of L4 DLS, we retrospectively analyzed 53 patients treated with NASP-OLIF or MIS-TLIF in L4 DLS at the Huazhong University of Science and Technology Union Shenzhen Hospital between 2017 and 2020. The inclusion criteria included: (1) diagnosis of Meyerding grade I or II in L4 DLS [11]); (2) being consistent in symptoms, physical examination and imaging; (3) having undergone an NASP-OLIF or MIS-TLIF procedure; (4) complete follow-up data; (5) follow-up time over 24 months. The exclusion criteria included: (1) severe osteoporosis, spinal tumors, infection, deformity or other similar conditions; (2) prior abdominal surgery; (3) cardiopulmonary function intolerable of surgery; (4) incomplete follow-up data. According to the above criteria, 25 and 28 patients were respectively included between two groups.

Surgical methods

NASP-OLIF

The patient was placed in the right decubitus position and the knee and hip joints were flexed bilaterally to loosen the psoas major muscles. The patient’s leg, pelvis and chest was fixed with tape on the bed. The surgeon then made a 4.5 cm incision on the left iliac crest, and the subcutaneous tissue, abdominal muscles were bluntly separated. The vertebrae between the blood vessels and the psoas major muscle were exposed. After radiographic confirmation of the target intervertebral disc, the surgeon inserted the working channel and special expander. Surgeon then scraped the intervertebral space tissue and cartilage endplate completely. During this process, the surgeon released the contralateral annulus fibrosus and avoided damage to the bony endplate. An properly-sized cage (Dabo Medical Technology Inc., Xiamen, Fujian, China) suffused with allogeneic bone (Shanxi Aorui biomaterial Inc., Shanxi, China) was then inserted into intervertebral disc. The wound was washed and closed; then, without changing the surgical position, O-arm navigation-assisted PPS fixation was performed. The surgeon inserted the reference frame of navigation system (Stealth Station® S7, Medtronic Inc., Dublin, Ireland). O-arm® system (Medtronic Inc., Minneapolis, MN, USA) was then applied in intraoperative CT imaging of the operative field. All PPS (Beijing Fule technology development Inc, Beijing, China) placement procedures, including determining screw incision, opening, tapping, and screw placement, were performed by two surgeons with the assistance of navigation system. After PPS placement, the rod (Beijing Fule technology development Inc, Beijing, China) was attached, the wound was then washed and closed (Fig. 1).

MIS-TLIF

For this procedure, the patient was placed in the prone position and a about 4.5 cm extent vertical incision beside the midline was perfomed. The guide wire and stepwise expansion sleeve were inserted for blunt dissection of the paravertebral muscle. Next, the working sleeve and special retractor were inserted to expose the facet joint. An appropriate posterior nerve decompression was performed with patients who have severe spinal stenosis. The Surgeon then scraped the intervertebral space tissue and cartilage endplate completely after unilateral facet joint resection. An properly-sized cage (Beijing Fule technology development Inc, Beijing, China) suffused with allogeneic bone (Shanxi Aorui biomaterial Inc., Shanxi, China) was inserted into the intervertebral disc and the appropriate location of the cage was confirmed with fluoroscopy. PPS and rod (Beijing Fule technology development Inc, Beijing, China) was then performed. The surgeon places a plastic drainage tube into the incision, and then cleans and closes the incision.

Evaluating indicators

Basic situation of all the subjects such as age, sex, body mass index (BMI), and follow-up time were analyzed. The intraoperative indicators were compared between the two groups, such as amount of intraoperative blood loss, operative duration times, postoperative first-floor activity time, cage height, total screw placement time, and per-screw placement time. The Clinical indicators included the visual analog scale of low back pain (VASB) and leg pain (VASL) and the Oswestry Disability Index (ODI), which were used to evaluate the clinical efficacy between groups.

All the subjects underwent imaging examination pre- and postoperative in order to analyze the surgical effect respectively. All radiographic parameters were measured and assessed by a spine surgeon and a radiologist. Lumbar lateral radiography was used to measure the sliding distance (SD) and segmental lordosis (SL). Lumbar CT was used to measure the intervertebral foraminal area (IFA) and intervertebral disc height (IDH). Spinal canal cross-sectional area (CSA) was measured using lumbar MRI. These imaging parameters were compared on preoperative, postoperative, and last follow-up between the two groups.

