Journal of Clinical Neuroscience 22 (2015) 1714–1721

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Review

Lateral lumbar interbody fusion for sagittal balance correction and spinal deformity Kevin Phan a,b,c, Prashanth J. Rao a,b,c, Daniel B. Scherman c, Gordon Dandie c, Ralph J. Mobbs a,b,⇑ a

NeuroSpine Clinic, Prince of Wales Private Hospital, Level 7, Barker Street, Randwick, NSW 2031, Australia University of New South Wales, Sydney, NSW, Australia c Westmead Hospital, Westmead, Sydney, NSW, Australia b

a r t i c l e

i n f o

Article history: Received 12 January 2015 Accepted 14 March 2015

Keywords: Direct lateral interbody fusion Lateral lumbar interbody fusion Minimally invasive Spinal deformity

a b s t r a c t We conducted a systematic review to assess the safety and clinical and radiological outcomes of the recently introduced, direct or extreme lateral lumbar interbody fusion (XLIF) approach for degenerative spinal deformity disorders. Open fusion and instrumentation has traditionally been the mainstay treatment. However, in recent years, there has been an increasing emphasis on minimally invasive fusion and instrumentation techniques, with the aim of minimizing surgical trauma and blood loss and reducing hospitalization. From six electronic databases, 21 eligible studies were included for review. The pooled weighted average mean of preoperative visual analogue scale (VAS) pain scores was 6.8, compared to a postoperative VAS score of 2.9 (p < 0.0001). The weighted average preoperative and postoperative coronal segmental Cobb angles were 3.6 and 1.1°, respectively. The weighted average preoperative and postoperative coronal regional Cobb angles were 19.1 and 10.0°, respectively. Regional lumbar lordosis also significantly improved from 35.8 to 43.3°. Sagittal alignment was comparable pre- and postoperatively (34 mm versus 35.1 mm). The weighted average operative duration was 125.6 minutes, whilst the mean estimated blood loss was 155 mL. The weighted average hospitalization length was 3.6 days. Whilst the available data is limited, minimally invasive XLIF procedures appear to be a promising alternative for the treatment of scoliosis, with improved functional VAS and Oswestry disability index outcomes and restored coronal deformity. Future comparative studies are warranted to assess the long term benefits and risks of XLIF compared to anterior and posterior procedures. Ó 2015 Elsevier Ltd. All rights reserved.

1. Introduction Open fusion and instrumentation has traditionally been the mainstay treatment for degenerative spinal deformity disorders [1]. However in recent years, there has been an increasing emphasis on minimally invasive fusion and instrumentation techniques, with the aim of minimizing surgical trauma, blood loss and reducing hospitalization [2–4]. Minimally invasive approaches for traditional access routes, including anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) have been developed [3,5,6]. More recently, McAfee et al. [7] described another approach termed extreme lateral interbody fusion (XLIF), a variant of the ALIF procedure performed through a lateral retroperitoneal, transpsoas corridor. With the use of a split blade retractor, the interbody cage

⇑ Corresponding author. Tel.: +61 2 9650 4766; fax: +61 2 9650 4943. E-mail address: [email protected] (R.J. Mobbs). http://dx.doi.org/10.1016/j.jocn.2015.03.050 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved.

is inserted with minimal muscle dissection and disruption to ligamentous structures, allowing minimally invasive restoration of disc height and correction of sagittal and coronal deformity. This technique was later refined by Ozgur et al. [8], and has been increasingly used in the last decade for sagittal correction and degenerative scoliosis. Several studies have reported good clinical and radiological outcomes for the XLIF procedure. In the largest prospective, multicenter study [9] on this procedure to date, significant improvements in visual analogue scale (VAS) and Oswestry disability index (ODI) scores for leg and back pain were observed in 107 patients, with successful correction of the Cobb angle from 20.9 to 15.2°. Improvements in coronal segmental angles have also been consistently reported in several studies [10–12], as well as restored segmental lordosis and disc height. However, results for regional lumbar lordosis and sagittal alignment have not been as optimistic. Some reports have also reported lower complication rates from the minimally invasive XLIF procedure compared to traditional open surgical approaches [9,13,14].

