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
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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Related Differential Diagnoses
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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
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
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