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V. Quack et al.
56.5 Patient Positioning
The patient is positioned on a radiolucent bendable surgical
table in a direct lateral right-sided decubitus position (90°),
perpendicular to the table, with the trochanter directly positioned over the table break and with legs and knees slightly
bent. This conguration increases the space between iliac
crest and ribs, especially relevant when accessing thoracolumbar junction or L4-L5 level. The ideal positioning is conrmed by uoroscopy, ensuring that when at 0°, the C-arm
provides a true anteroposterior (AP) image, and when at 90°,
a true lateral image. It is substantial that the lateral uoroscopic images show both vertebral plateaus and superior
pedicles aligned, presented as a single line, and that the AP
image reveals the spinous processes in a middle position, and
pedicles as circumferences.
It is substantial that the lateral uoroscopic images show
both vertebral plateaus and superior pedicles aligned, presented as a single line, and that the AP image reveals the
spinous processes in a middle position, and pedicles as
circumferences.
56.6 Planning oftheSkin Incision
A uoroscopic height localization with topographic projection of the corresponding intervertebral disk on the skin is
carried out in the strict lateral position with the aid of, for
example, a K-wire. The intervertebral disk and the adjacent
vertebral bodies are marked onto the skin and the incision is
planned according to the number of levels to be treated. We
prefer the one-incision-technique.
56.8 Technique
56.8.1 Lateral Retroperitoneal Access
After skin asepsis, a longitudinal skin incision, approximately
3–5cm, is made over the marked disk space. Following dissection of the subcutaneous fat layer, the fascia of the oblique
externus muscle is opened. The oblique externus, the oblique
internus, and the transverse abdominis muscle are now bluntly
dissected with the ngertip to develop the fascia under the
transverse abdominis muscle. Once this fascia is opened, the
retroperitoneal space can be entered with the nger and blunt
dissection, with dorsal to anterior movement of the ngertip,
is performed until the psoas muscle is reached. The index nger will now safely guide all dilators up to the psoas muscle,
protecting abdominal structures (Fig.56.1).
56.8.2 Psoas Traverse
The rst dilator is placed upon the junction of the posterior
third and the anterior two-thirds of the disk, as conrmed by
AP and lateral uoroscopy. Then, the bers are gently separated by the initial blunt dilator with concomitant EMG
monitoring for assessing the closeness to the lumbar plexus
and allowing determining the proximity of neural structures
56.7 Approach
Several studies have investigated the location of the neural
structures in the psoas muscle. For this purpose, Guérin
etal. divided the disk space into 4 zones (1 anterior to 4
posterior). Based on their cadaveric studies, they recommend positioning of the retractor at the level of L1/2in
zones 2 and 3, L2-L4 zone 3, and L4/5in zone 2 [16]. A
comparable classication was published by Uribe et al.
[17]. However, Banagan and colleagues concluded that
based on their study, there is no absolute safe zone and
they would recommend either direct visualization of the
nerve and/or the use of neuromonitoring [12]. In the segment L4/5, there is the greatest risk of a neurological damage [18].
Fig. 56.1 Possible approaches to the lumbar spine. TLIF transforaminal
lumbar interbody fusion, PLIF posterior lumbar interbody fusion, OLIF
oblique lateral interbody fusion, ALIF anterior lumbar interbody fusion
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Fig. 56.2 Initial Dilatator is placed on the disk using EMG monitor-
ing. Fluoroscopy is used to conrm the adequate location
that are adjacent to the surgical eld by using a probe
(Fig.56.2). The dilator must be rotated in position to determine proximity and spatial distribution of nerves. The dilators in sequence are placed over the previous, always
checking the EMG, until placement of the last retractor.
After conrming the ideal position by uoroscopy, the
blades of the retractor are inserted. Depending on the retractor system used, the blades may be further stabilized after
opening by the insertion of pins and visualization of the area
of interest is improved by a light source clipped on the
retractor blade. Retractor opening must be minimized in
order to prevent lack of blood ow to the nerves of the
plexus and prevent plexopathies due to compression. Now
bipolar can be used to achieve disk visualization. The disk is
now incised with a knife, and an annulotomy is performed
(Fig. 56.3). Using the disk preparation instruments, both
endplates are prepared and the annulus on the opposite side
is also released. This is critical to achieve the best possible
distraction of the disk space, proper coronary alignment,
placement of a large implant, and herewith also the best pos-
Fig. 56.3 The dilators in sequence are placed over the previous, always
checking the EMG, until the nal placement of the retractor. The disk is
then partially removed. The annulus on the opposite side should be
opened
sible indirect decompression. After adequate preparation of
the disk space, the cage can be inserted (Fig. 56.4). Some
hyperlordotic cages are available on the market, which can
achieve additional optimization of the sagittal alignment.