K. Phan et al. / Journal of Clinical Neuroscience 22 (2015) 1714–1721

In order to assess the relative merits and risks of XLIF, a systematic review was performed to analyze the clinical and radiological outcomes of XLIF in the correction of sagittal balance and spinal deformities. 2. Methods 2.1. Literature search Systematic literature searches were performed in six electronic databases, including Ovid Medline, PubMed, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the American College of Physicians Journal Club, and the Database of Abstracts of Review of Effectiveness of their data from inception to November 2014. To achieve maximum sensitivity in the search strategy, we combined variants of the terms: ‘‘minimally invasive lateral approach lumbar interbody fusion’’, ‘‘XLIF’’, ‘‘DLIF’’, ‘‘LLIF’’, ‘‘minimally invasive spine surgery’’, ‘‘extreme lateral lumbar interbody fusion’’, ‘‘sagittal’’, and ‘‘spinal deformity’’, as either key words or medical subject heading terms. The reference lists of all retrieved articles were reviewed for further identification of potentially relevant studies, assessed using the inclusion and exclusion criteria [15]. 2.2. Selection criteria Eligible comparative studies for the present systematic review included those in which patient cohorts underwent XLIF procedures for correction of sagittal balance or spinal deformity. When institutions published duplicate studies with accumulating numbers of patients or increased the lengths of follow-up, only the most complete reports were included for quantitative assessment at each time interval. Reference lists were also hand searched for further relevant studies. All publications were limited to human subjects and English language. Abstracts, case reports, conference presentations, editorials, reviews and expert opinions were excluded. 2.3. Data extraction and critical appraisal The primary outcomes of interest included operative, radiographic and clinical outcomes. The operative outcomes comprised the operation duration, estimated blood loss, hospital stay, and complications. The radiographic outcomes comprised the coronal segmental Cobb angle, coronal region Cobb angle, coronal plain alignment, sagittal segmental Cobb angle, regional lumbar lordosis and sagittal alignment. The clinical outcomes comprised the preoperative and postoperative VAS and ODI scores. All data were extracted from the article texts, tables and figures. Two investigators independently reviewed and assessed the quality of each retrieved article. Discrepancies between the reviewers were resolved by discussion and consensus. The weighted averages were calculated for the studied parameters, calculated by determining the total number of events divided by total sample size.

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with no randomized evidence available. A total of 948 patients underwent an XLIF procedure, with a total of 1920 levels involved. The primary indications for an XLIF procedure were degenerative scoliosis, sagittal correction and spondylolisthesis. At least some form of posterior intervention was reported in patients for all included studies, including lateral screws, percutaneous screws, or open pedicle screw procedures. The median follow-up duration from the included studies was 14 months (range: 2–37). The study characteristics are summarized in Table 1. 3.2. Demographics Overall, 33.4% of patients were male, with a weighted average age of 62.1 years. From the pooled patients, the overall body mass index was 23.2 kg/m2, with 20.8% of patients using tobacco and 10.4% with diabetes mellitus. Approximately 8.9% of patients had prior lumbar spine surgery, specifically, 3.5% had prior laminectomy procedures and 2.4% had prior microdiscectomies. A prior PLIF was performed in 1.4% of patients (Table 2). 3.3. Functional outcomes The majority of studies reported preoperative and postoperative VAS scores (Table 3). The pooled weighted average mean of preoperative VAS scores was 6.8, compared to the postoperative VAS score of 2.9, a reduction that was statistically significant (p < 0.0001). ODI scores were reported in 15 of the studies. The weighted average preoperative ODI score was 44.5, compared with the postoperative ODI score of 20.5. This difference was also significantly significant (p < 0.0001). 3.4. Radiological outcomes The radiological parameters were inconsistently reported across the studies (Table 4). The coronal segmental Cobb angle was reported in only three studies. The weighted average preoperative and postoperative angles were 3.6 and 1.1°, respectively. The weighted average preoperative and postoperative coronal regional Cobb angle was 19.1 and 10.0°, respectively. From one study [10], the coronal plain alignment was 19.1 mm preoperatively, and 12.5 mm postoperatively. The weighted mean sagittal segmental Cobb angles pre and postoperatively were 8.3 and 10.7°, respectively (p < 0.05). The regional lumbar lordosis also significantly improved from 35.8 to 43.3°. The sagittal alignment was comparable pre and postoperatively (34 versus 35.1 mm). 3.5. Operative outcomes and complications The weighted average operative duration across the pooled studies was 125.6 minutes, and the mean estimated blood loss was 155 mL. The weighted average hospitalization length was 3.6 days. The reported complications from each study are summarized in Table 5. 4. Discussion

3. Results 3.1. Literature search A total of 243 studies were identified through six electronic database searches. Following the application of the inclusion and exclusion criteria, as well as removal of duplicate or irrelevant studies, 21 studies [9–14,16–30] were finally included in the systematic review. These comprised four prospective observational studies [9,17,20,29] and 17 retrospective observational studies,

Spinal deformities are associated with a loss of sagittal, coronal and axial balance [31], parameters which have been separately shown to be strong predictors of disability, global imbalance, decompensation and intervention failure [31,32]. In order to minimize surgical trauma, reduce potential complications and shorten hospitalization, minimally invasive surgical techniques have been introduced. In particular, lateral minimally invasive surgical instrumentation has been increasing in popularity as an alternative treatment option for adult degenerative scoliosis and restoration of

