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Literature Evidence of the MIS Lateral Approach
Jim Youssef , Douglas Orndorff ,
and Sue Lynn Myhre
6
Minimally disruptive approaches continue to
gain adoption by spine surgeons in the hopes of
minimizing soft tissue damage and accelerating
postoperative recovery [ 1 ]. Lateral techniques
such as the extreme lateral interbody fusion
(XLIF®, NuVasive, Inc., San Diego, CA, USA)
are one of those minimally disruptive approaches.
The XLIF (XLIF®, NuVasive, Inc., San Diego,
CA, USA) approach was fi rst introduced in 2001
by Pimenta [ 2 ] and since then has gained accep-
tance and recognition as a spinal treatment.
Previous literature has proposed that XLIF
(XLIF®, NuVasive, Inc., San Diego, CA, USA)
is a safe, minimally invasive surrogate to conventional open fusion techniques [ 3 , 4 ]. Data from
long-term, large-series studies have demonstrated
fewer morbidities and complications than traditional open approaches [ 5 – 10 ]. However, one of
the biggest concerns is neural complications
within the psoas muscle due to the anatomical
position of the lumbar plexus [
This chapter presents literature evidence of the
MIS (minimally invasive surgery) lateral approach
from level 1, 2, and 3 papers that included treatment characteristics, clinical and radiographic
outcomes, and reports of complications. The
J. Youssef , MD (*) • D. Orndorff , MD
S. L. Myhre , PhD
Spine Colorado , Durango , CO 81301 , USA
jyoussef@spinecolorado.com
e-mail:
11 – 16 ].
chapter consists of two main sections: (1) patients
with adult spinal deformity and (2) patients with
degenerative conditions (spondylolisthesis, stenosis, disc disease, adjacent segment disease).
Within each main section, four subsections are
presented, which consist of (1) treatment characteristics, (2) clinical outcomes, (3) fusion success,
and (4) complications.
6.1 Adult Spinal Deformity
A posterior-only or a combined anterior-posterior
approach is a customary surgical technique for
treating adult spinal deformity in the thoracolumbar spine. Typically, adult deformity patients
undergo an anterior column reconstruction with
interbody cage placement and bone grafting and
subsequent posterior decompression, as well as
the option of osteotomy and posterior arthrodesis
[
17 – 19 ]. Despite an accepted and effective surgi-
cal approach, these traditional open techniques
have generally been affi liated with elevated morbidity and complications (blood loss, prolonged
surgical times, infection, inadequate correction
of sagittal/coronal balance), which has provided
motivation for the evolution of less invasive surgical techniques to manage spinal deformity [ 17 ,
20 – 22 ]. Recently, XLIF (XLIF®, NuVasive, Inc.,
San Diego, CA, USA) has been chosen as a less
invasive alternative to fusion and reconstruction
of the anterior column [ 6 , 23 – 29 ].
© Springer International Publishing Switzerland 2017
M.Y. Wang et al. (eds.), Lateral Access Minimally Invasive Spine Surgery,
DOI 10.1007/978-3-319-28320-3_6
35
36
J. Youssef et al.
6.1.1 Studies
Three papers met the inclusion criteria for this
section, including two level 2 papers and one
level 3 paper (Table 6.1 ). The study and treatment
characteristics are summarized in Tables 6.1 and
6.2 , respectively. The reported complications and
side effects and outcomes are outlined in
Tables 6.3 and 6.4 , respectively.
6.1.2 Treatment Characteristics
Many of the inherent complications affi liated
with a conventional anterior or posterior surgery
are avoidable with the XLIF (XLIF®, NuVasive,
Inc., San Diego, CA, USA) approach [ 25 , 30 –
32 ]. The literature has cited decreased blood
loss, quicker recovery, and lower costs as advantages of a lateral surgery [ 10 , 32 , 33 ]. Isaacs
et al. [ 32 ] reported an operative time of
177.9 min or 57.9 min per level. The length of
stay averaged 2.9 days for unstaged surgeries
and 8.1 days for staged procedures. Estimated
blood loss was minimal (≤100 mL) for the
majority of patients (62.5 %), while nine patients
did lose up to 300 mL. In comparison, results
from traditional procedures have reported a
much higher blood loss [ 34 , 35 ]. Daubs et al.
[ 34 ] demonstrated a mean blood loss of
2,056 mL (300–5,500). However, the average
number of levels was twice that of Isaacs et al.
[
32 ] (4.4 levels vs. 9 levels).