Particular care should be taken to ensure that the cage is
inserted well anteriorly. The position of the cage is now
checked uoroscopically in true lateral and AP images. If the
position of the cage is satisfactory, there is now the option of
additional stabilization by inserting a lateral plate or the percutaneous insertion of a transpedicular screw-rod system in the
lateral or a prone position. Prone positioning certainly has the
disadvantage that time is lost due to repositioning and renewed
skin asepsis. If a lateral plate is used, this certainly has the
advantage that no additional skin incision has to be made and
no repositioning has to be performed. The plate size is selected
depending on the disk space height and centered over the disk
space with an insertion instrument. Depending on the plate, it
is then xed with screws, if necessary, after preparing the
screw holes with an awl or a tap. Plate and screw placement is
carried out under uoroscopic control.
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Biomechanically, however, the lateral plate systems are
inferior to the pedicle screw systems, although overall good
fusion rates are described [13, 14]. Furthermore, voluminous
plate systems may irritate the psoas muscle and may cause
chronic pain.
Hereafter occurs the lavage of the situs, removal of the
retractor system, and wound closure in layers (Fig. 56.5).
After mobilization of the patient, a standing X-ray should be
taken as a control before discharge (Fig.56.6).
56.8.3 Complications
XLIF includes a disproportionate increase in the neurological complications of spinal surgery versus other constructs,
that is, plexus injuries 13.28%, sensory decits 0–75% (permanent in 62.5%), motor decits 0.7–33.6%, anterior thigh
pain 12.5–25%, and sympathectomy 4–8%.
Additional nonneurological complications include cage
subsidence (10–13.8%), major vascular injuries up to 0.4%,
bowel perforation, malpositioning of the cage, nonunion
(7.5%), and failure to decompress stenosis [19–22].
Fig. 56.4 After adequate preparation of the disk space, the cage can
now be inserted. The adequate position of the cage is conrmed
uoroscopically
Fig. 56.5 Left: Intraoperative position of the retractor. Right: Wound closure with staple suture. The use of a drain is not always necessary
56 Extreme Lateral Interbody Fusion (XLIF)
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Fig. 56.6 Postoperative radiographs after XLIF L2/3 and minimally invasive dorsal instrumentation
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 J. 2006;6:435–43.
2. Acosta FL, Liu J, Slimack N, etal. Changes in coronal and sagittal
plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in
adults: a radiographic study. J Neurosurg Spine. 2011;15:92–6.
3. Alimi M, Hofstetter CP, Tsiouris AJ, etal. Extreme lateral interbody
fusion for unilateral symptomatic vertical foraminal stenosis. Eur
Spine J. 2014;24(Suppl 3):346–52.
4. Quante M, Halm H. Extreme lateral interbody fusion: indication, surgical technique, outcomes and specic complications.
Orthopade. 2015;44:138–45.
5. Caputo AM, Michael KW, Chapman TM, et al. Extreme lateral
interbody fusion for the treatment of adult degenerative scoliosis. J
Clin Neurosci. 2013;20:1558–63.
6. Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic
assessment of the ability of the extreme lateral interbody fusion
procedure to indirectly decompress the neural elements. Spine.
2010;35(26 Suppl):S331–7.
7. Berjano P, Gautschi OP, Schils F, Tessitore E.Extreme lateral interbody fusion (XLF): how I do it. Aca Neurochir. 2015a;157:547–51.
8. Patel VC, Park DK, Herkowitz HN.Lateral transpsoas fusion: indications and outcomes. Sci World J. 2012;2012:893608.
9. Scherman DB, Rao PJ, Phan K, Mungovan SF, etal. Outcomes of
direct lateral interbody fusion (DLIF) in an Australian cohort. J
Spine Surg. 2019;5(1):1–12.
