Lateral lumbar interbody fusion, transpsoas, XLIF
The development of the lateral approach allows today the possibility of offering XLIF by this approach when the disc to fuse is above L5-S1. The risks of the anterior approach are eliminated and the neurophysiological monitoring of the nerves decreases the risk of traction injuries of the lumbar plexus in its transpsoas trajectory.
The XLIF procedure is what is termed a “minimally invasive” procedure. This means that instead of a traditional, larger single incision, the procedure is performed through one or more small incisions and an instrument known as a retractor is used to spread the tissues so that the surgeon can see the spine. This is made possible by the use of a dilator and retractor system, MaXcess®, developed by NuVasive®, Inc, in San Diego, CA. The system allows the surgeon to reach the spine via lateral access (from the side of the body).
- The XLIF procedure for lumbar fusion was developed to overcome the obstacles of both anterior (front) and posterior (back) approaches to access the spine. XLIF avoids significant musculature disruption by utilizing a natural path from the side of the body to the spine and provides significant benefits to patients, including reduced surgery time, less blood loss, shorter hospital stays, and significantly faster recovery time.
- The XLIF approach does not require back muscle and bone dissection or nerve retraction; it also allows for a more complete disc removal and predictable implant insertion, compared with traditional posterior procedures. XLIF also does not require the delicate abdominal exposure or present the same risk of vascular injury as traditional anterior procedures.
- Because the procedure is less disruptive than conventional posterior or anterior surgery, most patients are able to get up and walk around within a day of the surgery. In general, XLIF surgery results in faster recovery and return to normal activities.
- The less-disruptive lateral approach by NuVasive is a breakthrough for spine patients, but it is of particular benefit for active patients who want to return to their active lifestyles more quickly and easily, or those who cannot tolerate a larger, open procedure because of the increased risks of longer anesthesia time, greater blood loss, longer hospitalization, and longer recovery. Hospital Stay – 1-2 days with XLIF. 3-5 days with traditional surgery.
- The XLIF © minimally disruptive procedure can be performed for a number of situations. Any thoracolumbar case above L5-S1 requiring access to the disc space and/or vertebral bodies. It is important that you discuss the potential risks, complications, and benefits of XLIF © with your doctor prior to receiving treatment, and that you rely on your physician’s judgment. Only your doctor can determine whether you are a suitable candidate for this treatment.
The benefits of this technique, include minimal morbidity, avoiding mobilization of the great vessels, preserving the ALL, biomechanically stable orientation, and broader revision options than in anterior approach.
Minimally invasive spine surgery technology allows surgeons to reach the spine through several smaller incisions (as opposed to a single large incision). Some surgeons believe minimally invasive surgery is advantageous because it may allow for less tissue trauma, less scarring, shorter hospital stays and less postoperative discomfort, thereby affording a decreased need for post-operative pain medication.
Like all minimally invasive spine surgery techniques, the XL procedure was designed to treat disorders of the spine with the least amount of tissue (muscle, ligament, blood vessels and abdominal organs) disruption possible, so that there is minimal tissue-related damage from the surgery and the recovery time is therefore reduced.
There are a series of steps to complete an XL TDR:
- First, the patient will be positioned lying on his or her side. Then the surgeon will use x-rays to locate the disc that will be removed.
- Once the disc is located, the surgeon will mark the skin with a marker directly above the disc.
- Then the surgeon will make a small incision (cut) in the flank (low back region of the trunk) and use his or her finger to push away the peritoneum (sac covering the abdominal organs) from the abdominal wall.
- The surgeon will make a second incision directly on the side of the patient.
- The surgeon will then insert a tube-like instrument known as a dilator into this incision.
- The surgeon will use x-rays to make sure that this dilator is in a good position above the disc.
- The surgeon will then insert a probe (blunt tool) through a muscle known as the psoas muscle. The psoas muscle is a large muscle that runs from the lower spine, wrapping around the pelvic area and attaches at the hip. A monitoring device allows detecting any retraction stress on the nerves allowing replacing the retractor in a position avoiding the nerve stretching a potential damage.
- A complete discectomy is performed
- The appropriate ADR prosthesis size is selected and inserted in the void disc space with a controlled distraction to recover the desired disc space height.