6.1.3 Clinical Outcomes
Tormenti et al. [ 36 ] reported improved VAS
(visual analog scale) scores for both the combined XLIF and posterior and posterior-only
groups. The scores improved from 8.8 to 3.5 and
9.5 to 4.0 for the combined and posterior-only
groups, respectively. These scores were not statistically signifi cant between groups. The average
follow-up period was 10.5 and 11.5 months for
the combined and posterior-only groups, respectively. Unfortunately, the sample sizes were very
small for each group (8 = combined and 4 = posterior only), and VAS scores for only six of the
Table 6.1 Study characteristics for deformity
Author Procedure LOE Control
Tormenti et al. [
Isaacs et al. [
Phillips et al. [
LOE level of evidence (I-V)
TLIF minimally invasive transforaminal interbody fusion
PLF posterolateral fusion
XLIF extreme lateral interbody fusion
36 ] X, TLIF III PLF
PLF III X, TLIF
32 ] XLIF, L5S1 II –
37 ] XLIF, L5S1 II –
170
eight patients in the combined group were
available.
Phillips et al. [ 37 ] demonstrated signifi cantly
better ODI (Oswestry Disability Index), VAS
back and leg, SF-36 MCS (36-Item Short Form
Health Survey Mental Component Summary),
and SF-36 PCS (36-Item Short Form Health
Survey Physical Component Summary) scores
between presurgery and 2-years postsurgery
( p < 0.001). Additionally, a high percentage of
patients (85 %) were very satisfi ed with their outcomes and 86 % declared they would be willing
to do the procedure again. Although the sample
size was fairly large, only 77 % of the patients
were accessible at the 24-month follow-up.
6.1.4 Fusion
Previous literature has demonstrated a revision
rate for pseudarthrosis ranging from 0 to 19 % for
anterior plus posterior and posterior-only traditional approaches in deformity patients [
In contrast, Phillips et al. [ 37 ] showed a 2 % revi-
sion rate when pseudarthrosis was diagnosed.
This small percentage of revision surgeries
noticed after XLIF (XLIF®, NuVasive, Inc., San
Diego, CA, USA) agrees with prior studies who
have reported high rates of fusion success [ 25 , 28 ,
43 , 44 ]. The authors believed that the high rate of
fusion with XLIF (XLIF®, NuVasive, Inc., San
Diego, CA, USA) procedures most likely indicates the capacity to accomplish a complete discectomy and place a large cage within the disc
space packed with more abundant bone graft
within the interbody cage on the apophyseal
ring of the end plate, as compared to transforaminal lumbar interbody fusion (TLIF) or
38 – 42 ].
6 Literature Evidence of the MIS Lateral Approach
Table 6.2 Treatment characteristics for deformity
Anterior
Author Indication
Tormenti
et al. [
Isaacs
et al. [
Phillips
et al. [
ORT operating room time; EBL estimated blood loss; LOS length of hospital stay
Table 6.3 Complications and side effects for deformity
Author Minor (%) Major (%)
Tormenti et al. [
Isaacs et al. [
Phillips et al. [
Table 6.4 Outcomes for deformity
Author Fusion (%) VAS decrease (%) ODI decrease (%)
Tormenti et al. [
Isaacs et al. [
Phillips et al. [
ODI Oswestry disability index
Scoliosis 2–5 L1–L5 BP 6–12 8 10.5 months – – –
36 ]
Scoliosis 1–3 L2–S1 BP 4–11 4 11.5 months – – –
Scoliosis 1–6 T8–S1 Mixed 0–9 107 6 weeks 178 50–100 3.8
32 ]
Scoliosis 1–6 T8–S1 Mixed 0–9 82 24 months – – –
37 ]
32 ] 15.9 % 12.1 % – 36 % – – 24.3 %
37 ] – – – – – – –
32 ] – – – – –
37 ] −3.4 points – – 85 % 85 %
levels Levels
36 ] – – 75 % – – – 150 %
– – – – – – –
36 ] – 60.2 % – – –
– 57.9 % – – –
Internal
fi xation
# of
posterior
levels Total n
Transient thigh
sensory
symptoms (%) HFW (%)
Mean
follow-up
Motor
neural (%) Reops (%)
Outcome satisfaction
(%) Redo (%)
ORT
(mins)
EBL
(mL)
Total comps
(%)
37
LOS
(days)
posterior lumbar interbody fusion (PLIF) surgeries. However, due to poor radiographic
visualization, 10 % of patients were not able to
be assessed for fusion, and at the latest follow-up
of 12 months (range: 12–36 months), 58 % had a
solid fusion, 39 % had a partial fusion, and 3 %
showed no consolidation. Additionally, 8 % of
patients demonstrated nonfusion at ≥1 level. The
length of follow-up for the fused patients as compared to the nonfused patients was not provided in
this study. Also, 10.6 % of the patients were documented as smokers. Smoking has been shown to
affect outcomes and fusion [
45 , 46 ]. The authors
did state that fusion status was infl uenced by fi xation method. Thus, solid bridging was greater in
those with bilateral pedicle screw supplementation compared to those with either a stand-alone
XLIF (XLIF
®
, NuVasive, Inc., San Diego, CA,
USA), lateral supplementation, or unilateral pedicle screw fi xation.