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K. Phan et al. / Journal of Clinical Neuroscience 22 (2015) 1714–1721

Table 1 Study characteristics Study

Country

Study period

Study design

Patients, n

Levels, n

Anterior surgery

Posterior surgery

Indication

Mean followup months (range)

Manwaring, 2014 [16]

USA

2009– 2012

R, OS

27 (w/o ACR); 9 (with ACR)

XLIF 10L cage (w/o ACR); XLIF 10L cage + 30L at ALLlevel (with ACR)

27 ALL, 27 pPS, 11 TLIF, 4 ALIF, 9 pPS

Degenerative scoliosis

22.9 (6–37.1) w/o ACR; 11.3 (4.2– 16.7) with ACR

Malham, 2014 [17]

Australia

2011– 2012

P, OS

40

126 (w/o ACR); 15 (with ACR) 54

XLIF 10L

21 standalone, 19 PS

12

Lee, 2014 [18]

Korea

2011– 2013

R, OS

90

116

XLIF

TLIF

Kim, 2014 [19]

Korea

2011– 2014

R, OS

163

125 XLIF, standard cage 6L; 38 XLIF, wide cage 12L

Khajavi, 2014 [20] Castro, 2014 [21] Phillips, 2013 [9]

USA

2005– 2009 2004– 2008 NR

P, OS

21

70

XLIF

63 posterior decompression in the standard group, 32 in the wide group 11 PS

Degenerative disc disease, scoliosis, spondylolisthesis, adjacent segment disease Spinal stenosis, mild spondylolisthesis (Grade 1, 2, 3), degenerative scoliosis, postacute phase of infective spondylitis Spinal stenosis, mild spondylolisthesis (Grade 1, 2, 3), degenerative scoliosis, postacute phase of infective spondylitis Degenerative scoliosis

24

R, OS

35

107

XLIF

35 standalone

Degenerative scoliosis

24

P, OS

107

322

XLIF

Degenerative scoliosis

NR

Johnson, 2013 [11]

Italy

2009– 2011

R, OS

30

41

XLIF

Degenerative scoliosis and lumbar disc disease

>2

Caputo, 2013 [23] Ahmadian, 2013 [24] Marchi, 2012 [25] Le, 2012 [26] Caputo, 2012 [22] Sharma, 2011 [27] Karikari, 2011 [28]

USA

NR

R, OS

30

127

XLIF

80 PS, 20 standalone, 7 anterolateral fixation 24 standalone, 3 PS, 3 interspinous devices 30 pPS, 11 ALIF

Symptomatic degenerative scoliosis

14.3

USA

R, OS

31

NR

XLIF

pPS

Grade I, II spondylolisthesis

18.2

R, OS

8

17

XLIF

4 oPS, 4 standalone

R, OS

50

XLIF 10 L

USA

NR

R, OS

28 nl; 7 hl 30

127

XLIF

2 lateral screws included in the cage pPS, 11 ALIF

Sagittal imbalance with or without disc disease Lumbar degenerative disease

13.3

USA

2008– 2011 2009– 2010 NR

USA

NR

R, OS

43

87

XLIF 10 L

USA

2005– 2008

R, OS

22

47

XLIF

33 oPS, 10 standalone 1 PS

Acosta, 2011 [10]

USA

NR

R, OS

36

66

XLIF

35 oPS, 1 standalone

Wang, 2010 [14]

USA

NR

R, OS

23

85

XLIF

23 pPS

Tormenti, 2010 [12] Isaacs, 2010 [29] Dakwar, 2010 [13]

USA

2007– 2009 NR

R, OS

8

23

XLIF

8 oPS

Symptomatic degenerative scoliosis, failed 1 year conservative treatment Symptomatic degenerative lumbar spondylolysis with/without scoliosis Degenerative scoliosis, pathological fractures from tumors, adjacent level disease, thoracic disc herniations, discitis/osteomyelitis Lumbar spondylosis, degenerative scoliosis, adjacent segment disease, spondylolisthesis, pseudoarthrosis Presence of coronal deformity >20°, significant sagittal decompensation with loss of global spine balance Scoliosis correction

P, OS

107

322

XLIF

75.7% with PS

Degenerative scoliosis

6–24

USA

2007– 2009

R, OS

25

76

XLIF

Adult degenerative deformity

11 (3–20)

Anand, 2010 [30]

USA

NR

R, OS

28

42

XLIF

15 LP, 7 oPS, 1 LP and oPS, 2 standalone pPS

Scoliosis correction

22 (13–37)

Brazil USA

Brazil

USA

8.5

>6

13.3 14.3 Up to 1 year 16.4 (3–50)

