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Chapter 21 Lateral Lumbar Interbody Fusion 373
SECTION
III
A
B
FIG. 21.14 Release the anulus from the endplate with a Cobb retractor and
advance through the contralateral anulus in a controlled fashion to release
it while avoiding a contralateral plexus injury.
by Benglis et al. demonstrated that the lumbar plexus lies on
the dorsal surface of the psoas at a cle between transverse
process and vertebral body and there is a general trend toward
progressive dorsal to ventral migration as the psoas descends
from L1 to L5, with the L4–L5 disc space being most vulnerable to nerve injury.56 Park et al. showed the transpsoas exiting
nerve roots to be a relatively safe distance from the center of
the intervertebral disc space with the exception of a few anatomic variants.
57
In a 2010 cadaveric study, Uribe et al.55 further examined
the relationship of the lumbar plexus to the disc space, in
which the authors separated the vertebral body into four zones
on the sagittal plane, each representing a quarter of the distance across the body (Fig. 21.18).58 In their anatomic study,
the safe zone for levels L1–L2, L2–L3, and L3–L4 were at the
middle posterior quarter of the vertebral body (zone III) and
for L4–L5 at the midpoint of the vertebral body (junction of
zones II and III).
55,58
e genitofemoral nerve was found to be
at risk at zone II when it moves ventrally at L2–L3 and then
ventrally at zone I as it migrates caudally.
55
Although safe zones are useful guidelines, heterogeneity
exists in the relationship between the lumbar plexus and the
psoas. Meticulous preoperative planning, judicious dissection
without excessive pressure or manipulation of the psoas, direct
visualization of the surgical eld, and the use of electrophysi-
ologic monitoring are essential for success.
Immediately aer incision, caution should be taken when
splitting the lateral abdominal musculature to avoid injury to
the L1 branches of the iliohypogastric and ilioinguinal nerves
(encountered between the internal and external obliques) as
A
B
C
FIG. 21.15 Complete a thorough discectomy and endplate preparation to
enhance the biologic environment for a fusion.
FIG. 21.16 Trial for the proper graft height and lordotic angle to optimize
lordosis and/or coronal correction while providing enough foraminal height
for an indirect decompression.
374 SURGICAL ANATOMY AND APPROACHES
III III IV
5/S1 disc
FIG. 21.17 Impact the nal graft over shims to provide smooth translation of the graft to the contralateral side
while preventing strain and/or fracture of the endplates.
Zone A
2s
8
2i
2/3 disc
3s
3i
3/4 disc
4s
4i
4/5 disc
5s
5i
FIG. 21.18 Safe zone and the four quadrants of the disc space. (From
Arnold PM, Anderson KK, McGuire RA Jr. The lateral transpsoas approach to
the lumbar and thoracic spine: a review. Surg Neurol Int. 2012;3:S198–S215.)
2
2
2
2
3
5
10
6
2
8
2
11
4
12
9
12
12
12
10
12
12
12
12
12
12
12
12
9
10
12
12
12
7
12
12
12
12
12
12
muscle and its intrinsic motor branches with dilators or
retractor positioning/tension. Additionally, the amount and
duration of retraction used and operative time per level should
be taken into consideration in order to decrease the likelihood
of traction injury to nerves.
60
Advanced imaging should be evaluated for neurovascular
anatomy and its course with respect to the psoas and operative
level. Use of axial MRI (Fig. 21.19) to evaluate the size of the
psoas, rotation of the vertebral bodies, neurovascular anatomy,
and how the lumbosacral plexus migrates within the psoas
from proximal to distal is especially helpful in surgical plan-
12,61
ning.
A large psoas may present challenges to safe transpsoas entry, as can the location of the 11th or 12th rib during
access to the upper lumbar spine, alerting the surgeon to the
need for rib resection or use of an intercostal approach.
Our preference is to minimize “breaking” of the table to a
degree that is necessary to access the operative level(s). e
tension of the psoas is assessed by palpation in every procedure to minimize excessive traction of the lumbar plexus. If
breaking the table is required for lateral disc space access, we
have found that “unbreaking” the table aer only the inner
dilator and wire are in can substantially decrease psoas tension
while maintaining safe access with little anatomic distortion.
Real-time, directionally stimulated neuromonitoring is
employed intraoperatively to determine the proximity of the
exiting and traversing neural elements. e genitofemoral
nerve, most commonly seen at the L3–L4 lumbar level within
the more supercial dissection plane, should be directly
visualized and requires special attention because it is primarily
a sensory nerve and not detected by triggered or free-run
electromyography.