6.1.5 Complications
Isaacs et al. [ 32 ] reported 14 major complications
for 13 (12.1 %) of the 107 patients, 2 of which
were classifi ed as major medical and 12 were categorized as major surgical. Overall, 21 surgical
complications occurred in 16 patients, 9 of which
were minor, and 16 medical complications
among 11 patients, 14 of which were minor.
There were no infections with stand-alone XLIF
®
(XLIF
well as when posterior instrumentation was completed minimally invasively. However, three early
reoperations ensued due to deep wound infections, which were related to the open posterior
instrumentation approach. Prior minimally invasive studies have demonstrated fewer infections
compared to published rates for traditional open
techniques [
that patients with open posterior fi xation had
, NuVasive, Inc., San Diego, CA, USA) as
47 – 49 ]. Furthermore, it was shown
38
J. Youssef et al.
both a signifi cantly higher incidence of any complication ( p = 0.02) as well as a major complica-
tion ( p = 0.04) compared to individuals with
percutaneous posterior fi xation. In a subsequent
publication, Phillips et al. [ 37 ] reported that 13
patients needed a supplementary surgical procedure. Reasons for the additional surgeries
included pseudarthrosis, treatment at adjacent
segments, and posterior-only procedures.
Tormenti et al. [ 36 ] demonstrated an unusually
high number of complications including bowel
perforations, incidental durotomy, pleural effusions, pulmonary embolism, ileus, junctional
kyphosis, and a wound infection. By the 11.5month follow-up, no infections or indications of
hardware failure were seen. The authors noted the
nature of the scoliotic spine greatly enhances the
risk of complications to the intra- and retroperitoneal
anatomy. Additionally, the very small sample size
should be taken into consideration when interpreting these results. Despite these results [ 36 ], tradi-
tional approaches do seem to report much higher
complication rates than minimally invasive techniques. For instance, Pateder et al. [ 50 ] reported a
complication rate as high as 45 % for deformity
patients that underwent traditional surgery, and
Fujita et al. [ 35 ] demonstrated rates up to 66 %.
Compared to traditional procedures, the fewer
complications documented for lateral surgeries are
likely due to the method of the lateral approach.
The lateral technique is able to circumvent several
of the related complications seen with open anterior surgeries, since the abdominal vasculature,
ureter, and peritoneal cavity are not manipulated
[
37 ]. Along those lines, the prevalence of periop-
erative complications is reduced when walking
and mobility occurs early after surgery [ 51 ]. Thus,
patients who undergo a minimally disruptive lateral surgical procedure are more likely to have a
shorter length of hospital stay and therefore ambulate more rapidly following surgery [ 37 ].
6.1.6 Neural Defi cits
The lateral or XLIF (XLIF®, NuVasive, Inc., San
Diego, CA, USA) approach has both anatomical
access advantages and disadvantages [ 12 ]. One
of those disadvantages is the risk of injuring the
lumbar plexus due to the transpsoas exposures
[ 12 ]. As a result, it makes sense that motor and
sensory weaknesses will be seen after an assortment of advances through the psoas muscle [ 32 ].
The addition of neural monitoring has helped
guard these neural elements [ 12 ]. However,
unlike motor elements, the lateral femoral cutaneous nerve (LFCN) or sensory elements are not
identifi able by electromyogram (EMG) [ 12 ].
Isaacs et al. [ 32 ] reported that 33.6 % (36
patients) of their sample had some amount of
lower extremity weakness. The majority (29
patients) of those patients had isolated hip weakness, which as most likely the result of the placement of the retractors in the muscle to allow entry
to the spine; and this was signifi cantly associated
with length of surgery ( p = 0.03). That is, patients
with weakness had a longer surgery time compared to patients without weakness. However, for
86.2 % of these patients, the weakness was temporary. Only seven patients had defi cits that were
categorized as a serious surgical complication
either due to the weakness not being resolved
within 6 months or the weakness declined more
than two grades.
Tormenti et al. [ 36 ] reported two motor radic-
ulopathies and six thigh paresthesias/dysesthesias. One patient had sustained motor
radiculopathy at the 3-month follow-up, while
the other resolved by two months postoperatively.