21

13.4

10.5

ACR = anterior column release, ALL = anterior longitudinal ligament, hl = hypolordotic, L = lordotic, LP = lateral plate, nl = normolordotic, NR = not reported, oPS = open posterior screw, OS = observational study, P = prospective, pPS = percutaneous posterior screw, PS = posterior screw, R = retrospective, TLIF = transforaminal lumbar interbody fusion, w/o = without, XLIF = extreme lateral lumbar interbody fusion.

sagittal balance [13,29]. The XLIF procedure also provides a valuable opportunity to correct additional issues of foraminal stenosis, central canal stenosis, and spondylolisthesis using the same access approach. The present systematic review of XLIF has provided several insights into the current state of this technique. Firstly, across

the studies, the XLIF technique and associated posterior interventions were heterogeneous, with different shaped/sized cages used and a mixture of standalone XLIF, lateral screws, posterior screws, and percutaneous pedicle screws employed. The functional VAS and ODI scores were reported by the majority of studies, and both scores significantly improved following XLIF. Thus,

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K. Phan et al. / Journal of Clinical Neuroscience 22 (2015) 1714–1721 Table 2 Baseline study patient characteristics Study

Age, mean years ± SD/(range)

Male (%)

BMI, mean kg/ m2 ± SD/(range)

Tobacco use (%)

DM (%)

Prior lumbar spine surgery (%)

Prior laminectomy (%)

Prior microdiscectomy (%)

Prior PLIF (%)

Manwaring [16] Malham, standalone [16] Malham, PS [17] Lee [18] Kim, standard cage [19] Kim, wide cage [19] Khajavi [20] Castro [21] Phillips [9] Johnson [11] Caputo [23] Ahmadian [24] Marchi [25] Le [26] Caputo [22] Sharma [27] Karikari [28] Acosta [10] Wang [14] Tormenti [12] Isaacs [29] Dakwar [13] Anand [30] Weighted average

64.3 (32–80) 65.2 ± 12.1

36 33

NR 27.5 ± 5.1

NR 14

NR 10

NR 38

NR 19

NR 14

NR 5

61.8 ± 10.3 65.5 ± 14.3 60.51 ± 14.51

26 34 40

26.2 ± 5.3 NR NR

26 NR NR

11 NR NR

37 NR NR

21 NR NR

10 NR NR

5 NR NR

63.29 ± 9.99

68

NR

NR

NR

NR

NR

NR

NR

70.1 ± 8.2 68.2 ± 9.8 68 (45–87) 56 ± 10.4 65.9 (53–76) 61.5 71.8 (69–80) 61.3 (33–79) 65.9 (53–76) 63.9 ± 10.2 64.6 (50–81) 62 (43–84) 64.4 (42–84) 60 (48–69) 68.4 (45–87) 62.5 (35–77) 67.7 (22–81) 62.1

33 26 27 67 37 29 0 31 37 37 32 25 26 NR 26 40 46 33.4

29.3 ± 5.6 26.4 ± 4.6 NR NR 28.8 (19–38) NR 27.5 ± 2.4 NR 28.8 (19–38) 26 (18.1–39.9) NR NR NR NR NR NR NR 23.2

24 NR NR NR 37 NR NR NR 30 NR NR NR NR NR NR NR NR 20.8

29 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 10.4

38 0 0 NR 50 NR NR NR 50 NR NR NR NR NR NR NR NR 8.9

NR 0 0 NR 20 NR NR NR 20 NR NR NR NR NR NR NR NR 3.5

NR 0 0 NR 3 NR NR NR 3 NR NR NR NR NR NR NR NR 2.4

NR 0 0 NR 3 NR NR NR 3 NR NR NR NR NR NR NR NR 1.4

BMI = body mass index, DM = diabetes mellitus, NR = not reported, PLIF = posterior lumbar interbody fusion, SD = standard deviation.

Table 3 Functional outcomes Study (approach)

Preoperative VAS

Postoperative VAS

Preoperative ODI

Postoperative ODI

Manwaring [16] Malham (standalone) [17] Malham (PS) [17] Lee [18] Kim (standard cage) [19] Kim (wide cage) [19] Khajavi [20] Castro [21] Phillips [9] Johnson [11] Caputo [23] Ahmadian [24] Marchi [25] Le [26] Caputo [22] Sharma [27] Karikari [28] Acosta [10] Wang [14] Tormenti [12] Isaacs [29] Dakwar [13] Anand [30] Weighted average

