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KEY FACTS
Terminology
Procedure
Outcomes
TERMINOLOGY
Abbreviations
- Extreme lateral interbody fusion (XLIF)
- Direct lateral interbody fusion (DLIF)
- Lateral lumbar interbody fusion (LLIF)
XLIF
- Minimally invasive techniques to approach disc space from a lateral (trans-psoas) direction
- Originally described for mid lumbar spine
- Role has expanded with use for thoracolumbar and thoracic spine
Lumbosacral Plexus Anatomy
- Critical to avoid plexus in trans-psoas approaches
- Anterior rami of L1-4 coalesce in psoas muscle to form plexus
- Branching from plexus are
- Obturator nerve (L2-4) passes through posterior psoas and exits posteromedially
- Femoral nerve (L2-4) passes through posterior psoas and exits posterolaterally
- Innervates hip flexor and knee extensor muscles
- Distal anterior and medial cutaneous branches provide sensory innervation of anterior and medial thigh
- Primary sensory cutaneous nerves
- Iliohypogastric nerve (T12-L1)
- Ilioinguinal nerve (L-1)
- Lateral femoral cutaneous nerve (L2-3)
- Innervates skin of lateral thigh down to knee
- Genitofemoral nerve (L1-2)
- Only nerve that exits anterior aspect of psoas and continues down anterior surface of muscle
- Prior to exiting psoas, nerve follows posterior to anterior path between L3 and L4
- Disc space divided into 6 zones from ventral to dorsal: A, I, II, III, IV, P (Moro method)
- A: Anterior aspect of anterior vertebral body
- P: Posterior aspect of posterior vertebral body
- Zones I-IV equally divide anterior to posterior vertebral body into 4
- Moro-defined plexus
- Zone P at L1-2 disc space
- Zone IV at L2-3
- Zone III for L3-4 and L4-5
- Safe zones based on vessels and plexus (Moro et al, Hu et al, Benglis et al)
- Right side
- Zones II-IV at L1-2
- Zones II-III at L2-3
- Zone II at L3-4 and L4-5
- Left side
- Zones II-IV at L1-2
- Zones II-III at L2-3
- Zone II at L3-4
- Zones I-II at L4-5
- Right side
- Genitofemoral nerve
- Located at L1-2 and L2-3 in zone IV and zone P
- Nerve passes obliquely through psoas at L3
PROCEDURE
Procedure Steps
OUTCOMES
Complications
Selected References
- Cummock MD et al: An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion. J Neurosurg Spine. 15(1):11-8, 2011
- Houten JK et al: Nerve injury during the transpsoas approach for lumbar fusion. J Neurosurg Spine. 15(3):280-4, 2011
- Hu WK et al: An MRI study of psoas major and abdominal large vessels with respect to the X/DLIF approach. Eur Spine J. 20(4):557-62, 2011
- Karikari IO et al: Minimally invasive lumbar interbody fusion in patients older than 70 years of age: analysis of peri- and postoperative complications. Neurosurgery. 68(4):897-902; discussion 902, 2011
- Kepler CK et al: Anatomy of the psoas muscle and lumbar plexus with respect to the surgical approach for lateral transpsoas interbody fusion. Eur Spine J. 20(4):550-6, 2011
- Pimenta L et al: Lumbar total disc replacement from an extreme lateral approach: clinical experience with a minimum of 2 years' follow-up. J Neurosurg Spine. 14(1):38-45, 2011
- Rodgers WB et al: Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 36(1):26-32, 2011
- Sharma AK et al: Lateral lumbar interbody fusion: clinical and radiographic outcomes at 1 year: a preliminary report. J Spinal Disord Tech. 24(4):242-50, 2011
- Tohmeh AG et al: Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine. 14(1):31-7, 2011
- Cappuccino A et al: Biomechanical analysis and review of lateral lumbar fusion constructs. Spine (Phila Pa 1976). 35(26 Suppl):S361-7, 2010
- Daffner SD et al: Migrated XLIF cage: case report and discussion of surgical technique. Orthopedics. 33(7):518, 2010
- Isaacs RE et al: A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine (Phila Pa 1976). 35(26 Suppl):S322-30, 2010
- Jahangiri FR et al: Protecting the genitofemoral nerve during direct/extreme lateral interbody fusion (DLIF/XLIF) procedures. Am J Electroneurodiagnostic Technol. 50(4):321-35, 2010
- Oliveira L et al: A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements. Spine (Phila Pa 1976). 35(26 Suppl):S331-7, 2010
- Rodgers WB et al: Early complications of extreme lateral interbody fusion in the obese. J Spinal Disord Tech. 23(6):393-7, 2010
- Rodgers WB et al: Lumbar fusion in octogenarians: the promise of minimally invasive surgery. Spine (Phila Pa 1976). 35(26 Suppl):S355-60, 2010
- Youssef JA et al: Minimally invasive surgery: lateral approach interbody fusion: results and review. Spine (Phila Pa 1976). 35(26 Suppl):S302-11, 2010
- Benglis DM et al: An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 10(2):139-44, 2009
- Ozgur BM et al: Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 6(4):435-43, 2006
- Moro T et al: An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery. Spine (Phila Pa 1976). 28(5):423-8; discussion 427-8, 2003
Related Anatomy
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References
