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6 Literature Evidence of the MIS Lateral Approach
45
ual since their XLIF (XLIF®, NuVasive, Inc.,
San Diego, CA, USA) patients were able to return
to an independent and higher quality of life than
those in the PLIF group.
Finally, Rodgers et al. [ 7 ] showed no differ-
ences in complications for the healthy and obese
groups. Overall, the amount of complications
reported was quite low. The authors stated that
they believe their data is evidence of the potential
of an XLIF (XLIF®, NuVasive, Inc., San Diego,
CA, USA) procedure, especially for special populations (i.e., obese patients). Out of 432 patients,
there were zero infections, cerebrospinal fl uid
leaks, and blood transfusions.
6.2.8 Neural Defi cits
After a review of the minimally invasive lateral
approach literature, the most noticeable patient
complaint is postoperative thigh symptoms [ 5 , 6 ,
43 ]. In general, the prevalence of neurologic
events has been demonstrated to range from 0.6
to 33.6 % following an XLIF (XLIF®, NuVasive,
Inc., San Diego, CA, USA) procedure [ 9 , 10 , 32 ,
36 , 88 , 89 ]. Fortunately, for the majority of
patients these defi cits are transient and resolve
within a few months [ 10 , 54 , 56 , 58 , 90 , 91 ]. Yet,
in some patients, the sensory or motor weakness
does continue for multiple months [ 53 , 58 ]. To
date, the data still remains controversial and
incomplete for determining the absolute number
of sensory or motor defi cits and their natural
cause and related factors [
Pumberger et al. [ 54 ] observed minimal sen-
sory defi cits at the 12-month period. Sensory
defi cits progressively decreased from 28.7, 13.1,
5.7, and 1.6 % of patients at 6-week, 12-week,
6-month, and 12-month follow-ups, respectively.
It has been theorized that these sensory defi cits
are a result of a temporary irritation to the genitofemoral nerve at L2–3 [ 11 , 14 ] or direct cutane-
ous nerve neuropraxia or an infl ammatory
response from the mechanical dissection of the
psoas muscle [ 54 ].
Regression models for a psoas mechanical defi cit revealed that being female and the length of surgery are independent risk factors [ 54 ]. The duration
54 ].
of surgery was also a signifi cant risk factor for
psoas muscle associated defi cits. The authors stated
that the precise retraction times were unknown, so
operating times were used in the statistical analysis. Although not signifi cant, prior surgery and
multilevel fusions may also be potential risk factors. Psoas mechanical fl exion defi cits followed the
same pattern as the sensory defi cits. The incidence
and degree of defi cits diminished over time from
13.1 % of patients at 6 weeks to only 1.6 % at the
12-month postoperative visit.
On the other hand, the lumbar plexus associated
motor defi cits demonstrated a different pattern than
the sensory defi cits and psoas mechanical defi cits
[ 54 ]. Overall, the incidence of lumbar plexus defi -
cits was fewer (4.9 %), but the defi cits did not
resolve as well at 6 months (2.9 %) and 12 months
(2.9 %) compared to the sensory and psoas defi cits.
Regression models for a lumbar plexus associated
motor defi cit uncovered that the length of surgery
is an independent risk factor. Multilevel fusions,
prior surgeries, and inclusion of L4–5 demonstrated trends as possible risk factors.
Cummock et al. [ 58 ] reported thigh symptoms
in 62.7 % of their cases. Overall, numbness was
the most prevalent complaint postoperatively,
then pain, followed by muscle weakness, and
lastly paresthesias. At one year, thigh pain continued in 5.5 % of patients and numbness lingered
in 7.0 % of the cases. Favorably, paresthesias
were remedied for all by 214 days postoperatively. Sensory defi cits were more common than
motor defi ciencies, which makes sense due to the
ability of the EMG monitor to protect motor
nerves, but not sensory nerves [
12 , 13 ]. Therefore,
the genitofemoral nerves and other sensory
nerves are at risk, whereas the femoral nerve and
lumbar plexus should be protected by the EMG
monitoring. However, 23.7 % of patients still
experienced motor defi cits, despite a lack of signifi cant monitoring changes during surgery. The
authors theorized that the likely cause of these
motor defi cits was either a result of the dissection
of the psoas muscle or compressive neuropathy
due to dilating the muscle. Blunt stress to the
psoas tissue is an understandable source of hip
fl exor weakness. In fact, all 14 (23.7 %) motor
defi cit cases demonstrated hip fl exor weakness.
46
J. Youssef et al.
Fortunately, all patients’ symptoms related to this
weakness resolved within 10 months.
Malham and colleagues [ 55 ] reported compa-
rable neural adverse event rates to other published
data [ 92 ]. Interestingly, they noticed less sensory
complications with later cases (0 %) compared to
earlier surgeries (20 %). The authors suggested
that a decreased duration of surgery and retraction
of the psoas muscle as well as improved docking
position and better adherence to EMG neuromonitoring were likely explanations for the decline in
neural events. In addition to logic, these fi ndings
further demonstrate the importance of requiring
surgeons to be at the high end of the learning
curve before performing an XLIF (XLIF®,
NuVasive, Inc., San Diego, CA, USA) procedure
on a human patient.
Compared to other fusion procedures, lateral
lumbar interbody fusion seems to observe a lower
rate of permanent neurologic defi cits. For example, after PLIF and TLIF, a 6.1 and 4.1 % permanent motor defi cit has been demonstrated [ 72 , 92 ,
93 ]. In contrast, ALIF procedures report fewer
motor defi cits; however, the trade-offs are a
higher risk of visceral and vascular complications [ 92 , 94 ].
