XLIF and lateral approach fusions

[Liz]

For some reason XLIF and lateral approach fusions rarely get discussed but I think more patients should seriously consider consulting w/an XLIF surgeon pre-op to see if they are a candidate; XLIF cannot be applied to L5-S1. If surgeons are not trained in the lateral approach they will likely not mention it as a treatment option for you.

Here's a link to the Society of Lateral Access Surgeons website, http://www.lateralaccess.org/
where you can search for a surgeon in your area (i believe it's only working for the US right now) and you can learn more about the procedure.

The few patients that i've heard of that have XLIF fusions are doing quite well... there are two types, one which just uses a plastic spacer w/BMP which is promoted as gentler on adjacent segments (the cage fighter Nate Quarry has helped promote it); the other just uses XLIF as an approach but uses cage, screws, BMP, maybe a plate, maybe posterior rods. The latter approach is currently used by a few surgeons for revision ADR operations and I think it will be adopted by many more in the future to avoid the risks of a repeat anterior operation at L3-4 and L4-5 with the great vessels on top (mainly hemorrhage, possibly death).

In addition to XLIF (Nuvasive's product) there are surgeons that are using the lateral approach for fusions with hardware from other device companies b/c it avoids the vascular risks associated with anterior operations. I saw a neurosurgeon recently whom is going to start performing lateral fusions at L3-4 and L4-5.

This approach still has its risks as it requires going through the psoas muscle (mainly nerve damage), but to me the approach sounds very promising and much less invasive than anterior or posterior. It also avoids cutting the anterior longitudinal ligament which can sometimes result in instability.

good luck!
Liz

[KBear]

Very interesting. I think that fusion is still a very good surgery and should not be ruled out. ADR is a good surgery too; but there is still a lot we don't know about it. I took both into consideration, talked with 3 surgeons and decided that ADR was best for me (all 3 surgeons agreed). However, my surgeon told me, that if for whatever reason, during surgery he felt that ADR would not be the best choice, that he would do a fusion. I was very happy that this was his 'policy' as ultimately, I want what is best for my body. Thank you for putting this information on here, as so many are looking at fusions.
Kathy

[Katie]

Can someone explain how many different kinds of fusions are out there? My upcoming surgery is most likely going to involve hybrids, fusion plus ADR. We had so much to cover during the consult that I forgot to ask about the options with that.

I have emailed the doctor with several questions, but haven't heard back yet. I also don't know exactly what questions I should be asking him. I originally was planning on having ADR only with a different hospital, and when things turned around to this, I just wasn't prepared at the consultation. It was a whirlwind trip, very unexpected.

Is there any way to avoid all those rods and bone grafts? I've heard that a newer Medtronic artificial graft has caused a great deal of problems...I'll have to go back and do more research, as it was awhile ago.

[treefrog]

The neurosurgeon I talked to here at Duke University Hospital, does minimally invasive XLIF. But, because I have a bad L5/S1 disc, he said he wouldn't be able to get to it with that approach, as the hip bone is in the way.

There are many different fusion options, that I do think you need to discuss which one your surgeon is going to do. What type of approach, what type of hardware, whether a bone graft (from the iliac crest) will be used, or BMP (bone morphogenic protein)? There are so many variables, you need to understand what is going to be done, and why.

[Katie]

I've written to the doctor again, but with him booked solid with surgeries till the first of June, then being out of the country for two weeks after that, he will really be pushed for time in responding.

I didn't know there were quite so many different kinds of fusion out there...guess I have a lot to learn in a short time.

[KBear]

Katie, Maybe you could call and talk to one of his aides and ask what fusion he is planning on doing on you. This would at least allow you to start researching that. I completely understand how busy dr's are, email answering is not their top priority. I am amazed that he even does email with patients, that is nice of him. I am sure he has great reason for whatever technique he is going to do, he is a great surgeon.

[Liz]

Hi Katie,

i'm sorry if i confused you. I highly doubt Dr. Bitan is going to use an XLIF on you for several reasons.... you can't use it at L5-S1 and you are also having an ADR put it at L3-4 which w/the Charite requires an anterior approach so you really could only have it at L4-5. Typically surgeons want to minimize the approaches (and so do you) so I'm guessing he's planning on anterior fusion with ADR and then possibly also posterior fusion if you need stabilization at one or both levels of L4-5 and/or L5-S1. The XLIF uses a lateral approach through your psoas muscle on the left side so I think this is out for you or you'd be all sliced up!

I hope you hear from him soon for clarification on what he is planning for you.

I just sent you a PM w/some more info.

Best wishes,
Liz

[Tim]

Hi Liz
I totally agree - there is very little discussion available on the XLIF procedure.
I have been recommended this approach to fuse my L4/5 which is sandwiched between 2 existing Charite ADR’s at L5/S1 and L3/4.
Initially I was excited by this approach but as I’ve done more digging the vast majority of the, admittedly few, cases I’ve found online seem to be suffering from extreme postoperative leg pain. I’ve failed in my efforts to get any of these cases to correspond and frustratingly don’t know if their pain has subsequently subsided. I realise that any internet forum tends to be biased towards the negative outcomes as people who do well are too busy living to post but it would still be nice to hear more positive stories before committing. There is one guy posting on ADR Support who had a great outcome with his XLIF but of the stories I’ve found unfortunately he seems to be the exception.. One post I found claimed to be from a guy who was involved in using the Nuvasive neuro monitoring equipment – he was of the opinion that the neuro monitoring equipment supplied by Nuvasive wasn’t all that effective and that complications with the psoas approach are more common than surgeons or Nuvasive want to admit.
If anyone has personal experience with the XLIF – positive or negative – I’d love to hear from you..
All the best
Tim

[runagain]

Correct me if I am wrong, but I think in a certain percentage of people the sciatic nerve travels within the psoas muscle.
So if an XLIF approach is done, there is the possibility of injuring the nerve? I did look this up and they recommend nerve monitoring during the procedure that involves a trans psoas approach.

There is a video of an XLIF surgery on or-live.com.

[Justin]

Liz, thanks for bringing this topic up. I'd like to discuss it with the forum in greater detail when I have access to some documents on my laptop at home.

I wish you the very best and we'll catch up soon!