NR 8.5 ± 1.2/8.6 ± 1.6 9.0 ± 1.1/8.0 ± 1.7 6.2 ± 1.7 6.1 ± 2.4 5.9 ± 1.3 7/5.6 (b/l) 8.5 7.4/6.2 (b/l) 8±2 NR 6.9 8.8 ± 1.2/6.7 ± 2.6 NR 6.8/5.4 (b/l) 8.2 6.6 ± 3.1/6.4 ± 5.8 7.7 7.3/4.35 (b/l) 8.8 NR 8.1 7.05 6.8

NR 3.5 ± 2.9/2.5 ± 3.9 (b/l) 4.9 ± 3.5/4.3 ± 3.9 1.7 ± 0.7 2.3 ± 1.2 2.1 ± 0.9 2.9/3.3 (b/l) 2 3.8/2.6 (b/l) 4±2 NR 3.87 3.7 ± 2.0/3.2 ± 2.3 (b/l) NR 4.6/2.8 (b/l) 4.6 3.7 ± 2.7/1.1 ± 2.0 (b/l) 2.9 3.35/1.57 (b/l) 3.5 NR 2.4 3.03 2.9

NR 55.4 ± 10.8 54.8 ± 10.6 34.6 ± 10.5 41.4 ± 15.0 48.0 ± 15.1 48.4 50 48 54 ± 9 NR 50.4 82 ± 13 NR 24.8 42.6 42.3 ± 15.0 43 NR NR NR 53.6 39.13 44.5

NR 27.7 ± 7 37.9 ± 24.4 11.6 ± 5.6 12.5 ± 4.4 14.5 ± 7.6 24.4 30 26 26 ± 12 NR 30.9 49 ± 19 NR 19 31.5 34 ± 17.0 21 NR NR NR 29.9 7 20.5

(b/l) (b/l)

(b/l)

(b/l)

All values are reported as the mean, and ± standard deviation where appropriate. b/l = back and leg VAS scores, respectively, NR = not reported, ODI = Oswestry disability index, PS = posterior screw, VAS = visual analogue scale.

XLIF appears to be efficacious in reducing back pain and improving functional outcomes, similarly to the more conventional approaches (ALIF and TLIF). The pooled radiological outcomes suggest that XLIF is effective in restoring the coronal segmental Cobb angle (3.6 to 1.1°) and the coronal regional Cobb angle (19.1 to 10°). However, similarly to previously published reports,

corrections of regional lumbar lordosis and sagittal alignment were limited, and as such, may be indicated in patients requiring lumbar lordosis and sagittal correction of less than 10° and 5 cm, respectively. The operative characteristics of XLIF are acceptable, with a low estimated blood loss of 155 mL and hospital stay of 3.6 days.

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Table 4 Radiological outcomes Study (approach)

Manwaring, (w/o ACR) [16] Manwaring, (with ACR) [16] Malham (standalone) [17] Malham (PS) [17] Lee [18] Kim (standard cage) [19] Kim (wide cage) [19] Khajavi [20] Castro [21] Phillips [9] Johnson [11] Caputo [23] Ahmadian [24] Marchi [25] Le (nl) [26] Le (hl) [26] Caputo [22] Sharma [27] Karikari [28] Acosta [10] Wang [14] Tormenti [12] Isaacs [29] Dakwar [13] Anand [30] Weighted average

Coronal segmental Cobb (°)

Coronal plain alignment (mm)

Coronal regional Cobb (°)

Sagittal segmental Cobb (°)

Regional lumbar lordosis (°)

Sagittal alignment (mm)

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

NR NR NR NR 4.1 ± 4 NR NR NR NR NR NR NR NR NR NR NR NR 5.2 NR 4.5 NR NR NR NR NR 3.6

NR NR NR NR 1.1 ± 1.3 NR NR NR NR NR NR NR NR NR NR NR NR 1.5 NR 1.5 NR NR NR NR NR 1.1

24.8 28.9 NR NR NR NR NR 27.7 21.3 20.9 13 20.2 NR NR NR NR 20.2 10 22 7.6 31.4 38.5 24.3 20.7 22.3 19.1

9 12.4 NR NR NR NR NR 16.6 11.5 15.2 7.1 5.8 NR NR NR NR NR 6.8 14 3.6 11.5 10 NR 6.2 7.47 10.0

NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 19.1 NR NR NR NR NR 19.1

NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 12.5 NR NR NR NR NR 12.5

NR NR 7.9 7.6 9.9 ± 9.3 9.1 ± 4.4 8.9 ± 3.5 11.6 NR NR 3 9.2 NR 2.3 13 2.3 NR 5.4 NR 5.3 NR NR NR NR NR 8.3

NR NR 9.4 10.5 11.1 ± 8.0 10.1 ± 5.2 12.7 ± 6.1 17.2 NR NR 6.6 9.7 NR 27.1 15.3 5.9 NR 8.2 NR 8.2 NR NR NR NR NR 10.7

36.5 43.7 48.8 51.1 NR 39.5 ± 18.3 40.6 ± 9.8 31.8 32.6 27.7 42.8 43.5 NR 14.9 56.4 37.7 NR 47.8 39 42.1 37.4 47.3 NR NR NR 35.8

