Extreme lateral lumbar interbody fusion: Do the cons outweigh the pros?

Abstract

Background:Major factors prompted the development of minimally invasive (MIS) extreme lateral interbody fusion (XLIF; NuVasive Inc., San Diego, CA, USE) for the thoracic/lumbar spine. These include providing interbody stabilization and indirect neural decompression while avoiding major visceral/vessel injury as seen with anterior lumbar interbody fusion (ALIF), and to avert trauma to paraspinal muscles/facet joints found with transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterior-lateral fusion techniques (PLF). Although anticipated pros of MIS XLIF included reduced blood loss, operative time, and length of stay (LOS), they also included, higher fusion, and lower infection rates. Unanticipated cons, however, included increased morbidity/mortality rates.Methods:We assessed the pros and cons (e.g., risks, complications, comparable value/superiority/inferiority, morbidity/mortality) of MIS XLIF vs. ALIF, TLIF, PLIF, and PLF.Results:Pros of XLIF included various biomechanical and technical surgical advantages, along with multiple cons vs. ALIF, TLIF, PLIF, and PLF. For example, XLIF correlated with a considerably higher frequency of major neurological deficits vs. other constructs; plexus injuries 13.28%, sensory deficits 0–75% (permanent in 62.5%), motor deficits 0.7–33.6%, and anterior thigh pain 12.5–25%. XLIF also disproportionately contributed to other major morbidity/mortality; sympathectomy, major vascular injuries (some life-ending others life-threatening), bowel perforations, and seromas. Furthermore, multiple studies documented no superiority, and the potential inferiority of XLIF vs. ALIF, TLIF, PLIF, and PLF.Conclusion:Reviewing the pros of XLIF (e.g. radiographic, technical, biomechanical) vs. the cons (inferiority, increased morbidity/mortality) vs. ALIF, TLIF, PLIF, and PLF, we question whether XLIF should remain part of the lumbar spinal surgical armamentarium.

A UK-based pilot study of current surgical practice and implant preferences in lumbar fusion surgery

“…[ 26 , 27 ] Despite these advantages, XLIF has been also associated with a considerably higher frequency of neurological complications and other major morbidity. [ 28 ] XLIF usually utilizes a single ovoid implants and is anatomically indicated from the lumbar levels L1/L2 to L4/L5, whilst it is avoided at the L5/S1 level. [ 7 ] Indications for XLIF combined with posterior fixation include lumbar spinal stenosis and adjacent segment disease.…”

Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4–5

“…22,25 Neurological complications associated with lateral approaches are frequently discussed in the literature. 5,18 Previous anatomical and radiographic evaluations have identified that the lumbar plexus migrates dorsally to ventrally from L2-3 as the lumbosacral plexus descends caudally to the L4-5 and L5-S1 levels. 3,10,30 The underlying anatomical arrangement can endanger the lumbosacral plexus in a transpsoas approach to the L4-5 level.…”

“…1,11,15,25,27 However, concerns exist about the rate of neurological complications associated with the lateral approach. 5,10,14,24 Furthermore, these complications are most conspicuous at the L4-5 level due to the anatomical arrangement of the lumbar plexus with narrower safe working zones more inferiorly in the lower lumbar spine. 30 Anterolisthesis at the L4-5 level serves to exacerbate this risk.…”

Lateral Lumbar Interbody Fusion, Indications and Complications—An Updated Review

“…Epstein showed minimal invasive surgeries (TLIF, PLIF, ALIF, LLIF) has a higher incidence of root injuries, radiculitis or plexopathy [33][34][35]. He recommended LLIF was not safe, and we should stop this procedure.…”