At the latest follow-up, sensory radiculopathies
had resolved in fi ve of the six patients.
6.1.7 Conclusion
It appears that the XLIF (XLIF®, NuVasive, Inc.,
San Diego, CA, USA) approach is a promising
substitute to conventional approaches for treating
adult deformity patients. Typically, these individuals are older with multiple medical comorbidities, which make them poor candidates for
traditional open fusion procedures. Thus far, the
trend in the literature has demonstrated signifi cant
improvements in treatment characteristics, clinical and radiographic assessments, as well as the
occurrence of fewer complications in individuals
6 Literature Evidence of the MIS Lateral Approach
39
who have undergone a minimally invasive XLIF
(XLIF®, NuVasive, Inc., San Diego, CA, USA)
approach in comparison to patients who underwent traditional surgeries [ 32 , 33 ]. However,
high-level evidence-based data is still needed to
further clarify the effectiveness of the lateral technique for the adult deformity population.
6.2 Degenerative
The minimally invasive lateral approach has
become a steadily popular approach to treating
degenerative conditions including spondylolisthesis and fusion of the anterior column and
provide indirect foraminal decompression [ 28 ,
52 , 53 ]. Due to the increasing number of XLIFs
(XLIF®, NuVasive, Inc., San Diego, CA, USA)
performed each year, anticipated complications
and their predictive determinants, as well as
patient and procedural extenuating factors, need
to be further identifi ed and distinguished.
Although the minimally invasive lateral technique has its benefi ts over conventional open procedures, there still seems to be some ambiguity
about the total risk posed by this approach [ 54 ].
6.2.1 Studies
The studies reviewed in this section include one
level 1 paper, one level 2 paper, and 13 level 3
papers on the use of XLIF (XLIF®, NuVasive,
Inc., San Diego, CA, USA) in treating a variety
of degenerative conditions of the lumbar spine
(Table
6.5 ). The study and treatment characteris-
tics are summarized in Tables 6.5 and 6.6 , respec-
tively. The reported complications and side
effects and outcomes are presented in Tables 6.7
and 6.8 , respectively.
6.2.2 Treatment Characteristics:
Estimated Blood Loss
As a result of being minimally invasive as well as
the plane of the approach, the XLIF (XLIF®,
NuVasive, Inc., San Diego, CA, USA) technique
has the upper hand over traditional open approaches.
Minimal blood loss, fewer complications, shortened hospital stays, and faster recuperation and
return to one’s lifestyle have been documented [ 5 ,
7 , 9 , 28 ]. Overall, the mean estimated blood loss
for an XLIF (XLIF®, NuVasive, Inc., San Diego,
CA, USA) procedure appears to range between 50
and 100 mL per level [ 12 , 55 – 58 ].
In 2010, Rodgers et al. [ 8 ] showed that those
who underwent an open posterior lumbar interbody
fusion (PLIF) lost signifi cantly more blood than
those in the MIS cohort ( p < 0.0001). In addition, in
the open group, 14 patients required a blood transfusion versus zero patients in the MIS group. In
agreement with Rodgers et al. [ 8 ], others have also
reported a signifi cantly greater blood loss for the
open groups compared to the MIS groups [ 1 , 59 ].
Excessive intraoperative blood loss, as well as the
need for a transfusion, have been shown to be
meaningful risk factors for fostering untimely perioperative complications and increased risk of postoperative infections [ 8 , 60 – 63 ].
Youssef et al. [ 10 ] also reported less blood
loss for the XLIF (XLIF®, NuVasive, Inc., San
Diego, CA, USA)-only group compared to the
XLIF (XLIF®, NuVasive, Inc., San Diego, CA,
USA)/posterior spinal fusion (PSF) group.
However, this was anticipated due to the extra
posterior procedure. Regardless, the overall mean
blood loss was minimal (155 mL). In regards to
special populations, Rodgers and colleagues [ 7 ]
demonstrated that the estimated blood loss does
not signifi cantly differ between an obese and a
nonobese patient ( p = 0.16).
6.2.3 Operative Time
The operative time for an XLIF (XLIF®,
NuVasive, Inc., San Diego, CA, USA) approach
has been shown to range between 60 and 100 min
per level [ 12 , 55 – 57 ]. In comparison, the opera-
tive time for an open procedure has been demonstrated to last ~35 % longer than similar MIS procedures [ 1 , 59 ]. However, in studies with patients
who undergo multiple levels and combined
approaches, it is only logical that higher operative times are reported [ 10 , 58 ].