10. Young-Hoon K, Kee-Yong H, Kee-Won R, et al. Lumbar interbody fusion: techniques, pearls and pitfalls. Asian Spine J.
2020;14(5):730–41.
11. Meredith DS, Kepler CK, Huang RC, Hegde VV. Extreme lateral
interbody fusion (XLIF) in the thoracic and thoracolumbar spine:
technical report and early outcomes. HSS J. 2013;9:25–31.
12. Banagan K, Gelb D, Poelstra K, etal. Anatomic mapping of lumbar
nerve roots during a direct lateral transpsoas approach to the spine:
a cadaveric study. Spine (Phila Pa 1976). 2011;36(11):E687–91.
13. Berjano P, Langella F, Damilano M, et al. Fusion rate following extreme lateral lumbar interbody fusion. Eur Spine J.
2015b;24(Suppl 3):369–71.
14. Li H, Zhang R, Shen C.Differences in radiographic and clinical outcomes of oblique lateral interbody fusion and lateral lumbar interbody fusion for degenerative lumbar disease: a meta-analysis. BMC
Musculoskelet Disord. 2019;20(1):582.
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15. Regan C, Kang JD.The role of the minimally invasive extreme lateral interbody fusion procedure for complex spinal reconstruction.
Oper Tech Orthop. 2013;23:28–32.
16. Guérin P, Obeid I, Bourghli A, etal. (2011) The lumbosacral plexus:
anatomic considerations for minimally invasive retroperitoneal
transpsoas approach. Surg Radiol Anat. 2012 Mar;34(2):151–7.
17. Uribe JS, Arredondo N, Dakwar E. Dening the safe working zones using the minimally invasive lateral retroperitoneal
transpsoas approach: an anatomical study. J Neurosurg Spine.
2010;13(2):260–6.
18. Kepler CK, Sharma AK, Huang RC, etal. Indirect foraminal decompression after lateral transpsoas interbody fusion. J Neurosurg
Spine. 2012;16:329–33.
19. Epstein NE.Extreme lateral lumbar interbody fusion: do the cons
outweigh the pros? Surg Neurol Int. 2016a;7(Suppl 25):S692–700.
20. Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: a
review. Surg Neurol Int. 2016b;7(Suppl 3):S83–95.
21. Epstein NE.More nerve root injuries occur with minimally invasive
lumbar surgery: let’s tell someone. Surg Neurol Int. 2016c;7(Suppl
3):S96–S101.
22. Epstein NE. Incidence of major vascular injuries with extreme lateral interbody fusion (XLIF). Surg Neurol Int. 2020;11:70.
Part VIII
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Posterior Lumbar Spine
Overview ofSurgical Techniques
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andImplants
UweVieweg
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57.1 Introduction and Core Messages
Posterior lumbar spine surgery uses various access
routes (midline, lateral, far-lateral paracoccygeal) and
can employ classic open, miniopen (microscopic or
video assisted), or percutaneous access techniques.
Decompression operations can be performed by using
these access methods, and there are various possibilities of instrumentation as can various forms of instrumentation. The implants are divided into the following
groups: rigid systems (internal xator systems such as
rod-screw or screw-plate systems, screws, pedicle
screw-hook systems, cages, and spacers for interbody
fusion); different dynamic or semirigid systems; and
so-called nonfusion systems (pedicle-based systems,
interspinous spacers, facet replacements). The following are types of posterior stabilization systems available: tulip screw–type systems, side-loading systems,
and plate systems. For the interbody fusion, there are
cages in titanium as well as in PEEK on the market.
Also, there are implants for the motion preservation
available. The spectrum of those implants rises from
dynamic pedicle screw systems, interspinous spacers,
and facet replacement implants.
