Tag: extreme lateral interbody fusion

Posted on

The role of XLIF in spinal revision surgery involving failed interbody implants

Acta Neurochirurgica (2025) 167:221

This review evaluates the use of Extreme Lateral Interbody Fusion (XLIF) for removing failed spinal implants. XLIF offers advantages over traditional approaches, including reduced operative risk, blood loss, and hospital stay, but requires surgical expertise due to potential nerve and vascular complications.

• XLIF (Extreme Lateral Interbody Fusion) is increasingly used for spinal revision surgery to remove failed interbody implants and other foreign bodies.

• A systematic literature review identified only a few published cases (seven documented, four included) using XLIF for this purpose.

• XLIF offers advantages over anterior and posterior approaches, including reduced operative time, less blood loss, shorter hospital stays, and safer navigation around scar tissue and neurovascular structures.

• The technique allows for insertion of larger interbody cages, improving spinal stability and fusion outcomes.

• Most reported complications are minor and transient, such as temporary nerve injury, but careful patient selection and surgical expertise are required.

• XLIF is especially valuable in complex revision cases where traditional approaches pose higher risks due to scar tissue or anatomical challenges.

• Current evidence is limited to case reports and small series; more robust studies are needed to validate safety and efficacy.

Posted on

Lateral Transpsoas Interbody Fusion

International Journal of Spine Surgery, Vol. 19, No. S1, 2025, pp. S7–S18

• The lateral transpsoas approach to lumbar interbody fusion is widely adopted for various indications, offering benefits like disc height restoration and alignment correction, despite its risks such as bowel and vascular injury.

• XLIF (Extreme Lateral Interbody Fusion) is a minimally invasive technique introduced in 2006, primarily for degenerative disc disease, and has since expanded for other spinal conditions.

• The approach’s benefits include preserving the anterior and posterior longitudinal ligaments and creating a stable mechanical environment for alignment correction.

• Risks and complications include potential nerve injuries with variable incidences, anterior thigh pain, and vascular injuries, especially at L4-L5 levels due to anatomical constraints.

• Preoperative imaging and patient positioning are crucial for safety, involving detailed assessments of neurovascular structures and careful positioning to minimize risks.

• Intraoperative neuromonitoring is essential for protecting the lumbar plexus, with multimodal approaches recommended for enhanced safety.

• Outcomes of the approach have shown reliable fusion rates and significant improvements in pain and function, making it a valuable tool in spine surgery.

• Training and technique precision are critical for minimizing complications and maximizing the benefits of this minimally invasive approach.

Posted on

Complications associated with single-position prone lateral lumbar interbody fusion

J Neurosurg Spine 39:380–386, 2023

Lateral lumbar interbody fusion (LLIF) is a workhorse surgical approach for lumbar arthrodesis. There is growing interest in techniques for performing single-position surgery in which LLIF and pedicle screw fixation are performed with the patient in the prone position. Most studies of prone LLIF are of poor quality and without long-term followup; therefore, the complication profile related to this novel approach is not well known. The objective of this study was to perform a systematic review and pooled analysis to understand the safety profile of prone LLIF.

METHODS A systematic review of the literature and a pooled analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting prone LLIF were assessed for inclusion. Studies not reporting complication rates were excluded.

RESULTS Ten studies meeting the inclusion criteria were analyzed. Overall, 286 patients were treated with prone LLIF across these studies, and a mean (SD) of 1.3 (0.2) levels per patient were treated. The 18 intraoperative complications reported included cage subsidence (3.8% [3/78]), anterior longitudinal ligament rupture (2.3% [5/215]), cage repositioning (2.1% [2/95]), segmental artery injury (2.0% [5/244]), aborted prone interbody placement (0.8% [2/244]), and durotomy (0.6% [1/156]). No major vascular or peritoneal injuries were reported. Sixty-eight postoperative complications occurred, including hip flexor weakness (17.8% [21/118]), thigh and groin sensory symptoms (13.3% [31/233]), revision surgery (3.8% [3/78]), wound infection (1.9% [3/156]), psoas hematoma (1.3% [2/156]), and motor neural injury (1.2% [2/166]).