In our study, SD was described as the slipped distance of L4 with respect to L5, IDH was described as the average of anterior and posterior disc heights, and SL was described as the degree formulate between the L4 upper endplate and the L5 lower endplate on lumbar spine radiographs. Additionally, the accuracy of a total of 212 screw insertion was assessed using lumbar CT with Gertzbein-Robbins scale [12]. Based on the degree of cortical rupture by the screws, the screw classification was as follows: grade A (no cortical rupture), grade B (< 2 mm cortical rupture), grade C (< 4 mm cortical rupture), grade D (< 6 mm cortical rupture), and grade E (≥ 6 mm cortical rupture). We considered screw breakage < 2 mm (grade A and B) as satisfactory for screw placement, and the satisfactory rate of screw insertion in NASP-OLIF groups was equal to [(grade A + grade B)/100 × 100%].

Statistical analysis

SPSS 26.0 software (IBM Corporation, Armonk, NY, USA) was used to analyze the statistic. The counting data are signified as percentages and the quantitative data as the mean ± SD. The paired Student's t-test was used to compare pre-and postoperative parameters between groups. The independent sample Student's t-test and the chi-square test was used to compare measurement data and counting data between the two groups, respectively. Statistically significant difference was taken as less than 0.05.

In this study, a total of 53 subjects were included and divided into NASP-OLIF (n = 25) and MIS-TLIF groups (n = 28), according to the surgical method. Table 1 shows the basic data for the subjects with no remarkable difference between groups (P > 0.05). The intraoperative indicators of subjects in this study are displayed in Table 2. In the NASP-OLIF group, the intraoperative blood loss was lesser (101.4 ± 18.5 ml vs 226.89 ± 37.6 ml), the postoperative first-floor activity time was shorter (3.92 ± 0.84 d vs 9.07 ± 1.58 d), the operative duration times was simply shorter (125.84 ± 14.82 min vs 185.18 ± 15.37 min), the cage height was higher (12.16 ± 2.03 mm vs 10.07 ± 1.46 mm), which were a remarkable difference between groups (P < 0.05). In terms of comparison of screw placement, the total screw placement time and per screw placement time was simultaneous shorter (30.16 ± 5.45 min vs 67 ± 13.04 min; 7.54 ± 1.36 min vs 16.75 ± 3.26 min, P༜0.05).

Table 1

Comparison of baseline patient data
	NASP-OLIF	MIS-TLIF	P value
Number of patients	25	28
Age (years)	63.92 ± 11.3	61.57 ± 9.52	0.424
Sex
Male	11 (44%)	9 (32.1%)
Female	14 (56%)	19 (67.9%)	0.374
Body mass index (kg/m²)	21.85 ± 2.97	20.85 ± 2.52	0.200
Follow-up time (months)	41.82 ± 1.69	40.82 ± 2.41	0.439
Sliding degree
I°	16(64%)	17 (60.7%)
II°	9(36%)	11 (39.3%)
Distribution of symptoms
Low back pain	9(36%)	8 (28.6%)
Claudication	5 (20%)	7 (25%)
Both	11 (44%)	13 (46.4%)
*The difference was statistically significant.
NASP-OLIF, navigation-assisted single position oblique lumbar interbody fusion; MIS-TLIF, minimally invasive surgical transforaminal lumbar interbody fusion

Table 2

Comparison of Intraoperative indicators
	NASP-OLIF	MIS-TLIF	P value
Number of patients	25	28
Intraoperative blood loss (ml)	101.4 ± 18.5	226.89 ± 37.6	0.000^*
Cage height (mm)	12.16 ± 2.03	10.07 ± 1.46	0.000^*
Postoperative first-floor activity time (days)	3.92 ± 0.84	9.07 ± 1.58	0.000^*
Operative duration times (min)	125.84 ± 14.82	185.18 ± 15.37	0.000^*
Total screw placement time (min)	30.16 ± 5.45	67 ± 13.04	0.000^*
Per-screw placement time (min)	7.54 ± 1.36	16.75 ± 3.26	0.000^*
*The difference was statistically significant.
NASP-OLIF, navigation-assisted single position oblique lumbar interbody fusion; MIS-TLIF, minimally invasive surgical transforaminal lumbar interbody fusion

The clinical efficacy of the subjects in this study is shown in Table 3. VASB, VASL, and ODI between groups decreased remarkably between groups in contrast to preoperative (P < 0.05). The postoperative VASB and ODI in NASP-OLIF group were significant lower (2.16 ± 0.73 vs 3.36 ± 0.89; 20.96 ± 5.69 vs 31.79 ± 7.06, P < 0.05). VAS and ODI at last follow-up were no apparent difference between groups (P > 0.05).