U. Vieweg (*)
Department of Conservative and Surgical Spine Therapy with
Interdisciplinary Spinal Deformities Centre and Rummelsberg
Sectional Center, Hospital Rummelsberg,
Schwarzenbruck, Germany
e-mail: uwe.vieweg@sana.de
57.2 Approaches (see Fig.57.1)
• Midline posterior approach
A midline approach to the lumbar region is most frequently used for posterior lumbar spine surgery. The
exposure of the deeper layer of muscles, however, is
imprecise and can entail substantial tissue damage and
blood loss. Besides providing access to the cauda equina
and the intervertebral disks, the midline approach can
expose the posterior elements of the spine: the spinous
processes, laminae, facet joints, and pedicles. The midline
approach can be extended proximally and distally. The
skin incision is made straight along the midline, even in
scoliosis cases. For fusion cases, the incision should be
one to two segments longer than the section to be fused.
The preparation has to be performed strictly subperiosteally to preserve the blood vessels and nerves, which supply the muscles, and to prevent bleeding. In this approach
technique, the lumbar spine is prepared from cranial to
caudal.
• Mediolateral posterior approaches
The paramedian approach, as well as the intermuscular
Wiltse approach, allows a good exposure of the nerve
roots at the lumbar levels [1]. The Wiltse technique is a
paramedian approach to the lumbosacral junction. Unlike
a midline incision, where the exposure is created by cutting through the muscle planes, a Wiltse approach utilizes
a blunt dissection of the muscles, this means between the
fascial planes of the multidus and longissimus muscles
to create the exposure. In the 1960s, Wiltse etal. described
the sacrospinalis-splitting approach to the lumbar spine
[2]. This procedure was accomplished by making a paraspinous incision through the deep fascia and developing
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_57
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Approaches
posterior lumbar spine
Midline Medio-lateral Far-lateralParacoccygeal
Fig. 57.1 Approaches for the posterior lumbar spine
the plane between the multidus and longissimus muscles. A paramedian skin incision is made to perform the
transmuscular approach.
The intramuscular Wiltse approach allows the surgeon
to approach the spine in a less invasive way in comparison
to a midline incision. It is known as a miniopen approach,
invasive because it preserves the posterior musculature of
the spine and it is performed unilaterally. In 1953, Watkins
described a far-lateral approach, a route between the erector spinae (iliocostalis) and the quadratus lumborum,
which requires some resection of the ilium for proper
muscle reection. Another option is the lateral intramuscular planar approach to the lumbar spine described by
Newman [3].
• Transforaminal approach
The transforaminal approach to the L5–S1 interspace
provides a minimally invasive corridor through which discectomy and interbody fusion can safely be performed. It
may provide an alternative route of access to the L5–S1
interspace in those patients who have unfavorable anatomy for, or contraindication to, the traditional open anterior approach to this level [4].
57.3 Access Techniques (see Fig.57.2)
The access techniques used can be subdivided into classic
open, miniopen, and percutaneous techniques. The access
routes can be made considerably smaller if special retractors are used [5]. These include MLD-retractor, Caspar
retractor (Aesculap); METRx or Quadrant (Medtronic);
and ProView Minimal Access Portal System (Blackstone
Medical) MaXcess (Nuvasive). These techniques are subsumed under the heading of miniopen access. To optimize
visualization, especially in minimally invasive and less
invasive spine surgery, either an operating microscope or an
optic is used. The techniques are referred to with reference
to the visualization method employed (microscopic or
Access techniques
Mini-open
− Endoscope assisted
− Microscopic
Fig. 57.2 Access techniques
Classic open
Percutaneous
Endoscopic percutaneous
video assisted) [5, 6]. Combinations of percutaneous,
microscopic, endoscopic, and miniopen access techniques
can be used (see Fig.57.2) [6].
57.4 Implants (see Fig.57.3)
57.4.1 Rigid Systems
• Screws and pins
For the posterior approach, there are several translami-
nar screws or translaminar pins (ECF Peek from Signas)
available. This translaminar pin is a further development
of the translaminar facet screw xation (TLPF). The
implantation is performed by using a percutaneous paracoccygeal approach. A reduction and stabilization of
minor spondylolisthesis can be achieved by direct screwing as described by Buck [7].
With a special-designed interbody fusion device
(AxiaLIF), a transsacral approach can be achieved, for
example, with the transsacral screw of TranS1.
Examples: Multiple fragment screw–translaminar
screw, transsacral screw (TranS1 Inc.) and ECF PEEK
translaminar pin (Signus). Using a percutaneous paracoccygeal approach, axial uoroscopically guided interbody
fusion (AxiaLIF) is possible with a special transsacral
screw (TranS1 Inc.) [4]. Translaminar pin xation (TLPF)
is a further development of translaminar facet screw xation (TFSR). Compression and stabilization of minor
spondylolisthesis can be achieved by direct screwing, as
described by Buck [7].