53.4 45.9 55.2 45.8 NR 44.5 ± 18.8 46.2 ± 9.6 44 41.46 33.6 44.4 48.5 NR 40.8 57.3 39.4 NR 49.3 44 46.2 45.5 40.4 NR NR NR 43.3

83 23 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 41.5 NR NR NR NR NR 34.0

37 38 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 42.4 NR NR NR NR NR 35.1

All values are reported as the mean, and ± standard deviation where appropriate. ACR = anterior column release, hl = hypolordotic, nl = normolordotic, NR = not reported, Post = postoperative, Pre = preoperative, PS = posterior screw, w/o = without.

The lateral XLIF procedure offers several advantages which should be considered when evaluating treatment options for spinal deformities and sagittal correction. XLIF remains a potentially useful surgical alternative for lumbar degenerative scoliosis, as it allows relatively easy access to multiple levels from T11–L5. Given the nature of the lateral approach, the XLIF procedure preserves the anterior longitudinal ligament, posterior longitudinal ligament, and facet joints. This contrasts with the anterior (ALIF) and posterior (TLIF, PLIF) approaches where the ligamentous structures are disrupted. As such, XLIF allows for conserved stability and anatomical load at the treated levels. This approach also avoids iatrogenic instability, since there is no resection of the posterior bony elements. In contrast to ALIF approaches, XLIF can avoid injury to the abdominal viscera and peritoneal penetration, whilst reducing the risk of injury to great vessels, including the common iliac vein, inferior vena cava, and iliolumbar vein, as well as the sympathetic chain [33,34]. In contrast to TLIF/PLIF, there is a lesser chance of dural tear injury, nerve root injury and paraspinal muscle injury [35,36]. Furthermore, the XLIF cage has a higher profile and greater width, which is important for restoring disc height and for decompression of the neural foramen [27,37]. While long term results and comparative data are still limited, the current evidence supports the XLIF surgical exposure as adequate, safe and reproducible. There are several limitations to the XLIF procedure which warrant careful consideration. Results from the current study corroborate with prior reports, demonstrating that XLIF could effectively restore coronary deformity, but that it has a lesser impact on restoring lumbar lordosis and sagittal balance. Some institutions have attempted to tackle this issue by releasing the anterior longitudinal ligament [38]. XLIF is also associated with several complications. The lateral approach means that the patient is prone to psoas muscle injury and edema, which in the postoperative period can lead to hip flexor weakness. For example, Lee et al. [18]

reported 13.6% of patients with psoas muscle injury, compared to 15.8% in the Kim et al. [19] study. Khajavi et al. [20] reported hip flexion weakness in 24% of patients, compared to 26% of patients in the study by Sharma et al. [27] However, in the majority of papers included in this review, hip flexion weakness generally resolved in 6–12 months. During the XLIF procedure, the genitofemoral nerve may be stretched and injured, giving rise to symptoms of thigh and groin pain [39]. Likewise, injury to the lateral femoral cutaneous nerve and lumbosacral plexus can lead to numbness and Meralgia paresthetica, respectively [40]. Cage subsidence is another reported complication for XLIF, found in 29% of patients at 6 weeks follow-up in the study by Castro et al., compared to 3% [11], 13% [25], 5% [28], and 4% [13] in other studies. While retrograde ejaculation is a known complication of ALIF, this was not reported in the XLIF studies [8]. Furthermore, careful patient selection is critically important for achieving optimal outcomes. In scoliosis patients with severe rotational deformities, vascular structures may be displaced by coronal and sagittal rotations and impede lateral access [8]. For high grade spondylolisthesis, it may be difficult to place the interbody graft, since the exiting nerve root is located more anteriorly than usual. Additionally, the L5–S1 level is unable to be accessed using the XLIF approach, and surgeons may choose to opt for ALIF/TLIF/PLIF as an alternative access approach. Prior retroperitoneal surgery is also a known contraindication [8]. 4.1. Limitations The present systematic review is constrained by several notable limitations. Firstly, the included studies were all observational with non-randomized designs, therefore, they are susceptible to selection bias. All the studies were single arm and non-comparative, and as such, direct statistical comparisons between XLIF with other approaches such as ALIF, TLIF and PLIF

K. Phan et al. / Journal of Clinical Neuroscience 22 (2015) 1714–1721

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Table 5 Operative outcomes and complications of XLIF Study

Mean operating time (minutes) ± SD/(range)

Mean blood loss (ml) ± SD/(range)

Mean hospital stay (days) ± SD/(range)

Complications, n (%)