Table 3

Comparison of the VAS and ODI before and after surgery
	NASP-OLIF	MIS-TLIF	P value
Number of patients	25	28
VASB
Preoperative	5.72 ± 1.28	5.68 ± 1.28	0.909
postoperative	2.16 ± 0.73	3.36 ± 0.89	0.000^*
At the last follow-up	0.92 ± 0.63	1.14 ± 0.74	0.255
VASL
Preoperative	5.16 ± 1.19	5.14 ± 1.09	0.957
Postoperative	1.76 ± 0.59	1.54 ± 0.73	0.236
At the last follow-up	0.48 ± 0.5	0.57 ± 0.49	0.515
ODI
Preoperative	66.96 ± 8.02	67.79 ± 10.81	0.760
postoperative	20.96 ± 5.69	31.79 ± 7.06	0.000^*
At the last follow-up	12.32 ± 3.82	13.61 ± 3.1	0.191
*The difference was statistically significant.
NASP-OLIF, navigation-assisted single position oblique lumbar interbody fusion; MIS-TLIF, minimally invasive surgical transforaminal lumbar interbody fusion; VAS, visual analog scale; VASB: VAS for low back pain, VASL: VAS for leg pain; ODI, Oswestry disability index

The radiological outcomes of subjects in this study are shown in Table 4. The SD, IDH, IFA, SL, and CSA of subjects have better improvement. In the NASP-OLIF group, IDH and IFA remarkably improved at postoperative and last follow-up (P < 0.05). In contrast, SD, SL, and CSA were no apparent discrepancy between two groups on postoperative and last follow-up (P > 0.05). A total of 100 pedicle screws in NASP-OLIF group, were implanted (90 were grade A, 6 were grade B, 3 were grade C, 1 were grade D, None was grade E, according to the Gertzbein–Robbins scale). The satisfactory rate of 100 pedicle screws insertion was 96%. There were no serious complications such as screw-related nerve or vascular injuries. Typical conditions are shown in Figs. 2 and 3.

Table 4

Radiological outcomes of the NASP-OLIF and MIS-TLIF groups
	NASP-OLIF	MIS-TLIF	P value
Number of patients	25	28
SD (mm)
Preoperative	12.39 ± 1.83	13.04 ± 2.24	0.263
Postoperative	1.49 ± 0.3	1.45 ± 0.29	0.586
At the last follow-up	0.81 ± 0.33	0.76 ± 0.34	0.592
IDH (mm)
Preoperative	7.82 ± 1.1	7.74 ± 1.15	0.799
Postoperative	12.67 ± 0.79	10.15 ± 0.93	0.000^*
At the last follow-up	10.94 ± 0.84	8.63 ± 1.07	0.000^*
IFA (mm²)
Preoperative	99.19 ± 13.95	101.55 ± 12.02	0.519
Postoperative	188.66 ± 15.84	149.01 ± 10.64	0.000^*
At the last follow-up	168.88 ± 12.42	132.65 ± 11.54	0.000^*
SL (°)
Preoperative	8.92 ± 3.62	9.4 ± 4.71	0.669
Postoperative	14.38 ± 3.58	12.79 ± 3.56	0.118
At the last follow-up	12.73 ± 3.06	11.26 ± 3.01	0.092
CSA (mm²)
Preoperative	105.95 ± 18	103.1 ± 20.57	0.603
Postoperative	179.8 ± 20.82	186.43 ± 18.14	0.230
At the last follow-up	166.96 ± 19.79	170.38 ± 21.55	0.485
Number of screws inserted	100	112
Screw classification
Grade A	90 (90%)	89 (79.4%)
Grade B	6 (6%)	16 (14.3%)
Grade C	3 (3%)	4 (3.6%)
Grade D	1 (0%)	3 (2.7%)
Grade E	0 (0%)	0 (0%)
*The difference was statistically significant.
NASP-OLIF, navigation-assisted single position oblique lumbar interbody fusion; MIS-TILF, minimally invasive surgical transforaminal lumbar interbody fusion; SD, slipping distance; IDH, intervertebral disc height; IFA, intervertebral foraminal area; SL, segmental lordosis; CSA, spinal canal cross-sectional area