40
J. Youssef et al.
Table 6.5 Study characteristics for degenerative
Author Procedure LOE Control
Pumburger
(2012)
Cummock (2012) X, D,
Knight et al. [
Moller et al. [
Kepler et al. [
Lee et al. [
Lucio et al. [
Malham et al.
55 ]
[
Marchi et al. [
Pimenta (2013) XLIF w BMP I SiCaP
Rodgers et al.
7 , 8 ]
[
Rodgers et al.
7 , 8 ]
[
Smith et al.
33 , 85 ]
[
Tohmeh et al.
92 ]
[
Youssef et al.
[
10 ]
LOE Level of evidence (I-V)
XLIF Extreme lateral interbody fusion
SD Possible shallow docking technique used, Scoli,
LIF Lateral interbody fusion
DLIF Direct lateral interbody fusion
PLIF Open posterior interbody fusion
BMI Body mass index
91 ] XLIF III –
degenerative scoliosis
XLIF/cougar/
SD
axiaLIF
12 ] X, DLIF III –
90 ] DLIF III –
66 ] XLIF III –
1 ] X, TLIF III PLIF
Open PLIF III XLIF
XLIF III –
56 ] XLIF III –
XLIF w
SiCaP
XLIF III BMI > 30
XLIF III BMI < 30
XLIF III PLIF
PLIF III XLIF
XLIF III ALIF
ALIF III XLIF
XLIF II –
XLIF III –
III –
III –
I BMP
170
6.2.4 Length of Stay
Just like estimated blood loss and operative time,
the length of stay has been shown to be signifi cantly shorter for MIS patients than open patients
[ 1 , 8 , 59 ]. The length of hospital stay primarily has
ranged between 1 and 3.5 days for an XLIF
(XLIF®, NuVasive, Inc., San Diego, CA, USA)
procedure with and without an additional posterior
procedure [ 1 , 7 , 8 , 10 , 58 ]. Yet, Knight et al. [ 12 ]
reported an unusually long length of stay of 5 days.
It was noted that their data was from four surgeons
with different amounts of experience. Additionally,
it is the oldest study included in this chapter.
Similar to operative time, the length of stay
does signifi cantly increase when an additional
posterior procedure is involved compared to
XLIF (XLIF ® , NuVasive, Inc., San Diego, CA,
USA) alone [ 10 ] and when more levels are
involved [ 58 ]. However, obesity does not seem to
infl uence the length of hospital stay. Rodgers
et al. [ 7 ] reported that obese patients have a com-
parable length of stay compared to nonobese
patients. However, the length of stay did become
signifi cantly longer for patients with a complication versus those without complications [ 7 ].
6.2.5 Clinical Outcomes
Published clinical outcomes data from XLIF
(XLIF®, NuVasive, Inc., San Diego, CA, USA)
patients has been shown to be comparable or better
to traditional surgical techniques. [ 64 , 65 ] The
XLIF (XLIF®, NuVasive, Inc., San Diego, CA,
USA) procedure has shown great improvements in
reducing back pain (37–80 %) and disability scores
(39–82 %) [ 10 ]. For example, Marchi et al. [ 56 ]
examined two implant sizes (18 mm and 22 m) for
stand-alone XLIF (XLIF®, NuVasive, Inc., San
Diego, CA, USA) procedures. Although the biomechanics of the lateral approach and cage subsidence are the focus of other chapters, these authors
did provide clinical outcome data. Both groups
signifi cantly improved their VAS scores at all time
points (postoperative, 6 weeks and 12 months)
from preoperative scores. Similarly, Malham et al.
[
55 ] reported signifi cant improvements between
preoperative scores and the latest follow-up
(11.5 months) for VAS back (63 %), VAS leg
(56 %), ODI (41 %), SF-36 and PCS (51 %). MCS
also improved by 8 %, but it was not signifi cant.
Much the same, Kepler et al. [ 66 ] and Youssef
et al. [ 10 ] also demonstrated improved ODI, SF-12
MCS and SF-12 PCS, and VAS scores from preoperatively to postoperatively. Most recently,
Pimenta et al. [ 57 ] showed substantial as well as
maintained clinical improvements for VAS leg/
back and ODI measures at all time points (preoperative, 2 and 6 weeks, and 3, 6, 12, 24, and
36 months). Still at 3 years post, the VAS scores
were improved 46 % from baseline scores.
