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Extreme Lateral Interbody Fusion
Jeffrey S. Ross, MD
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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
          • 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

            1. 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
            2. Houten JK et al: Nerve injury during the transpsoas approach for lumbar fusion. J Neurosurg Spine. 15(3):280-4, 2011
            3. 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
            4. 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
            5. 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
            6. 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
            7. 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
            8. 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
            9. Tohmeh AG et al: Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine. 14(1):31-7, 2011
            10. Cappuccino A et al: Biomechanical analysis and review of lateral lumbar fusion constructs. Spine (Phila Pa 1976). 35(26 Suppl):S361-7, 2010
            11. Daffner SD et al: Migrated XLIF cage: case report and discussion of surgical technique. Orthopedics. 33(7):518, 2010
            12. 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
            13. 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
            14. 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
            15. Rodgers WB et al: Early complications of extreme lateral interbody fusion in the obese. J Spinal Disord Tech. 23(6):393-7, 2010
            16. Rodgers WB et al: Lumbar fusion in octogenarians: the promise of minimally invasive surgery. Spine (Phila Pa 1976). 35(26 Suppl):S355-60, 2010
            17. Youssef JA et al: Minimally invasive surgery: lateral approach interbody fusion: results and review. Spine (Phila Pa 1976). 35(26 Suppl):S302-11, 2010
            18. 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
            19. 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
            20. 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
                    • 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

                      1. 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
                      2. Houten JK et al: Nerve injury during the transpsoas approach for lumbar fusion. J Neurosurg Spine. 15(3):280-4, 2011
                      3. 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
                      4. 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
                      5. 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
                      6. 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
                      7. 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
                      8. 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
                      9. Tohmeh AG et al: Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine. 14(1):31-7, 2011
                      10. Cappuccino A et al: Biomechanical analysis and review of lateral lumbar fusion constructs. Spine (Phila Pa 1976). 35(26 Suppl):S361-7, 2010
                      11. Daffner SD et al: Migrated XLIF cage: case report and discussion of surgical technique. Orthopedics. 33(7):518, 2010
                      12. 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
                      13. 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
                      14. 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
                      15. Rodgers WB et al: Early complications of extreme lateral interbody fusion in the obese. J Spinal Disord Tech. 23(6):393-7, 2010
                      16. Rodgers WB et al: Lumbar fusion in octogenarians: the promise of minimally invasive surgery. Spine (Phila Pa 1976). 35(26 Suppl):S355-60, 2010
                      17. Youssef JA et al: Minimally invasive surgery: lateral approach interbody fusion: results and review. Spine (Phila Pa 1976). 35(26 Suppl):S302-11, 2010
                      18. 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
                      19. 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
                      20. 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