60
Vascular Anatomy
well as for “pseudohernia” prevention related to denervation
of the oblique muscles and resultant paresis of the abdominal
wall as described by Dakwar et al.59 Aer development of the
retroperitoneal plane by nger dissection, careful dissection
of the iliopsoas must be performed to avoid injury to the
e retroperitoneal space houses the great vessels, including
the aorta, inferior vena cava, and common iliacs. Vascular
anatomy should be well visualized and carefully evaluated on
preoperative MRI. Regev et al. found that the highest risk of
injury to the retroperitoneal vessels was at L4–L5 due to the
A B
Chapter 21 Lateral Lumbar Interbody Fusion 375
SECTION
III
C D
FIG. 21.19 (A) Axial T1 magnetic resonance image (MRI) of the lumbar spine showing anastomosis between
the renal and segmental vessels in close proximity to the L1–L2 disc space (arrow). Red area, abdominal aorta.
(B) Axial T1-weighted MRI of the lumbar spine at the L5 level showing the left common iliac vein. Blue area,
inferior vena cava. Yellow arrow, left common iliac vein. (C) Axial T2-weighted MRI of the lumbar spine at the
L3–L4 level. Yellow arrow, lateral lumbar interbody fusion cage. Note the close proximity of the cage and the
great vessels. (D) Axial T2-weighted MRI of the lumbar spine. Red area, abdominal aorta. Blue area, inferior vena
cava. Yellow arrow, lumbar arteries branching o the aorta. Red arrow, proximal vessel of lumbar arteries
anastomosis. (From Alkadhim M, Zoccali C, Abbasifard S, et al. The surgical vascular anatomy of the minimally
invasive lateral lumbar interbody approach: a cadaveric and radiographic analysis. Eur Spine J. 2015;24[Suppl
7]:906–911.)
more posterior location of the retroperitoneal vessels.62 Furthermore, the risk of vasculature injury is further increased
with rotatory deformities.62 Rare contralateral injuries to
vasculature can also occur; therefore, particular care should
be taken with the use of instruments when dissecting across
the disc space and when inserting the interbody gra.
63,64
High Iliac Crest/Lumbosacral Junction
During preoperative evaluation, standing anteroposterior
lumbar radiographs should be scrutinized for access to the
operative level, with particular attention to the height of the
lateral iliac crest and angle required for accessing L4–L5.
Positioning the patient in a true lateral decubitus position with
lateral bending (see Fig. 21.1) of the torso can increase the
distance between the iliac crest and ribs. However, this must
be weighed against the increased tension and traction placed
on the psoas and lumbar plexus.
L5–S1 is limited by a high lateral ilium, anterior course of the
neural elements pulled directly across the lateral disc, and/or
60,65
In most cases, access to
the vasculature, precluding safe access. Uncommonly, L5–S1
may be approached when the intercrestal line transects the
mid to lower L5 body or the L5–S1 disc space. Angled instruments are also an option to improve access.
Scoliosis
Special consideration must be made in scoliosis patients.
Identify abnormal displacement of vascular structures with
severe rotational deformity and approaching from the convex
side because the approach angle is more rostral. Preoperative
planning with identifying the lumbar plexus, iliac vein and
artery, aorta, and inferior vena cava on MRI is important to
determine which side is safer to approach (see Fig. 21.19).
56,66,67
Thoracolumbar Junction
Rostrally, the 12th rib may obstruct access from T12 to L2,
which may require excision or manipulation. Partial rib resection can be commonly performed in thoracolumbar approaches
376 SURGICAL ANATOMY AND APPROACHES
with little morbidity. Another technique to improve access is
to place a bump or roll under the contralateral ank to help
increase the distance between the 12th rib and iliac crest (see
Fig. 21.2).
6
A retrodiaphragm approach can be done by partial rib
resection and using the rib posteriorly as a guide to the disc
space and as a plane to retract the diaphragm anteriorly. Care
should be taken not to injure the diaphragm. Sometimes a
transdiaphragm approach is required for the thoracolumbar
junction since the diaphragm cannot be mobilized suciently
to gain access to the disc. With signicant diaphragm dissection, the diaphragm should be repaired prior to closure.
Thoracic Spine
Partial rib resection can be commonly performed in anterolateral thoracic approaches with little morbidity. Several other
techniques to minimize rib resection or preserve this anatomy
have been utilized, including performing LLIF in between
ribs. If that technique is performed, expansion of the lateral
access retractor should be minimized to prevent prolonged
compression of the neural elements on the rib underside for
risk of postoperative radicular/rib pain.