• Hook-screw systems
Example: Hook-screw construct described by
Morscher [8].
This surgical procedure is to reconstruct and stabilize
the fractured pars interarticularis in minimal spondylolytic
spondylolisthesis. It allows compression of the defect without crossing the defect with the screw. Direct repair is indi-
57 Overview ofSurgical Techniques andImplants
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Fig. 57.3 Implants for the
posterior lumbar spine
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cated only in the absence of disk degeneration. After the
age of 25years, this procedure should not be carried out.
• Internal xator (screw-rod or screw-plate systems)
Dorsal stabilization procedures employ transpedicu-
larly positioned implants with stable angle xation. From
the internal xator as described by Dick, further development led to the xator described by Kluger and the
Universal Spine System USS (Synthes) and MOSS
System (DePuy). The rigid internal xator systems can be
grouped into different types according to their design
details, for example, top-loading and side- loading systems, polyaxial screw, monoaxial screw, reduction screws,
augmentation screws, and cannulated screws [9, 34].
57.4.1.1 Internal Fixator Systems forOpen
Implantation (Current andOlder
Systems)
Examples: TSRH (Texas Scottish Rite Hospital) 3D Spinal
Instrumentation (Medtronic), CD HORIZON LEGACY
(Medtronic), MOSS-MIAMI Family (DePuy), SFS Spinal
Fixation System (Blackstone Medical), Monarch Spine
system (Zimmer Spine), ST 360° Spinal Fixation System
(Zimmer Spine), Synergy Spinal System (Interpore Cross
International), USS-Universal Spinal System (Synthes),
Click’X (Synthes) (see Fig. 57.4), SOCON (Aesculap),
Silhouette Spinal Fixation System (Zimmer Spine), Sequoia
(Zimmer Spine), Instinct Java (Zimmer Spine), Xia
(Stryker), ConKlusion (Signus), SSE Spine System
Evolution (Aesculap), and S4 Spinal System (Aesculap)
(see Fig.57.5).
57.4.1.2 Systems forLess Invasive
Percutaneous Implantation
Silverbolt (VertiFlex), CD Horizon Longitude System
(Medtronic), CD Horizon Sextant System I/II (Medtronic),
Pathnder (Zimmer Spine), MANTIS (Stryker), SpheRx
(Nuvasive), SpiRIT (Synthes), ProView, ICON (Blackstone
Medical), and Expedium Viper (DePuy Spine).
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Fig. 57.4 Click’X, internal xator system (Synthes)
Fig. 57.5 Cosmic internal xator (Ulrich) with mobile (hinged)
screwhead
Fig. 57.6 Cannulated pedicle screw click’X for augmentation
(Synthes)
57.4.1.3 Pedicle Screw Systems
forAugmentation
SOCON (Aesculap), S4 Spinal System (Aesculap), and
Click’X (Synthes) (see Figs.57.4 and 57.6)
• Cable-clamp systems
Example: Universal Clamp System (Zimmer Spine)
• The universal clamp is a polyester band passed under the
lamina and connected to a rod by a titanium clamp. This
is an alternative for replacing screws and hooks for thoracolumbar spinal diseases.
• Screw-plate systems
Monarch plate or rod system (DePuy Spine)
It is about a combination of pedicle bolt and in-line
polyaxial screw technology. Modular polyaxial washers
can be added to provide an angulation at any position.
Example: Monarch plate or rod system (DePuy Spine)
• Rod-cable systems
Luque rod and rectangle with wire xation (Surgicraft),
ISOLA (DePuy Spine).
It is used in deformity cases and employs screws,
wires, slotted connectors, hooks, and rods to correct the
thoracolumbar spine.
Examples: Luque rod and rectangle with wire xation
(Surgicraft), ISOLA (DePuy Spine)
• Interbody implants (cages, spacers)
– Titanium net cylinders
Examples: Harms titanium net cylinder (DePuy Spine),
SynMesh (Synthes)
NGage Surgical Mesh System (Blackstone Medical)
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