Manwaring [16] Malham [17]

NR NR

NR NR

NR NR

Lee [18]

1 level: 39.2 ± 18.4 2 level: 49.2 ± 17.8 3 level: 65.0 ± 10.8 39.7 ± 16.2

NR

NR

NR

NR

Kim (wide cage) [19]

38.5 ± 23.1

NR

NR

Khajavi [20]

218 (100–360)

68 (25-150)

2.2 (1–8)

Castro [21]

137 (80–240)

54

1.4 (1–4)

Phillips [9]

XLIF procedure 177.9 (43–458); interbody fusion level 57.9

62.5% 6 100 mL; 9 patients (8.4%) = 300 mL

* unstaged procedure 2.9 (2); staged procedure 8.1 (8); overall 3.8 (3)

Johnson [11]

NR

NR

NR

Caputo [22]

NR

NR

NR

Ahmadian [24]

NR

94 (20–250)

3.5

Marchi [25]

210 ± 127.2

131.3 ± 92.3

NR

Le [26] Caputo [22]

NR NR

NR NR

NR NR

Sharma [27]

186 (90–300)

200 (50–350)

standalone 3.4 (3–5); with posterior instrumentation 8.2 (3–28)

Karikari [28]

NR

227.5

4.8

Acosta [10] Wang [14]

NR 401 (200–660)

NR 477 (200–3500)

NR 6.2 ± 3.6

NR Radicular symptoms requiring decompression and bilateral pedicle screw fixation: 2 (5) Psoas muscle symptoms: 11 (12.2) Lateral femoral cutaneous nerve symptoms: 4 (4.4) Genitofemoral nerve symptoms: 2 (2.2) Psoas muscle injury: 17 (13.6) Lateral femoral cutaneous nerve injury: 3 (2.4) Genitofemoral nerve injury: 5 (4.0) Bowel perforation: 1 (0.8) Infection: 1 (0.8) Psoas muscle injury: 6 (15.8) Lateral femoral cutaneous nerve injury: 2 (5.3) Genitofemoral nerve injury: 3 (7.9) Postoperative foot drop: 1 (5) Hip flexion weakness: 5 (24) Intraoperative anterior longitudinal ligament rupture: 3 Cage subsidence by 6 week follow-up: 10 (29) Radiculopathy: 2 (6) Persistent back pain due to cage micromotion: 1 (3) Lower extremity weakness: 36 (34) Persistent weakness: 5 (5) Revisions for pseudarthrosis of XLIF level: 2 (2) Additional anterior procedures at adjacent segments: 4 (4) Additional posterior-only procedures for reasons unrelated to nonunion: 7 (7) Cage subsidence (further surgery): 1 (3) Pseudoarthrosis (further surgery): 1 (3) Transient motor weakness in lower limbs immediately postoperatively (full recovery): 2 (7) Transient anterior thigh hypoaesthesia (completely resolved): 5 (17) Lateral incisional hermia: 1 (3) Rupture of anterior longitudinal ligament: 2 (7) Wound breakdown: 2 Cardiac instability: 1 (3) Pedicle fracture: 1 (3) Nonunion requiring revision: 1 (3) Broken guidewire during percutaneous posterior pedicle screw placement (no clinical consequence): 1 (3) Restenosis following severe subsidence (revision: minimally invasive over-the-top compression): 1 (13) NR Lateral wound breakdown (healed via secondary intention): 2 (7) Pedicle fracture (asymptomatic): 1 (3) Symptomatic nonunion (revision fusion and extension of hardware): 1 (3) Hernia at lateral incision (elective hernia repair): 1 (3) Uncontrolled atrial fibrillation after XLIF stage: 1 (3) Iatrogenic rupture of ALL: 2 (7) Anterior thigh pain: 15 (35) Hip flexor weakness: 11 (26) Quadricep weakness, intraoperative end plate fractures (69 grade 0, 14 grade I, one grade II, three grade III), nonunion (5 disc levels): 4 (9) Vertebral body fracture: 2 (5) Infection: 1 (2) Anterior malpositioned cage: 1 (2) Retroperitoneal hemorrhage: 1 (2) Wound infection: 1 (5) Death from metastatic breast cancer: 1 (5) Adjacent level disease: 1 (5) Subsidence of graft into L2: 1 (5) NR New onset atrial fibrillation: 1 (4) Pneumothorax: 1 (4) CSF leak: 1 (4) Return to OR to extend construct to ilium after S1 screw pullout on postoperative day 34: 1 (4) Requiring partial corpectomy resulting in 3500 mL blood loss: 1 (4) Thigh numbness/pain/weakness/dysesthesia lateralised on side of anterolateral approach: 7 (30) Severe and persistent sensory and motor changes requiring the use a device for amputation: 1 (4)