Complications
Although the minimally invasive nature of LLIF avoids many
serious approach-related risks of the anterior and posterior
techniques, there exists a signicant risk of neurologic injury.
e most common and well-documented complication is
lumbar plexus nerve root injury from either direct compression, laceration, or traction while traversing the psoas or
through prolonged retraction.
of LLIF cases, Rodgers et al. reported a 0.66% incidence of
transient hip exor weakness that occurred only when
approaching the L4–L5 level and a 6.2% overall complication
rate.12 ese authors contend that approach-related complica-
tion rates of LLIF are lower than the traditional open
approaches, including posterolateral lumbar fusion, PLIF,
TLIF, and ALIF. However, it should be noted that these rates
are signicantly lower than other smaller series reported in
the literature. Moller et al. found in their series of 53 patients
that 36% of patients experienced subjective hip exor weak-
ness, 23% experienced thigh numbness, and 25% experienced
thigh pain.13 Hip exion weakness resolved in 84% at 6
months, with most patients returning to baseline at 8 weeks;
69% and 75% of patients with thigh numbness and pain,
respectively, returned to baseline at 6 months and with many
reporting improvement at 8 weeks. Cummock et al. observed
thigh pain and numbness in 39% and 42.4% of 59 patients,
respectively, and nearly half resolved at 3 months and 90%
resolved at 1 year.70 Pumberger et al. reviewed 235 patients
who underwent LLIF and found sensory decits in 1.6% of
patients, psoas motor decit in 1.6%, and lumbar plexus decit
in 2.9% at 12 months follow-up.
Transient hip exor weakness and pain that occurs in the
absence of sensory decits is thought to be due to splitting of
12,13,47,59,65,68,69
71
In the largest series
the psoas muscle bers rather than a neurapraxia. Weakness
is typically transient and resolves within 3 months.46 Longer
duration of retraction has been suggested to predict postoperative weakness.46 If a nerve injury is suspected, electrodiagnostic studies have been recommended at 6 weeks and 3 months
postoperatively. If no clinical recovery is observed, some
surgeons perform a limited electromyographic test monthly
over the subsequent 3 months to evaluate for reinnervation.
65
Although rare, permanent or disabling nerve injury may
occur. Knight et al. reported two cases of L4 nerve injury in
their study of 58 patients.69 e incidence appears to be higher
in scoliosis patients, with Tormenti et al. reporting ve of eight
patients treated with LLIF for adult degenerative scoliosis
suering persistent sensory and motor radiculopathy.
37
e incidence of lumbar plexus nerve root injuries varies
widely, in part due to inconsistency in the literature regarding
diagnosis and evaluation. Ahmadian et al. therefore developed
a diagnostic standardization of and classication for postop-
erative nerve injuries seen with LLIFs that correspond to
sensory dermatomal zones.
65
e retroperitoneal nature of the approach also exposes
thoracoabdominal structures to potential injury that can be
signicant. Reported complications include bowel perfora-
tion,
37,72
incisional hernias,
12,59
pleural eusions,37 kidney
lacerations,47 retrocapsular hematoma,73 abdominal wall
paresis,
59,74
and pseudohernia.
59,74
Each case of bowel perforation required emergent exploratory laparotomy with resection
of bowel. When operating in the thoracolumbar spine,
the pleural space can be violated, leading to pleural eusion
and requiring careful intraoperative evaluation to evaluate
whether a chest tube is needed.
e most common implant-related complication is symp-
tomatic gra subsidence, which can lead to pseudarthrosis,
back and/or leg pain, adjacent vertebral body fractures, or
neurologic complications. Rodgers et al. reported 3 cases of
subsidence in 600 patients that required reoperation due to
adjacent vertebra fracture, gra fracture, and screw penetration of the endplate.12 Other authors have reported early
subsidence with stand-alone LLIFs due to excessive motion
that resolved aer posterior instrumentation was performed.27
Karikari et al. reported a 16.7% incidence of subsidence in a
series of patients older than 70 years of age who underwent
LLIF for degenerative conditions.17 Excessive motion and
osteoporotic bone are the common etiologies for gra subsidence, but “overstung” the interbody space and endplate
perforation can be precursors to subsidence. Consideration
for supplemental posterior instrumentation should be made
that includes patient’s bone mineral density. e risk of sub-
sidence is theoretically lower with the use of wider LLIF cages
with larger surface contact area and greater distribution of
force throughout the apophyseal ring.