6 Literature Evidence of the MIS Lateral Approach
LOS
(days)
41
# of posterior
levels Total n Mean follow- up ORT (mins) EBL (mL)
Internal
fi xation
Anterior
levels Levels
Author Indication
Table 6.6 Treatment characteristics for degenerative
1.9 pp T12–L5 NR – 235 Perioperative – – –
1–3 L1–L5 PS – 59 10 month 255 138 4.0
Degenerative
Degenerative
Pumburger
scoliosis
scoliosis
Cummock
(2012)
(2012)
2.3 pp L1–L5 Mixed – 29 6 months – – –
Degenerative 1–3 L2–L5 NR – 58 15 months 161 136 5
90 ] NR 1.9 pp L NR – 53 21.2 months – – –
66 ] Degenerative
12 ]
Knight et al.
Kepler et al. [
[
Moller et al. [
1–3 L NR – 33 6 months – – –
scoliosis
scoliosis
91 ] Degenerative
Lee et al. [
Mixed – 30 11.5 months – – –
(T6–7)
1–3 L1–5
Degenerative 2 L1–S1 BP 2 101 45 days 156.5 – 3.2
Degenerative
scoliosis
1 ] Degenerative 2 L1–S1 BP 2 109 45 days 163.2 – 1.2
55 ]
Malham et al.
Lucio et al. [
[
1–2 L None – 46 12 months 72.8 50 –
scoliosis
56 ]
[
Pimenta (2013) Degenerative 1 L4–5 None – 15 36 months 67 <50 –
Degenerative 1 L4–5 None – 15 36 months 71 <50 –
Degenerative
Marchi et al.
Degenerative 1–4 L Mixed – 156 3 months – – 1.24
Degenerative 1–4 L Mixed – 157 3 months – – 1.24
Degenerative 1–3 TL Mixed – 40 Perioperative – – 1.3
Degenerative 1–8 TL PS – 20 Perioperative – – 5.3
7 , 8 ]
Rodgers et al.
7 , 8 ]
[
Rodgers et al.
[
NR – 102 Perioperative – – –
or L4–5
1–2 L3–4 and/
Degenerative
Degenerative 1–2 L PS – 87 24 months 150 241.7 3.0
85 ]
Tohmeh et al.
scoliosis
92 ]
[
Degenerative 1–2 L PS – 115 24 months 93.4 79.1 1.5
33 ,
Smith et al. [
1–3 L Mixed – 82 15.7 months 199 155 2.6
Degenerative
scoliosis
10 ]
Youssef et al.
[
ORT operating room time; EBL estimated blood loss; LOS length of hospital stay; PS pedicle screws
42
Table 6.7 Complications and side effects for degenerative
Transient thigh
Author Minor (%) Major (%)
Pumburger (2012) – – 28.7 % 13.1 % 4.9 % – –
Cummock (2012) – – 42.4 % 23.7 % 6.8 % – –
Knight et al. [
Moller et al. [
Kepler et al. [
Lee et al. [
Lucio et al. [
Malham et al.
55 ]
[
Marchi et al. [
Pimenta (2013) – – – 13 % – 47 % 27 %
Rodgers et al. [
8 ]
Rodgers et al. [
8 ]
Smith et al. [
85 ]
Tohmeh et al.
92 ]
[
Youssef et al. [
12 ] 13.8 % 8.6 % 8.6 % – – 1.7 % 22.4 %
90 ] – – 25 % 36 % 0 % – –
66 ] – – – – – – –
91 ] – – – – – – –
1 ] – – – – – – 6 %
– – – – – – 14 %
– – – – – 7 % 13 %
56 ] 38 % (SE) 0 % 15.2 % 23.9 % – 21.7 % –
– – – 13 % – 20 % 27 %
– – – – – 0.6 % 6.4 %
7 ,
– – – – – 1.9 % 10.8 %
– – – – – – 7.5 %
7 ,
– – – – – – 60 %
– – – – – – 8.2 %
33 ,
2 % – 17.6 % 27.5 % 2.9 % – –
10 ] – – 1.2 % 1.2 % – 2.4 % 9.8 %
sensory
symptoms (%) HFW (%)
Motor
neural (%) Reops (%) Total comps (%)