Lumbar interbody fusion is a prevalent surgical procedure for DLS for which TLIF can achieve slipping reduction, immediate segmental stability, and intervertebral fusion by direct decompression and posterior pedicle screw fixation, which is a prevalent fusion procedure for DLS [13]. Owing to the development of minimally invasive technology, MIS-TLIF utilizes tubular channels to expose the operative field. Compared with traditional TLIF, MIS-TLIF can minimize the injury of soft tissues and muscles which can lesson intraoperative blood loss, perioperative infection rate [14]. OLIF, a new minimally invasive fusion procedure, can expose the intervertebral disc completely and insert the cage as much as necessary. OLIF can correct DS through effective ligament stretching and can achieve reductions in slipping, immediate segmental stability, and intervertebral fusion. Simultaneously, OLIF can cause indirect decompression by providing segmental lordosis, expanding the foraminal area, restoring the spinal canal area, and so forth. Compared with posterior fusion, OLIF avoids damage to the posterior spinal structure and offers the advantages of shortening operation duration and reducing blood loss [15]. OLIF is widely used in clinical practice. For intervertebral instability, endplate injury, osteoporosis, and posterior revision surgery, OLIF should be supplemented with pedicle screw fixation [16]. Takayoshi et al. reported a mean 12-months fusion rate of 51 subjects treated with OLIF combined pedicle screw fixation was 87.2% [17]. In our study, no cage subsidence nor nonfusions were found at the last follow-up, providing further evidence that posterior pedicle screw fixation can descend the incident of cage settlement while increase intervertebral fusion rate.

Traditional OLIF involves inserting a cage in lateral decumbent position and PPS inserted in prone position. This turning of patient prolongs the operation time and increases risks including cage displacement, posterior peritoneal injury, anesthesia accidents, and so on [18–19]. In recent years, a navigation system combined with an O-arm system has been extensively applied in spinal surgery [20]. O-arm and Navigation system integrates three functions of intraoperative three-dimensional imaging: real-time infrared tracking, visual image display, and real-time feedback on the adjacent relationship between the screw and the bony structure. Therefore, the surgeon can track the position of the surgical instrument accurately which helps them to achieve pedicle screw insertion accurately [21]. We have modified the OLIF using the O-arm and navigation system to insert PPS in the lateral position. The advantages of this modified procedure include avoiding cage shifting, conserving medical supplies, and shortening the duration of the operation. In the NASP-OLIF group, 100 screws were implanted. The total screw insertion time was 30.16 ± 5.45 min, the per screw placement time was 7.54 ± 1.36 min, the adequate accuracy of screw placement rate was 96%, and no complications related to screw track dislocation occurred after the operation. Blizzard et al. clarified that the per screw placement time of this technology was 5.9 min and the adequate precision of the screw placement rate was 94.9% [22]. Additionally, it was reported that the adequate precision of the screw placement rate was 98.2% by Ouchida et al. [23]. In this study, the NASP-OLIF group had significantly shortened operation times, reduced intraoperative blood loss, and shortened postoperative first-floor activity duration. These changes may have occurred for the following reasons: (1) NASP-OLIF does not require changing the patient’s surgical position, which helped to reduce operation time; and (2) NASP-OLIF is based on O-arm navigation-assisted screw placement, which can assist with avoiding pedicle screw misplacement and shorten the operation duration. In another study, Wang et al. reported the surgical efficacy in 20 patients who underwent PLIF [24]. The study participants were divided into free-hand and O-arm groups according to different screw placement methods. The results indicated that the total operation time in the free-hand group was 255.19 ± 40.26 min, while that in the O-arm group was 222.55 ± 38 min. In conclusion, NASP-OLIF is a safe and efficient technique.

