Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Jun 18, 2021; 12(6): 445-455
Published online Jun 18, 2021. doi: 10.5312/wjo.v12.i6.445
Nuances of oblique lumbar interbody fusion at L5-S1: Three case reports
Chirag A Berry
Chirag A Berry, Department of Orthopaedics, Cincinnati VA Medical Center, Cincinnati, OH 45220, United States
Author contributions: Berry CA contributed to all aspects of this manuscript, namely, conception, design, data collection and interpretation, literature review, primary surgeon of all patients, drafting, revisions, and final approval.
Informed consent statement: Informed written consent was obtained from each patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The author declares that they have no conflict of interest.
CARE Checklist (2016) statement: The author has read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Chirag A Berry, MD, Assistant Professor, Department of Orthopaedics, Cincinnati VA Medical Center, 3200 Vine Street, Cincinnati, OH 45220, United States.
Received: February 15, 2021
Peer-review started: February 15, 2021
First decision: May 3, 2021
Revised: May 4, 2021
Accepted: May 27, 2021
Article in press: May 27, 2021
Published online: June 18, 2021

Oblique lumbar interbody fusion is a mini-open retroperitoneal approach that uses a wide corridor between the left psoas muscle and the aorta above L5. This approach avoids the limitations of lateral lumbar interbody fusion, is considered less invasive than anterior lumbar interbody fusion, and is similarly effective for indirect decompression and improving lordosis while maintaining a low complication profile. Including L5-S1, when required, adds to these advantages, as this allows single-position surgery. However, variations in vascular anatomy can affect the ease of access to the L5-S1 disc. The nuances of three different oblique anterolateral techniques to access L5-S1 for interbody fusion, namely, left-sided intra-bifurcation, left-sided pre-psoas, and right-sided pre-psoas approaches, are illustrated using three representative case studies.


Cases of three patients who underwent multilevel oblique lumbar interbody fusion including L5-S1, using one of the three different techniques, are described. All patients presented with symptomatic degenerative lumbar pathology and failed conservative management prior to surgery. The anatomical considerations that affected the decisions to utilize each approach are discussed. The pros and cons of each approach are also discussed. A parasagittal facet line objectively assesses the relationship between the left common iliac vein and the L5-S1 disc and assists in choosing the approach to L5-S1.


Oblique retroperitoneal access to L5-S1 in the lateral decubitus position is possible through three different approaches. The choice of approach to L5-S1 may be individualized based on a patient’s vascular anatomy using preoperative imaging. While most surgeons will rely on their experience and comfort level in choosing the approach, this article elucidates the nuances of each technique.

Keywords: Oblique lumbar interbody fusion, Prepsoas approach, Anterior to psoas, Common iliac vein, Iliolumbar vein, Case report

Core Tip: Oblique lumbar interbody fusion (OLIF) provides safe retroperitoneal access to nearly all lumbar levels, including L5-S1, thus, allowing single-position surgery. L5-S1 OLIF access may be attempted through three alternative approaches — left intra-bifurcation, left pre-psoas and right pre-psoas approaches — the choice of which can be customized according to the patient’s vascular anatomy.