CONCLUSIONS Single-position LLIF in the prone position appears to be a safe surgical approach with a low complication profile. Longer-term follow-up and prospective studies are needed to better characterize the long-term complication rates related to this approach.

Posted on

The impact of cage positioning on lumbar lordosis and disc space restoration following minimally invasive lateral lumbar interbody fusion

Neurosurg Focus 54(1):E7, 2023

OBJECTIVE The objective of this study was to evaluate patient and surgical factors that predict increased overall lumbar lordosis (LL) and segmental lordosis correction following a minimally invasive lateral lumbar interbody fusion (LLIF) procedure.

METHODS A retrospective review was conducted of all patients who underwent one- or two-level LLIF. Preoperative, initial postoperative, and 6-month postoperative measurements of LL, segmental lordosis, anterior disc height, and posterior disc height were collected from standing lateral radiographs for each patient. Cage placement was measured utilizing the center point ratio (CPR) on immediate postoperative radiographs. Spearman correlations were used to assess associations between cage lordosis and radiographic parameters. Multivariate linear regression was performed to assess independent predictors of outcomes.

RESULTS A total of 106 levels in 78 unique patients were included. Most procedures involved fusion of one level (n = 50, 64.1%), most commonly L3–4 (46.2%). Despite no differences in baseline segmental lordosis, patients with anteriorly or centrally placed cages experienced the greatest segmental lordosis correction immediately (mean anterior 4.81° and central 4.46° vs posterior 2.47°, p = 0.0315) and at 6 months postoperatively, and patients with anteriorly placed cages had greater overall lordosis correction postoperatively (mean 6.30°, p = 0.0338). At the 6-month follow-up, patients with anteriorly placed cages experienced the greatest increase in anterior disc height (mean anterior 6.24 mm vs posterior 3.69 mm, p = 0.0122). Cages placed more posteriorly increased the change in posterior disc height postoperatively (mean posterior 4.91 mm vs anterior 1.80 mm, p = 0.0001) and at 6 months (mean posterior 4.18 mm vs anterior 2.06 mm, p = 0.0255). There were no correlations between cage lordotic angle and outcomes. On multivariate regression, anterior cage placement predicted greater 6-month improvement in segmental lordosis, while posterior placement predicted greater 6-month improvement in posterior disc height. Percutaneous screw placement, cage lordotic angle, and cage height did not independently predict any radiographic outcomes.

CONCLUSIONS LLIF procedures reliably improve LL and increase intervertebral disc space. Anterior cage placement improves the lordosis angle greater than posterior placement, which better corrects sagittal alignment, but there is still a significant improvement in lordosis even with a posteriorly placed cage. Posterior cage placement provides greater restoration in posterior disc space height, maximizing indirect decompression, but even the anteriorly placed cages provided indirect decompression. Cage parameters including cage height, lordosis angle, and material do not impact radiographic improvement.

Posted on

Major vascular injury following lateral transpsoas approach

Major vascular injury following lateral transpsoas approach

J Neurosurg Spine 21:794–798, 2014

Extreme lateral interbody fusion (XLIF) has gained popularity among spine surgeons for treating multiple conditions of the lumbar spine. In contrast to the anterior lumbar interbody fusion (ALIF) approach, the minimally invasive XLIF approach affords wide access to the lumbar disc space without an access surgeon and causes minimal tissue disruption. The XLIF approach offers many advantages over other lumbar spine approaches, with a reportedly low complication profile.

The authors describe the first fatality reported in the literature following an XLIF approach. They describe the case of a 50-year-old woman who suffered a fatal intraoperative injury to the great vessels during a lateral transpsoas approach to the L4–5 disc space.

Posted on

Radiological and clinical outcomes following extreme lateral interbody fusion

Radiological and clinical outcomes following extreme lateral interbody fusion

 J Neurosurg Spine 20:623–635, 2014

Extreme lateral interbody fusion (ELIF) is a popular technique for anterior fixation of the thoracolumbar spine. Clinical and radiological outcome studies are required to assess safety and efficacy. The aim of this study was to describe the functional and radiological impact of ELIF in a degenerative disc disease population with a longer follow-up and to assess the durability of this procedure.