The study indicated that both NASP-OLIF and MIS-TLIF groups can obtain good surgical effects in the treatment of L4 DLS. IDH and IFA in the NASP-OLIF group were significantly improved on postoperative and the last follow-up, which may be related to the following reasons:

(1) NASP-OLIF can expose intervertebral disc completely, which helps for thorough removal of the intervertebral disc tissue. However, MIS-TLIF can only expose a part of the intervertebral disc; (2) The cage of NASP-OLIF is longer, wider, and more solid, and it is placed across the cortical bone on both sides of the intervertebral space; thus, it coffers intervertebral distraction and maintenance. Many biomechanical studies have shown that the cage of OLIF provides stronger stabilization than the cage of TLIF. Yuan et al. [25]. indicated that lateral cages was stiffer than bullet cages. It was also shown that the average stiffness of NASP-OLIF constructs was stronger than that of MIS-TLIF constructs; (3) Posterior PPS fixation was mainly used to maintain the postoperative vertebral space height, and both groups were treated with posterior PPS fixation. There were no difference in Segmental lordosis between groups on postoperative and last follow-up, which may be related to the following reasons: (1) The bony endplate may be injured during intervertebral decompression in two groups, which may lead to intervertebral subsidence after cage implantation, and the segmental lordosis is easily lost in postoperative follow-up; and (2) The cage of NASP-OLIF provides a specific lordosis (generally 6°). Further, the large cage inserted in anterior position of intervertebral disc can provide a certain segment lordosis; and (3) the correction of segmental lordosis mainly depends on the compression shortening of the structure of posterior pedicle screws and connecting rods. There was no remarkable difference of improvement in CSA between groups. However, the MIS-TLIF procedure could remove posterior bony ligament structures such as facet joints and ligamentum flavum, which can cause direct decompression in the spinal canal. NASP-OLIF was able to remove the intervertebral disc tissue completely and insert a large cage to stretch the ligament structure, which can cause indirect decompression in the spinal canal.

In this study, VAS and ODI of subjects between groups were improved on postoperative follow-up. It was shown that NASP-OLIF and MIS-TLIF can obtain a good surgical effect. However, the NASP-OLIF group had superior improvement in VASB and ODI on postoperative and last follow-up. This was because the NASP-OLIF group had less injury to paraspinal muscles and posterior bony structures.

This study has several limitations. First, the full-length spine radiography was not performed, and the parameters of the spine and pelvis were not evaluated. Second, the overall sample size was tiny and follow-up time was not longer. Multicenter clinical observations with large sample sizes and long-term follow-up are necessary to assess and compare clinical efficiency of NASP-OLIF and MIS-TLIF in the future. Third, as this study is a retrospective analysis, its results require confirmation by higher-level evidence.

This study assessed and compared the surgical efficacy of NASP-OLIF and MIS-TLIF, which found that both techniques can obtain favorable clinical efficacy for L4 DLS. However, compared with MIS-TLIF, NASP-OLIF is a safe and efficient technique with less local tissue injury and faster recovery. Its use may offer benefits toward efficiency, patient outcomes, and resource conservation.

MIS-OLIF: Minimally invasive surgical oblique lumbar interbody fusion

DLS: Degenerative lumbar Spondylolisthesis

NASP-OLIF: Navigation-assisted single position oblique lumbar interbody fusion

MIS-TLIF: Minimally invasive surgical transforaminal lumbar interbody fusion

VAS: Visual analog scale

VASB: VAS for low back pain

VASL: VAS for leg pain

ODI: Oswestry disability index

SD: slipping distance

SL: segmental lordosis

IFA: intervertebral foraminal area

IDH: intervertebral disc height

CSA: spinal canal cross-sectional area

PPS: percutaneous pedicle screws

OLIF: oblique lumbar interbody fusion

TLIF: transforaminal lumbar interbody fusion

Ethics approval and consent to participate

This study was approved by the medical ethics committee of Huazhong University of Science and Technology Union Shenzhen Hospital (approval number: 2022010). In this study, all surgical subjects participating known this study and signed the informed consent.

Consent for publication

All subjects agreed to publish their data.

Availability of data and materials

The data analyzed during this study are included in this published article, without undue reservation.

Competing interests

None of the authors have a conflict of interest.

Funding

This study was gratefully funded by Shenzhen Healthcare Research Project (SZLY2018012) and we sincerely thank all the participants and workers involved in this study.

Authors' contributions

All authors contributed to the design and conception of the study. Material preparation, data collection, and statistical analysis were done by HHW, DZY, MW and WHY. The first script of the manuscript was written by HHW, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Acknowledgments

None.

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No competing interests reported.

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Comparison of navigation-assisted single position oblique lumbar interbody fusion and minimally invasive surgical transforaminal lumbar interbody fusion in L4 degenerative lumbar spondylolisthesis: A retrospective analysis

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Materials And Methods

Study design

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NASP-OLIF

MIS-TLIF

Evaluating indicators

Statistical analysis

Results

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