16.7 %
J. Youssef et al.
Table 6.8 Outcomes for degenerative
Author Fusion (%) VAS decrease (%) ODI decrease (%) Outcome satisfaction (%) Redo (%)
Pumburger (2012) – – – – –
Cummock (2012) – – – – –
– – – – –
Knight et al. [
Moller et al. [
Kepler et al. [
Lee et al. [
Lucio et al. [
Malham et al. [
Marchi et al. [
Pimenta (2013) 100 % 46 % 31 % – –
Rodgers et al. [
Rodgers et al. [
Smith et al. [
Tohmeh et al. [
Youssef et al. [
12 ] – – – – –
12 ] – – – – –
66 ] – – 39.6 % – –
91 ] – – – – –
1 ] – – – – –
55 ] 85 % 63 % 41 % – –
56 ] 91 % 59.2 % – – –
100 % 46 % 31 % – –
7 , 8 ] – – – – –
7 , 8 ] – – – – –
33 , 85 ] – 68 % 60 % – –
– 65 % 59 % – –
92 ] – – – – –
10 ] 100 % (pts
wf/u)
77 % 56 % – –
6 Literature Evidence of the MIS Lateral Approach
43
Smith and colleagues [ 59 ] compared patients
with an XLIF (XLIF®, NuVasive, Inc., San Diego,
CA, USA) procedure to those who underwent an
ALIF procedure. Up to 24 months post, both groups
showed similar as well as signifi cant improvements
in leg pain, low back pain, and ODI. Back pain was
measured using a 0–10 scale, with 10 being the
worst pain possible. At 24 months, low back pain
and leg pain decreased 68 % and 65 % and 72 %
and 63 % for the XLIF (XLIF®, NuVasive, Inc., San
Diego, CA, USA) and ALIF patients, respectively.
ODI also improved approximately 35 % for both
groups from preoperatively to postoperatively.
Interestingly, outcomes scores were comparable at
all follow-up time points between groups, as well
as in the difference recorded from preoperative to
postoperative.
Signifi cant improvements in clinical outcomes
have also been reported in the elderly population
who underwent and XLIF (XLIF®, NuVasive,
Inc., San Diego, CA, USA) procedure [ 8 ]. VAS
scores signifi cantly improved between baseline
8.6/10 points and 12 months 1.4/10 points.
Unfortunately, outcomes were not collected for the
open group, so no comparisons could be made
between surgical approaches. Additionally,
Rodgers et al. [ 7 ] demonstrated that clinical out-
comes after an XLIF (XLIF®, NuVasive, Inc., San
Diego, CA, USA) procedure do not differ between
obese and nonobese patients, and complications
also do not seem to affect clinical outcome scores
between the two groups [ 7 ]. However, the average
follow- up period was only 3 months long.
bone morphogenetic protein 2 (rh-BMP2) and
synthetic silicate calcium phosphate (SiCap)
groups. The authors suggested that the demonstration of a 100 % fusion rate at the fi nal follow up is most likely due to the advantageous
characteristics of the XLIF procedure (XLIF®,
NuVasive, Inc., San Diego, CA, USA) [ 23 , 28 ]
such as, the favorable biomechanics and surface
area of the cage, and the amount of biologics
delivered within the intervertebral space [ 67 ].
Lucio et al. [ 1 ] reported similar fusion rates at
12 months for both the lateral transpsoas interbody fusion group and the open group. Based on
the comparable fusion success between techniques, the authors theorized that both techniques
have the capability to handle underlying pathologies. However, the advantages of a minimally
invasive approach and the differences in direct
and indirect costs will help determine which is
most benefi cial for a patient.
Additionally, the elderly population appears to
fuse well after undergoing an XLIF (XLIF®,
NuVasive, Inc., San Diego, CA, USA) procedure.
Rodgers et al. [ 8 ]. demonstrated an average 1.1
modifi ed Lenke fusion score [ 68 ] at 12 months,
where (1) = consolidation, (2) = partially consolidated, and (3) = not yet consolidated.
Unfortunately, outcomes were not collected for
the open group, so no comparisons could be
made between surgical approaches.
6.2.7 Complications
6.2.6 Fusion
Thus far, the literature has shown encouraging
fusion rates for the XLIF (XLIF ® , NuVasive, Inc.,
San Diego, CA, USA) procedure ranging from 87
to 100 % [ 25 , 27 , 43 , 44 , 57 ]. However, longer-
term data comparing MIS procedures to traditional open procedures is still needed. Both
Pimenta et al. [ 57 ] and Malham et al. [ 55 ] dem-
onstrated that fusion is a slow but steady progression within the fi rst year after surgery. Pimenta
et al. [ 57 ] demonstrated a 100 % fusion rate at the
3-year follow-up for both the recombinant human
Some of the justifi cations of minimally invasive
procedures are decreased postoperative morbidity, fewer complications, improved treatment
characteristics, reduced soft tissue interruption,
less blood loss, and shorter operating times and
hospital stays [ 7 – 9 , 69 – 74 ]. By comparison, tra-
ditional surgeries such as TLIF and PLIF have
generally demonstrated higher complication rates
compared to the minimally invasive lateral
approach [ 75 , 76 ]. Percutaneous pedicle screw
placement has further advanced the minimally
invasive approach through decreasing infections
and minimizing paraspinal muscle dissection,
which are characteristics of traditional posterior
44
J. Youssef et al.
approaches [ 63 , 74 , 77 – 81 ]. Complications that
have been reported include inadequate decompression, interbody graft subsidence, hematoma
formation, BMP-induced postoperative seroma,
wound infections, and an additional surgery
[ 56 – 58 ].