Methods. Demographic and perioperative data for all patients who had undergone ELIF for degenerative lumbar disorders between 2007 and 2011 were collected. Trauma and tumor cases were excluded. For radiological outcome, the preoperative, immediate postoperative, and latest follow-up coronal Cobb angle, lumbar sagittal lordosis, bilateral foraminal heights, and disc heights were measured. Pelvic incidence (PI) and PI–lumbar lordosis (PI-LL) mismatch were assessed in scoliotic patients. Clinical outcome was evaluated using the Oswestry Disability Index (ODI) and visual analog scale (VAS), as well as the Macnab criteria.

Results. One hundred forty-five vertebral levels were surgically treated in 90 patients. Pedicle screw and rod constructs and lateral plates were used to stabilize fixation in 77% and 13% of cases, respectively. Ten percent of cases involved stand-alone cages. At an average radiological follow-up of 12.6 months, the coronal Cobb angle was 10.6° compared with 23.8° preoperatively (p < 0.0001). Lumbar sagittal lordosis increased by 5.3° postoperatively (p < 0.0001) and by 2.9° at the latest follow-up (p = 0.014). Foraminal height and disc height increased by 4 mm (p < 0.0001) and 3.3 mm (p < 0.0001), respectively, immediately after surgery and remained significantly improved at the last follow-up. Separate evaluation of scoliotic patients showed no statistically significant improvement in PI and PI-LL mismatch either immediately postoperatively or at the latest follow-up. Clinical evaluation at an average follow-up of 17.6 months revealed an improvement in the ODI and the VAS scores for back, buttock, and leg pain by 21.1% and 3.7, 3.6, and 3.7 points, respectively (p < 0.0001). According to the Macnab criteria, 84.8% of patients had an excellent, good, or fair functional outcome. New postoperative thigh numbness and weakness was detected in 4.4% and 2.2% of the patients, respectively, which resolved within the first 3 months after surgery in all but 1 case.

Conclusions. This study provides what is to the authors’ knowledge the most comprehensive set of radiological and clinical outcomes of ELIF in a fairly large population at a midterm follow-up. Extreme lateral interbody fusion showed good clinical outcomes with a low complication rate. The procedure allows for at least midterm clinically effective restoration of disc and foraminal heights. Improvement in coronal deformity and a small but significant increase in sagittal lordosis were observed. Nonetheless, no significant improvement in the PI-LL mismatch was achieved in scoliotic patients.

Posted on

Mini-open lateral approach for thoracic disc herniation

J Neurosurg Spine 16:264–279, 2012. DOI: 10.3171/2011.10.SPINE11291

Symptomatic herniated thoracic discs remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less invasive approaches. Many of these techniques, such as thoracoscopy, have not been widely adopted due to technical difficulties. The current study was performed to examine the safety and early results of a minimally invasive lateral approach for symptomatic thoracic herniated intervertebral discs.

Methods. Sixty patients from 5 institutions were treated using a mini-open lateral approach for 75 symptomatic thoracic herniated discs with or without calcification. The mean age was 57.9 years (range 23–80 years), and 53.3% of the patients were male. Treatment levels ranged from T4–5 to T11–12, with 1–3 levels being treated (mean 1.3 levels). The most common levels treated were T11–12 (14 cases [18.7%]), T7–8 (12 cases [16%]), and T8–9 (12 cases [16%]). Symptoms included myelopathy in 70% of cases, radiculopathy in 51.7%, axial back pain in 76.7%, and bladder and/or bowel dysfunction in 26.7%. Instrumentation included an interbody spacer in all but 6 cases (10%). Supplemental internal fixation included anterolateral plating in 33.3% of cases and pedicle screws in 10%; there was no supplemental internal fixation in 56.7% of cases. Follow-up ranged from 0.5 to 24 months (mean 11.0 months).

