Review of Risks and Complications of Extreme Lateral Interbody Fusion (XLIF)

Abstract

Background: Extreme lateral interbody fusions (XLIF) and Minimally Invasive (MIS) XLIF were developed to limit the vascular injuries associated with anterior lumbar interbody fusion (ALIF), and minimize the muscular/ soft tissue trauma attributed to transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterolateral lumbar fusion (PLF). Methods: Nevertheless, XLIF/MIS XLIF pose significant additional risks and complications that include; multiple nerve injuries (e.g. lumbar plexus, ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, and subcostals (to the anterior abdominal muscles: abdominal oblique), and sympathectomy), major vascular injuries, bowel perforations/postoperative ileus, seromas, pseudarthrosis, subsidence, and reoperations. Results: The risks of neural injury with XLIF/MIS XLIF (up to 30-40%) are substantially higher than for TLIF, PLIF, PLF, and ALIF. These neural injuries included: lumbar plexus injuries (13.28%); new sensory deficits (0-75% (21.7%-40%); permanent 62.5%); motor deficits (0.7-33.6%-40%); iliopsoas weakness (9%-31%: permanent 5%), anterior thigh/groin pain (12.5-34%), and sympathectomy (4%-12%). Additional non-neurological complications included; subsidence (10.3%-13.8%), major vascular injuries (0.4%), bowel perforations, recurrent seroma, malpositioning of the XLIF cages, a 45% risk of cage-overhang, pseudarthrosis (7.5%), and failure to adequately decompress stenosis. In one study, reviewing 20 publications and involving 1080 XLIF patients, the authors observed “Most (XLIF) studies are limited by study design, sample size, and potential conflicts of interest.” Conclusion: Many new neurological deficits and other adverse events/complications are attributed to MIS XLIF/ XLIF. Shouldn’t these significant risk factors be carefully taken into consideration before choosing to perform MIS XLIF/XLIF?

Incisional hernia after extreme lateral interbody fusion on the lumbar spine: A case report

“…Conversely, the abdominal muscles and psoas major have to be split to gain access to the spine during XLIF. Therefore, caution is required to prevent damage, including traction injuries, to the nerves running along these areas, and the possibility of nerve damage as a complication cannot be ignored [ 3 ]. In addition, the procedure involves an incision in the fascia lining the abdominal wall to split the muscles, which can lead to the development of an incisional hernia in the abdominal wall.…”

“…The procedure is gradually becoming widespread as it has a lower risk of complications and shorter postoperative recovery time than traditional procedures [ 1 , 2 ]. However, more procedures result in various complications [ 3 ]. Incisional hernias occur commonly after abdominal surgery or anterior spinal surgery, but rarely after an XLIF.…”

The anterior-to-psoas approach for interbody fusion at the L5–S1 segment: clinical and radiological outcomes

“…The necessity for aborting this procedure during the psoas transgression, especially for a highly degenerated and rotated L4-5 segment, is also a commonly reported experience. [27][28][29] ATP is a retroperitoneal approach based on dissection of the surgical corridor between the arterial axis (medial) and the psoas tendon (lateral). This corridor has been well described in different anatomical and morphological MRI studies, and it represents a safe path to lumbar discs.…”

A Review of Minimally Invasive Techniques in Thoracolumbar Trauma

“…The natural progression from anterior transperitoneal and retroperitoneal minimally invasive approaches is a lateral psoas splitting approach to the anterior spine, as in the direct lateral interbody fusion (DLIF) or extreme lateral interbody fusion (XLIF) technique. 2,3,[8][9][10]12,16 This approach, which utilizes muscle sparing at every level, has the advantage of negating retraction and dissection of the muscles of the abdominal wall. The disadvantage is that the roots of the lumbosacral plexus are at risk during blunt dissection through the muscle itself.…”