Knight et al. [ 12 ] noticed 18 adverse events
including but not limited to approach-related complications such as ipsilateral L4 nerve root injury
and sensitivity of the lateral femoral cutaneous
nerve. Adverse medical events consisted of a myocardial infarction, urinary retention, and acute
dementia. The authors indicated that their results
were similar to published data [ 82 ], and unlike
open procedures, they demonstrated zero vascular
injuries and no incidences of retrograde ejaculation
[ 83 , 84 ]. It was also remarked by the authors that
some of the adverse events happened before the
surgeons were highly experienced and thus, most
likely the adverse events were representation of the
learning curve of these MIS approaches.
Malham et al. [ 55 ] observed four complica-
tions including a bowel injury, motor defi cit,
symptomatic subsidence, and cage breakage.
Additionally, there were three other asymptomatic subsidence cases noticed without ramifi cations. Interestingly, three of the four cage
subsidence incidences were after stand-alone
XLIF (XLIF®, NuVasive, Inc., San Diego, CA,
USA) procedures. Besides the stand-alone variable, smaller cages (18 mm vs. 22 mm), low bone
density, BMP-2, and iatrogenic end plate violations have all been implicated as causes of cage
subsidence [
85 , 86 ]. Also, two reoperations were
necessary due to a cage placed posteriorly and
symptomatic facet arthropathy.
When comparing MIS and open procedures,
Smith et al. [ 59 ] noted signifi cantly more periop-
erative complications in the open group (16.7 %)
compared to the XLIF (XLIF®, NuVasive, Inc.,
San Diego, CA, USA) group (8.2 %). Fortunately,
the most prevalent complications were minor in
nature for both groups. However, infections from
the posterior instrumentation were also common,
mainly in patients who underwent the traditional
ALIF procedure (5.7 %) in comparison to the
XLIF (XLIF®, NuVasive, Inc., San Diego, CA,
USA) group (0.9 %). Similarly, Lucio and col-
leagues [ 1 ] also demonstrated signifi cantly fewer
perioperative complications in the minimally
invasive lateral approach group (6 %) versus the
open group (14 %). In the open group, three postoperative infections developed compared to zero
in the XLIF (XLIF®, NuVasive, Inc., San Diego,
CA, USA) group. Furthermore, only one transfusion was required in the XLIF (XLIF®, NuVasive,
Inc., San Diego, CA, USA) group, whereas 18
transfusions were necessary among the patients
who underwent an open procedure. Favorably,
reoperations throughout the perioperative stage
were infrequent for both groups. However, a
number of perioperative residual events did occur
in both groups, 37 in the open group and 23 in the
XLIF (XLIF®, NuVasive, Inc., San Diego, CA,
USA) group. Statistically speaking, the open
group demonstrated signifi cantly more events
than the minimally invasive group.
Rodgers and colleagues [ 8 ] also observed a
signifi cantly higher complication rate in the PLIF
group than the XLIF (XLIF®, NuVasive, Inc.,
San Diego, CA, USA) group. For instance, infections were noticed in the PLIF group (15 %) compared to none in the XLIF (XLIF®, NuVasive,
Inc., San Diego, CA, USA) group. Much the
same, the incidence of postsurgical fatality rate
was meaningfully higher in the PLIF group
(age = 84.2 years) versus the XLIF (XLIF®,
NuVasive, Inc., San Diego, CA, USA) group
(age = 82.6 years). After surgery, six of the PLIF
patients were deceased within 18 months compared to one patient in the XLIF (XLIF®,
NuVasive, Inc., San Diego, CA, USA) group who
was within 6 months of the operation. However,
postoperative mortality rates present the dilemma
of separating the aftermath of surgery from the
consequence of aging. Additionally, the urgency
for subsequent relocation to a rehabilitation service may possibly be the most vital factor to an
elderly population undergoing spine surgery
[
87 ]. All of the patients in the PLIF group trans-
ferred to a nursing facility, whereas 92.5 % of
those in the XLIF (XLIF®, NuVasive, Inc., San
Diego, CA, USA) group got well quickly and
were able to move back home after surgery. Thus,
the authors concluded that a minimally invasive
approach is clearly better for an elderly individ-