Results. The median operating time, estimated blood loss, and length of stay were 182 minutes, 290 ml, and 5.0 days, respectively. Four major complications occurred (6.7%): pneumonia in 1 patient (1.7%); extrapleural free air in 1 patient (1.7%), treated with chest tube placement; new lower-extremity weakness in 1 patient (1.7%); and wound infection in posterior instrumentation in 1 patient (1.7%). Reoperations occurred in 3 cases (5%): one for posterior reexploration, one for infection in posterior instrumentation, and one for removal of symptomatic residual disc material. Back pain, measured using the visual analog scale, improved 60% from the preoperative score to the last follow-up, that is, from 7.8 to 3.1. Excellent or good overall outcomes were achieved in 80% of the patients, a fair or unchanged outcome resulted in 15%, and a poor outcome occurred in 5%. Moreover, myelopathy, radiculopathy, axial back pain, and bladder and/or bowel dysfunction improved in 83.3%, 87.0%, 91.1%, and 87.5% of cases, respectively.

Conclusions. The authors’ early experience with a large multicenter series suggested that the minimally invasive lateral approach is a safe, reproducible, and efficacious procedure for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional surgical techniques and without the use of endoscopes. Symptom resolution was achieved at similar rates using this approach as compared with the most efficacious techniques in the literature, and with fewer complications in most circumstances.

Posted on

Lumbar total disc replacement from an extreme lateral approach: clinical experience with a minimum of 2 years’ follow-up

J Neurosurg Spine 14:38–45, 2011. (DOI: 10.3171/2010.9.SPINE09865)

Current lumbar total disc replacement (TDR) devices require an anterior approach for implantation. This approach has inherent limitations, including risks to abdominal structures and the need for resection of the anterior longitudinal ligament (ALL). Placement of a TDR device from a true lateral (extreme lateral interbody fusion [XLIF]) approach is thought to offer a less invasive option to access the disc space, preserving the stabilizing ligaments and avoiding scarring of anterior vasculature. In this study, the authors attempted to quantify the clinical and radiographic outcomes of a lateral approach to lumbar TDR from a prospective, single-center experience.

Methods. A TDR device designed for implantation through a true lateral, retroperitoneal, transpsoas approach (XLIF) was implanted in 36 patients with discography-confirmed 1- or 2-level degenerative disc disease. Clinical (pain and function) and radiographic (range of motion [ROM]) data were prospectively collected preoperatively, postoperatively, and serially for a minimum of 24 months’ follow-up.

Results. Thirty-six surgeries were performed in 16 men and 20 women (mean age 42.6 years). Surgeries included 15 single-level TDR procedures at L3–4 or L4–5, three 2-level TDR procedures spanning L3–4 and L4–5, and 18 hybrid procedures (anterior lumbar interbody fusion [ALIF]) at L5–S1 and TDR at L4–5 [17] or L3–4 [1]). Operative time averaged 130 minutes, with an average blood loss of 60 ml and no intraoperative complications. Postoperative radiographs showed good device placement. All patients were walking within 12 hours of surgery and all but 9 were discharged the next day (7 of 9 had hybrid TDR/ALIF procedures). Five patients (13.8%) had psoas weakness and 3 (8.3%) had anterior thigh numbness postoperatively, both resolving within 2 weeks. One patient (2.8%) demonstrated weakness of the leg ipsilateral to the approach side, which lasted through the 3-month visit but was resolved by the 6-month visit. One patient (2.8%) was found to have hypertrophy of the quadriceps contralateral to the approach side at the 12-month visit, which was resolved by the 2-year visit. Four patients (11%) had postoperative facet joint pain, all in hybrid cases. All patients were 2 years or more postsurgery as of this writing, although 3 were lost to follow-up between the 1- and 2-year visits. In 2 cases (5.6%), removal of the TDR device and revision to fusion were required due to unresolved pain. At 2 years’ follow-up, the average visual analog scale and Oswestry Disability Index scores had improved 69.6% and 61.4%, respectively, and ROM averaged 8.6°, well within physiological norms.

Conclusions. Long-term results of a laterally placed TDR device demonstrate maintenance of pain relief and functional improvement. The benefits of this technique—minimal morbidity, avoiding mobilization of the great vessels, preserving the ALL, biomechanically stable orientation, and broader revision options—suggest a promising new direction for TDR procedures.

Proudly powered by WordPress