Kim (standard cage) [19]

(continued on next page)

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Table 5 (continued) Study

Mean operating time (minutes) ± SD/(range)

Mean blood loss (ml) ± SD/(range)

Mean hospital stay (days) ± SD/(range)

Complications, n (%)

Tormenti [12]

NR

NR

NR

Isaacs [29]

177.9 (43–458)

Shown as column graph

2.9

Dakwar [13]

108 per level

53 per level

6.2

Anand [30]

232 (104–448)

241 (20–2000)

10 (3–20)

Weighted average

125.6

155

3.6

Bowel perforation: 1 (13) Infection/meningitis: 1 (13) Postoperative sensory radiculopathy: 6 (75) Postoperative motor radiculopathy: 2 (25) Pleural effusion necessitating chest tube placement: 2 (25) Intraoperative hemodynamic instability: 1 (13) Pulmonary embolism: 1 (13) Ileus: 1 (13) Durotomy (during posterior stage): 1 (13) Myocardial infarction: 1 (1) Sepsis (secondary to UTI): 1 (1) UTI: 2 (2) Atrial fibrillation: 2 (2) Hypertension requiring transfusion: 2 (2) Bacterial infection: 2 (2) Postanesthesia delirium: 1 (1) Asymptomatic congestive heart failure: 1 (1) Pleural effusion: 1 (1) Hyponatremia: 1 (1) Pulmonary hypertension: 1 (1) Gastrointestinal bleed without transfusion: 1 (1) Posterior wound infection: 3 (3) Kidney laceration: 1 (1) Deep vein thrombosis: 1 (1) Motor deficit: 7 (7) Ileus: 4 (4) Pleural cavity violation requiring chest tube: 2 (2) Anemia requiring transfusion: 2 (2) Sensory deficit: 1 (1) Numbness: 3 (12) Subsidence: 1 (4) Hardware failure: 1 (4) Rhabdomyolysis: 1 (4) Immediate postop thigh dysesthesias: 17 (61) Removal of proximal screw at T12: 1 (4) Asymptomatic proximal screw fraction at L2, 2 quadriceps palsy with weakness of vastus medialsis: 1 (4) Intraoperative retrocapsular renal hematoma: 1 (4) Unrelated cerebellar hemorrhage: 1 (4) -

ALL = anterior longitudinal ligament, CSF = cerebrospinal fluid, NR = not reported, postop = postoperative, SD = standard deviation, UTI = urinary tract infection, XLIF = extreme lateral lumbar interbody fusion. * Mean (median).

were not conclusive. Other inherent limitations were the relatively incomplete reporting of the demographic data beyond age and sex, as well as poor reporting for hospital stay, operation times and blood loss. Additionally, spinal alignment measurements were available for only a small number of studies. The heterogeneity of the included studies is another limitation, with a mixture of standalone XLIF, lateral/posterior screw instrumentation and open versus percutaneous fixation approaches used. The data could not be stratified to facilitate a subgroup analysis for comparison. It is known that these subgroups have complication profiles. Screw fixation is associated with malpositioning and a risk of wound infections [23,41], whilst standalone XLIF may cause interbody subsidence and promote restenosis [7,13,19]. Further prospective studies comparing XLIF with other surgical approaches, and with long term follow-up, will provide a better assessment of the relative benefits and risks of the XLIF procedure. 5. Conclusion Whilst acknowledging the limitations of the available data, minimally invasive XLIF procedures appear to be a promising alternative for restoration of sagittal balance and treatment of scoliosis, warranting further study. The available data suggests that there is

potential for improved functional VAS and ODI outcomes and restored coronal Cobb angles with the minimally invasive XLIF approach, although it achieves limited corrections in lumbar lordosis and sagittal alignment. Future comparative studies are warranted to assess the long term benefits and risks of XLIF compared to anterior and posterior procedures. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Mummaneni PV, Haid RW, Rodts GE. Lumbar interbody fusion: state-of-the-art technical advances. Invited submission from the joint section meeting on disorders of the spine and peripheral nerves. J Neurosurg Spine 2004;1:24–30. [2] Starkweather AR, Witek-Janusek L, Nockels RP, et al. The multiple benefits of minimally invasive spinal surgery: results comparing transforaminal lumbar interbody fusion and posterior lumbar fusion. J Neurosci Nurs 2008;40:32–9. [3] Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine (Phila Pa 1976) 2003;28:S26–35. [4] Schwender JD, Holly LT, Rouben DP, et al. Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Tech 2005;18:S1–6.

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Lateral lumbar interbody fusion for sagittal balance correction and spinal deformity.

We conducted a systematic review to assess the safety and clinical and radiological outcomes of the recently introduced, direct or extreme lateral lum...
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