Elsevier

The Spine Journal

Volume 6, Issue 4, July–August 2006, Pages 435-443
The Spine Journal

Technical Report
Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion

https://doi.org/10.1016/j.spinee.2005.08.012Get rights and content

Abstract

Background

Minimally disruptive approaches to the anterior lumbar spine continue to evolve in a quest to reduce approach-related morbidity. A lateral retroperitoneal, trans-psoas approach to the anterior disc space allows for complete discectomy, distraction, and interbody fusion without the need for an approach surgeon.

Purpose

To demonstrate the feasibility of a minimally disruptive lateral retroperitoneal approach and the advantages to patient recovery.

Methods/results

The extreme lateral approach (Extreme Lateral Interbody Fusion [XLIF]) is described in a step-wise manner. There have been no complications thus far in the author's first 13 patients.

Conclusions

The XLIF approach allows for anterior access to the disc space without an approach surgeon or the complications of an anterior intra-abdominal procedure. Longer-term follow-up and data analysis are under way, but initial findings are encouraging.

Introduction

Since 1991, when Obenchain described the first laparoscopic lumbar discectomy [1], the field of minimally invasive spine surgery has continued to evolve. Surgeon and patient alike have been attracted by the advantages of minimally invasive surgery, including less tissue trauma during the surgical approach, less postoperative pain, shorter hospital stays, and faster return to activities of daily living. These reported advantages led to the laparoscopic anterior lumbar approach and mini-open anterior lumbar interbody fusion (ALIF) becoming commonly performed procedures [2], [3], [4], [5], [6], [7].

However, greater acceptance of these minimally invasive procedures has been hampered by known complications and challenges associated with endoscopic spine surgery. Reported problems include anesthetic complications [8], visceral damage [9], large vessel bleeding [10], [11], and sexual dysfunction [12], [13]. Surgeons attempting to use this surgical technique are challenged by the required technical skills, steep learning curve, and continued requirement for access surgeon.

The current report describes a novel, minimally disruptive spine procedure called the Extreme Lateral Interbody Fusion or XLIF (NuVasive, Inc., San Diego, CA). This technique is novel in that it can be used to gain access to the lumbar spine via a lateral approach that passes through the retroperitoneal fat and psoas major muscle. Hence, the potential complications with an anterior transperitoneal approach to the lumbar spine can be avoided, major vessels are not encountered, an anterior access is not required, and the procedure can be done through two, 3–4-cm incisions. Here we report the techniques of this approach to the lower lumbar spine.

Section snippets

Patient selection and surgical indications

Patients who presented with axial low back pain without severe central canal stenosis were considered candidates for this surgery if they failed at least 6 months of conservative, traditional nonoperative management. Contraindications included significant central canal stenosis, significant rotatory scoliosis, and moderate to severe spondylolisthesis. In some patients, discography was used as a tool to assist in level selection. The group of patients is essentially the same as those with

Results

During preoperative consultation, all patients were informed of all surgical options including ALIF, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion (TLIF), and XLIF. A complete discussion and description of the XLIF technique was described to all patients interested in the technique. Informed consent was attained for every patient.

All XLIF procedures were supplemented with percutaneous pedicle screw fixation (either immediate or staged), and all procedures concluded

Discussion

New techniques and technologies continue to push the limits of minimally invasive spine surgery [19]. Laparoscopic ALIF has been reported to be a safe surgical technique [2] and is commonly performed [2], [3], [4], [5], [6], [7]. The primary advantages over the open surgical approach are less tissue trauma, reduced postoperative pain, shorter hospital stays, and earlier return to work. Nonetheless, the advantages of laparoscopy over open techniques have recently been questioned [20].

Conclusion

Given the known complications and challenges of endoscopic spine surgery, the XLIF may be a valuable alternative to laparoscopic anterior approaches for an interbody spine fusion. Subsequent articles shall report our longer-term follow-up data and efficacy. As comfort with this technique expands, so too do the indications for it. It has more recently also been used to treat low-grade spondylolisthesis and adult degenerative lumbar scoliosis with great success [27]. Longer follow-up is certainly

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