With an XL procedure, the following recovery facts are typical:
- Pain at the incision sites after surgery is normal and should be expected. This pain should eventually go away and should be easily controlled with oral pain medication that is prescribed upon discharge from the hospital.
- Because the XL surgery only splits muscles but does not cut muscles), many patients are able to get up and walk around the night after they have had surgery.
- The total time a patient spends in the hospital after the surgery depends on several factors, such as the number of vertebral levels that were treated, the severity of the problem and the patient’s overall health.
- Some patients who undergo an XL procedure are able to return home the same day as the surgery; others require a stay of a few days in the hospital.
- Most patients are able to return to their normal activities within a few months of surgery.
Anterior fusion, lumbar ALIF and cervical ACDF
Some surgeons prefer accessing the disc space through an anterior incision in the abdomen, called an anterior lumbar interbody fusion (ALIF).
An anterior approach affords the best exposure to the disc space. It allows a large device to be used for the fusion, increasing the surface area for a fusion to set up and allowing for more postoperative stability. An anterior approach often makes it possible for a better reduction of the deformity caused by the spondylolisthesis.
Jacking the disc open in the front re-establishes the patient’s normal sagittal alignment, giving them a more normal inward curve to their low back. This approach does require an extra incision in the abdomen, in addition to an incision in the low back.
There is also the added risk of a great vessel injury, as the aorta and vena cava lie in front of the spine. However, with an experienced vascular and spine surgeon team, the risk of a vessel injury should be very low, and the benefits of added stability and fusion area very often outweigh the risks of the extra surgery.
For male patients having an ALIF at L5-S1, there is a risk of retrograde ejaculation, in which the ejaculation goes into the bladder. This is a 1% risk, and will often resolve spontaneously in about a year. The biggest problem retrograde ejaculation causes is increased difficulty in conceiving a child, although it is still possible.
Percutaneous transpedicular screws for lumbar fusion
Percutaneous fixation is an elegant method by which pedicles screws are inserted through small incision in the skin guided by neuronavigation or radioscopically. The screws system is canulated to easy the insertion procedure. The system provides elements to make a reduction, such as those needed for spondylolisthesis. Then it can still be distracted, i.e. stretched and finally, the screws are connected with rods and secured with nuts.
Lumbar spinal fusion is designed to stabilize or stop the motion of the vertebral segment where the degenerated disc is located. The operation involves accessing the segment through a back incision.
Presently percutaneous techniques have minimized the soft tissue damage to a minimum. The hardware (such as pedicle screws, interbody cage, spacers, or structural bone graft) used to temporarily immobilize the affected segment while the fusion is healing, is inserted through this minimal access technique.
We prefer percutaneous pedicles screws with XLIF (extreme lateral interbody fusion) in the majority of cases, but TILF transforaminal (removing one entire facet joint) interbody lumbar fusion and ALIF (anterior incision in the abdomen) anterior lumbar interbody fusion remain the best option in selected cases.
The XLIF procedure for lumbar fusion was developed to overcome the obstacles of both anterior (front) and posterior (back) approaches to access the spine.
XLIF avoids significant musculature disruption by utilizing a natural path from the side of the body to the spine and provides significant benefits to patients, including reduced surgery time, less blood loss, shorter hospital stays, and significantly faster recovery time.
The XLIF approach does not require back muscle and bone dissection or nerve retraction; it also allows for a more complete disc removal and predictable implant insertion, compared with traditional posterior procedures. XLIF also does not require the delicate abdominal exposure or present the same risk of vascular injury as traditional anterior procedures.
Because the procedure is less disruptive than conventional posterior or anterior surgery, most patients are able to get up and walk within approximately a day of the surgery.
In general, XLIF surgery results in faster recovery and the patient is able to get up the next day and return to normal activities shortly after.
Posterior transforaminal interbody fusion TLIF
A posterior fusion (approached from the back) with pedicle screw instrumentation is generally considered the gold standard of spinal fusion for spondylolisthesis. However, there is also an increasing acceptance that an accompanying fusion of the disc space can lead to a better fusion and increased stability.
About 80% of the stress goes through the disc space, so supporting the anterior column (the disc space in the front of the spinal column) with a fusion greatly increases the stiffness of the fusion construct. The manner in which the disc is fused is largely guided by the surgeon’s preference.
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