I recently published a case series of patients with either complex medical problems or complex past spinal surgery (or both!) who had received XLIF surgery. This was from work and surgeries done during my complex spinal surgery fellowship at Guy’s and St Thomas’ Hospital with Mr. Khai Lam, a technically excellent orthopaedic spinal surgeon now working at London Bridge Hospital.
XLIF (eXtreme Lateral Interbody Fusion) is a minimally invasive spinal fusion surgery where a small cut is made in the patient’s flank and an artificial cage filled with bone substitute inserted into the disc space. Our experience was that it was best complemented by minimally invasive percutaneous pedicle screws placed on both sides of the spine to keep the construct straight and strong. My take home message from my research is that, with XLIF being a brief surgery with a small cut and minimal tissue disruption and muscle cutting compared to some other fusion surgeries like conventional TLIF or PLIF, it is well suited to patients who might have medical problems like obesity, diabetes, atrial fibrillation or otherwise not be the best candidates for a bigger operation. Patients went home soon after surgery with pain and quality of life much improved. My research showed it can effectively ‘indirectly decompress’ moderately squashed spinal nerves.
Other advantages of XLIF are that the wider surface area of the cage means fusion should be at least as good as for TLIF and for patients with a curved or a flat back, the scoliosis can be corrected somewhat and the lordosis improved.
Two important drawbacks to XLIF are that it is limited to certain levels of the lumbar spine (best from T12 to L5) and that there is a fair risk of altered or reduced sensation in the legs, in particular the feet. This commonly resolves after a few weeks and is usually due to traction on the lumbosacral plexus. I’ve found the best way to minimise this risk is to be in and out of the XLIF part of the surgery as quickly as possible. I use lumbosacral plexus monitoring for the surgery to keep this risk down.
XLIF is a recent and useful addition to the complex spine surgeon’s thoracolumbar spinal surgical toolbox and I’m pleased to be able to make a contribution to the literature on it and add it to the list of surgeries I can offer patients for whom it is best suited.