27
Outcomes
e minimally invasive lateral approach for interbody
fusion has shown promise in minimizing approach-related
morbidity by minimizing surgical dissection and so tissue
Chapter 21 Lateral Lumbar Interbody Fusion 377
trauma with shorter operating room time, shorter hospital
stay, and decreased blood loss while maintaining equivalent
or improved clinical and radiographic outcomes compared to
traditional open anterior or posterior approaches.
12–14
In 2013, Ahmadian et al. reported in a series of 31 patients
who underwent LLIF for grade I or grade II spondylolisthesis
that there was signicant reduction in anterolisthesis, with
27 of 31 achieving complete reduction of the spondylolisthesis.65 At 6 months, all patients had clinical and radiographic
evidence of fusion on computed tomography (CT) and plain
radiographs as well as signicant improvements in Oswestry
Disability Index (ODI), visual analog scale (VAS), and Short
Form-36 scores.
e lateral approach has been shown to be a feasible
operative treatment for adjacent-segment degeneration. In
a prospective series of 100 patients who underwent LLIF
for adjacent-segment degeneration, Rodgers et al. reported
signicant improvement in VAS pain scores (from 8.6 to 2.8),
low complication rate (9%), and evidence of radiographic and
clinical fusion at 6 months.47 e benet of utilizing an alternative lateral approach avoids the technically challenging task
and increased risk of complications with reoperation through
the prior anterior or posterior scar.
46
With obese patients, the lateral approach has been
suggested to be a favorable alternative. In a comparative
series of 313 obese and nonobese patients who underwent
LLIF for degenerative conditions, Rodgers et al. found no
greater incidence of complication.75 is nding is not seen
with traditional open anterior or posterior fusion approaches
in which body habitus presents a technical challenge and
has been shown to increase rates of infection and other
complications.
76
e use of LLIF for deformity correction in adult degenerative scoliosis (ADS) has been shown to result in lower complication rates, shorter operative times, and less blood loss
with equal or better clinical and radiographic outcomes
when compared to traditional open anterior or posterior
approaches.
12,27,40,47,73,77,78
is is particularly relevant to the
elderly patient population that suers from ADS given that
they frequently have coexisting osteoporosis and multiple
comorbidities that put them at higher risk for pseudarthrosis,
hardware failure, and other complications with multilevel
deformity correction.
79,80
Complication rates of up to 66% have
been reported.81 Charosky et al. reported a 39% complication
rate with 20% requiring reoperation in 306 patients undergoing primary ADS treatment by traditional anterior, posterior,
or combined approaches.82 Daubs et al. reported a 37% complication rate, with 20% major complications in patients over
60 years.83 In a large prospective series of 107 patients who
underwent LLIF for ADS, Phillips et al. demonstrated signi-
cant improvements in clinical and radiographic outcomes at
24 months with a lower incidence of complications (24%, with
half being minor complications).47 e lower rate is likely
attributed to the lateral approach avoiding mobilization of
abdominal viscera and great vessels or dissection of the posterior musculature.47 Perioperative morbidity is also decreased
by the minimally invasive nature of the lateral approach,
which minimizes surgical morbidity and allows for early
ambulation and shorter hospital stay.
12–14
Although minor
complications of hip exor weakness and thigh pain have been
reported, most are transient and resolved by 6 months.
13
Coronal deformity correction achieved with LLIF for ADS
has been reported to be similar to that achieved by traditional
approaches. Wang and Mummaneni reported a mean coronal
correction of 20 degrees (63%) in 23 patients with a solid
fusion at all interbody levels.39 Anand et al.73 reported a
15-degree correction (68%) in 28 patients, all of whom fused
and maintained their correction at 12 months. Acosta et al.13
reported an 11.7-degree correction (55%) in eight patients.
Tormenti et al.37 reported a 70% curve correction in eight
patients. Phillips et al.46 reported a 7.4-degree (35%) correction in 107 patients, with greater correction seen with posterior
instrumentation. In comparison, in a systematic review of 49
publications on ADS deformity correction, mean postoperative coronal correction was 40.7%.84 Anand et al. also reported
signicant improvements in VAS and ODI scores with no
major complications.73 Uribe et al. demonstrated that deformity corrections in a series of 39 ADS patients were all
maintained with ongoing improvement in VAS pain scores up
to 3 years postoperatively.49 Dakwar et al. reported that all 25
adult deformities in their series maintained correction at 2
years, achieved fusion on CT and plain radiographs, and
experienced signicant improvement in VAS and ODI scores
with only minor complications.85 Ozgur et al. reported excellent clinical and radiographic results equal to or superior to
traditional approaches with no major complications in their
62 patients.16 Wang and Mummaneni also encountered no
intraoperative complications.39 Pimenta et al. and Benglis
et al. independently found signicant deformity correction
with signicant mid- to long-term clinical outcomes in their
individual series of ADS patients who underwent LLIF.