Tables
Tables
KEY FACTS
Terminology
Procedure
Outcomes
TERMINOLOGY
Abbreviations
- Extreme lateral interbody fusion (XLIF)
- Direct lateral interbody fusion (DLIF)
- Lateral lumbar interbody fusion (LLIF)
XLIF
- Minimally invasive techniques to approach disc space from a lateral (trans-psoas) direction
- Originally described for mid lumbar spine
- Role has expanded with use for thoracolumbar and thoracic spine
Lumbosacral Plexus Anatomy
- Critical to avoid plexus in trans-psoas approaches
- Anterior rami of L1-4 coalesce in psoas muscle to form plexus
- Branching from plexus are
- Obturator nerve (L2-4) passes through posterior psoas and exits posteromedially
- Femoral nerve (L2-4) passes through posterior psoas and exits posterolaterally
- Innervates hip flexor and knee extensor muscles
- Distal anterior and medial cutaneous branches provide sensory innervation of anterior and medial thigh
- Primary sensory cutaneous nerves
- Iliohypogastric nerve (T12-L1)
- Ilioinguinal nerve (L-1)
- Lateral femoral cutaneous nerve (L2-3)
- Innervates skin of lateral thigh down to knee
- Genitofemoral nerve (L1-2)
- Only nerve that exits anterior aspect of psoas and continues down anterior surface of muscle
- Prior to exiting psoas, nerve follows posterior to anterior path between L3 and L4
- Disc space divided into 6 zones from ventral to dorsal: A, I, II, III, IV, P (Moro method)
- A: Anterior aspect of anterior vertebral body
- P: Posterior aspect of posterior vertebral body
- Zones I-IV equally divide anterior to posterior vertebral body into 4
- Moro-defined plexus
- Zone P at L1-2 disc space
- Zone IV at L2-3
- Zone III for L3-4 and L4-5
- Safe zones based on vessels and plexus (Moro et al, Hu et al, Benglis et al)
- Right side
- Zones II-IV at L1-2
- Zones II-III at L2-3
- Zone II at L3-4 and L4-5
- Left side
- Zones II-IV at L1-2
- Zones II-III at L2-3
- Zone II at L3-4
- Zones I-II at L4-5
- Right side
- Genitofemoral nerve
- Located at L1-2 and L2-3 in zone IV and zone P
- Nerve passes obliquely through psoas at L3
PROCEDURE
Procedure Steps
OUTCOMES
Complications
Selected References
- Cummock MD et al: An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion. J Neurosurg Spine. 15(1):11-8, 2011
- Houten JK et al: Nerve injury during the transpsoas approach for lumbar fusion. J Neurosurg Spine. 15(3):280-4, 2011
- Hu WK et al: An MRI study of psoas major and abdominal large vessels with respect to the X/DLIF approach. Eur Spine J. 20(4):557-62, 2011
- Karikari IO et al: Minimally invasive lumbar interbody fusion in patients older than 70 years of age: analysis of peri- and postoperative complications. Neurosurgery. 68(4):897-902; discussion 902, 2011
- Kepler CK et al: Anatomy of the psoas muscle and lumbar plexus with respect to the surgical approach for lateral transpsoas interbody fusion. Eur Spine J. 20(4):550-6, 2011
- Pimenta L et al: Lumbar total disc replacement from an extreme lateral approach: clinical experience with a minimum of 2 years' follow-up. J Neurosurg Spine. 14(1):38-45, 2011
- Rodgers WB et al: Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 36(1):26-32, 2011
- Sharma AK et al: Lateral lumbar interbody fusion: clinical and radiographic outcomes at 1 year: a preliminary report. J Spinal Disord Tech. 24(4):242-50, 2011
- Tohmeh AG et al: Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine. 14(1):31-7, 2011
- Cappuccino A et al: Biomechanical analysis and review of lateral lumbar fusion constructs. Spine (Phila Pa 1976). 35(26 Suppl):S361-7, 2010
- Daffner SD et al: Migrated XLIF cage: case report and discussion of surgical technique. Orthopedics. 33(7):518, 2010
- Isaacs RE et al: A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion for the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine (Phila Pa 1976). 35(26 Suppl):S322-30, 2010
- Jahangiri FR et al: Protecting the genitofemoral nerve during direct/extreme lateral interbody fusion (DLIF/XLIF) procedures. Am J Electroneurodiagnostic Technol. 50(4):321-35, 2010
- Oliveira L et al: A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements. Spine (Phila Pa 1976). 35(26 Suppl):S331-7, 2010
- Rodgers WB et al: Early complications of extreme lateral interbody fusion in the obese. J Spinal Disord Tech. 23(6):393-7, 2010
- Rodgers WB et al: Lumbar fusion in octogenarians: the promise of minimally invasive surgery. Spine (Phila Pa 1976). 35(26 Suppl):S355-60, 2010
- Youssef JA et al: Minimally invasive surgery: lateral approach interbody fusion: results and review. Spine (Phila Pa 1976). 35(26 Suppl):S302-11, 2010
- Benglis DM et al: An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 10(2):139-44, 2009
- Ozgur BM et al: Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 6(4):435-43, 2006
- Moro T et al: An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery. Spine (Phila Pa 1976). 28(5):423-8; discussion 427-8, 2003