86,87
e anterior column fusion rates achieved with LLIF are
equivalent or greater than traditional approaches such as
ALIF, for which 92% to 97% have evidence of fusion on CT
at 12 months.88 A 96% fusion rate by CT and over 90% patient
response of “satised or very satised” was reported by Rodgers
et al. at 12-month follow-up in a series of 66 patients who
underwent LLIF of 88 levels.89 Similarly, Ozgur et al. reported
radiographic evidence of fusion aer LLIF for degenerative
disease in 91% of 62 patients with 113 levels, and signicant
improvement in VAS and ODI scores at 24 months.16 is high
rate of fusion is consistent with a low incidence of revisions for
pseudarthrosis. Phillips et al.46 observed a 2% rate of revision
for pseudarthrosis, which is superior to rates of 0% to 19%
90-94
reported for anterior and/or posterior approaches.
Indications for the MIS lateral approach have expanded
to the thoracolumbar junction, including corpectomy and
reconstruction. Addressing anterior column pathology in the
thoracic spine is technically challenging and a thoracotomy can
lead to poor pulmonary function postoperatively, with major
complications reported in up to 12% of patients.95 Khan et al.
followed a series of 25 patients who underwent an MIS lateral
approach for corpectomy and observed shorter operative
times, decreased blood loss, decreased use of blood products,
shorter postoperative time to extubation, and signicant pain
relief compared to a standard open corpectomy.96 e benet
SECTION
III
378 SURGICAL ANATOMY AND APPROACHES
is attributed to the minimally invasive nature of the approach
and the absence of prolonged lung deation. Karikari et al.17
reported a series of 22 patients who underwent LLIF for thoracolumbar disease, including degeneration, tumor, adjacentsegment disease, disc herniation, and infection. ey observed
that 95.5% of patients achieved a substantial clinical benet
and demonstrated evidence of fusion at 6 months postoperatively. Although deformity correction was less pronounced
than with the traditional open thoracolumbar approach, no
major complications occurred. e MIS lateral approach to
the thoracolumbar spine may be a well-suited safe alternative
for elderly patients or those with signicant comorbidities,
and in multiple other settings including trauma, infection,
tumor, and corpectomies for canal decompression for a variety
of pathologies.
In regard to costs, Lucio et al. performed a cost analysis for
two-level LLIF and two-level PLIF for degenerative lumbar
disease; they showed a cost saving of $2825.37 (10.4%) per
patient in the early perioperative period with LLIF.97 e costs
were calculated from the index procedure, transfusions, reoperations, and residual events, which were dened by hospital
readmissions, emergency department visits, postoperative
rehabilitation, and additional diagnostics. ese authors also
reported shorter hospital stay and decreased blood loss in the
LLIF group.
Summary
LLIF has evolved over decades into a safe and common procedure. LLIFs provide superior fusion rates compared to other
fusion options. LLIFs provide indirect decompression of
foraminal, lateral recess, and central stenosis. With osteoporosis, LLIF allows load sharing over a large footprint on the
apophyseal ring and decreases osteoporotic-related hardware
complications. Preoperative MRI evaluation is imperative to
identify the neurovascular anatomy to prevent vascular and
lumbar plexus injuries. LLIFs provide signicant coronal and
sagittal correction in ADS compared to traditional open
procedures. Anterior column reconstruction through the
lateral approach provides equivalent sagittal plane correction
as pedicle subtraction osteotomy with signicantly less blood
loss. LLIFs meet the demand for earlier postoperative recovery
and return to work. Lateral interbody fusions limit infection
rates compared to open posterior fusions with the obese population. Last, minimally invasive lateral interbody fusion is
cost-eective and provides health care savings compared to
other lumbar fusion options.
KEY REFERENCES
1. Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral
Interbody Fusion (XLIF): a novel surgical technique for anterior
lumbar interbody fusion. Spine. 2006;6:435-443.
2. Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early
postoperative complications in extreme lateral interbody fusion:
an analysis of 600 cases. Spine. 2011;36:26-32.
3. Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic
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4. Phillips FM, Isaacs RE, Rodgers WB, et al. Adult degenerative
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380 SURGICAL ANATOMY AND APPROACHES
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