The literature demonstrates that with suitable
neuromonitoring, the neural elements are safe
during the lateral approach. Yet, the rates of neural events widely vary among the published data
most likely accredited to diversity in study inclusion criteria and experience as well as the number of treated levels [
11 , 13 , 15 , 16 ]. Prior studies
have proposed that the chance of a neural event
increases at L4–5 due to the anatomical differences among the lumbar levels [ 36 , 58 ]. More
studies that assess neurologic events prospectively and in greater depth with bigger sample
sizes are needed [ 54 ].
Conclusions
The exclusive advantages of an XLIF (XLIF®,
NuVasive, Inc., San Diego, CA, USA) procedure over a traditional anterior or posterior
approach are well known and documented and
include the following: access is minimally
invasive, indirect decompression, ability to
circumvent prior scar tissue, does not require
contending with instrumentation from a prior
surgery, corrects deformities, smaller incisions, less blood loss, fewer transfusions, and
shorter hospital stays [ 8 , 58 ].
Based on the literature, the minimally invasive
lateral approach has shown to be an overall valuable tool for the treatment of lumbar deformity
and degenerative conditions as well as for the
elderly and obese populations. The XLIF
(XLIF®, NuVasive, Inc., San Diego, CA, USA)
approach has reported comparable clinical outcomes and decreased perioperative morbidities
7 , 95 ] compared to traditional techniques. Yet, to
[
achieve a safe and adequate remedy, it is vital that
indications, risk factors, and surgical techniques
continue to be more thoroughly defi ned especially for special patient populations. Future
work should include prospective, randomized
studies with matched cohorts of patient age and
size and matched indications for treatment, longterm follow-up, large sample sizes, and high
compliance rates. Until then, the conclusions
drawn will be limited in nature. All together, it is
expected that the minimally invasive lateral lumbar interbody fusion technique will remain to
have an infl uential role in treating various conditions in the spine.
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Part II
Approach and Localization
Selecting the Proper Patient for Lumbar Lateral Interbody Fusion and Minimally Invasive Spinal Deformity Surgery
Todd D. Vogel and Praveen V. Mummaneni
7
7.1 Indications for LLIF
Minimally invasive techniques to access the spine
are attractive to surgeons and patients alike as
they offer less blood loss, less tissue trauma during surgery, less postoperative pain, shorter hospital stays, and a quicker return to normal
activities [ 4 ]. Previous techniques for achieving
interbody fusion involve open anterior, open retroperitoneal, and posterior approaches. McAfee
was among the fi rst to describe the minimally
invasive LLIF using a retroperitoneal fi nger dissection, insuffl ation of the retroperitoneal space,
and endoscopes for viewing and decompressing
the spine and using BAK cages for fusion where
indicated [ 3 ].
Ozgur and Pimenta’s original description for
the LLIF technique was intended for the patient
with axial low-back pain and minimal central
canal stenosis [
expanded those indications [ 1 ]. Indications for
the LLIF procedure include degenerative disk
8 ]. Evolutions in technique have
disease with axial low-back pain, low-grade
(Meyerding grade I or II) spondylolithesis, recurrent disk herniation with mechanical low-back
pain, disk collapse following diskectomy causing
foraminal narrowing and secondary radiculopathy, treatment of post-laminectomy kyphosis,
pseudarthrosis, proximal junctional kyphosis,
adjacent level disease above or below a prior
fusion, adult degenerative scoliosis with coronal
and sagittal deformities, trauma, and tumor.
Lateral approaches are being used to treat midand lower-thoracic soft disk herniation or calcifi ed thoracic disks causing myelopathy [ 7 ].
Contraindications for this procedure include
disk herniation causing radiculopathy without
mechanical low-back pain or instability, highgrade (Meyerding III or IV) spondylolisthesis,
and severe osteoporosis. Relative contraindications include osteoporosis, prior same-side retroperitoneal surgery and active infection in the
psoas muscle (Table
7.1 ).
7.2 The MISDEF Algorithm
The incidence of adult spinal deformity is
T. D. Vogel • P. V. Mummaneni (*)
Department of Neurological Surgery ,
University of California, San Francisco ,
505 Parnassus Ave, M780 ,
San Francisco , CA 94143 , USA
vmum@aol.com
e-mail:
© 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_7
increasing as the population ages. Spinal deformity patients are typically evaluated with long
cassette 36 in. x-rays to assess a variety of
radiographic parameters. Relative radiographic
indications to consider surgical intervention
53
54
T.D. Vogel and P.V. Mummaneni
Table 7.1 Indications, contraindications, and relative
contraindications for LLIF
Indications Degenerative disk disease
with axial low-back pain
Low-grade (Meyerding
grade I or II)
spondylolithesis
Recurrent disk herniation
with low-back pain
Disk collapse following
diskectomy causing
foraminal narrowing and
secondary radiculopathy
Treatment of postlaminectomy kyphosis
Pseudoarthrosis
Proximal junctional
kyphosis
Adjacent level disease
above or below a prior
fusion
Adult degenerative scoliosis
with coronal and sagittal
deformities
Trauma
Tumor
Contraindications Disk herniation causing
radiculopathy without
mechanical low-back pain
or instability
High-grade (Meyerding III
or IV) spondylolithesis
Severe osteoporosis
Relative
contraindications
Osteoporosis
Prior same-side
retroperitoneal surgery
Active infection in the
psoas
include a sagittal vertebral axis (SVA) greater
than 5 cm, a coronal Cobb measurement greater
than 20°, lumbar lordosis-pelvic incidence
(LL-PI) mismatch greater than 10°, pelvic tilt
(PT) greater than 25°, or a lateral listhesis
affecting coronal balance to name a few [ 2 , 9 ,
10 ]. These radiographic parameters must be
accompanied by correlative clinical symptomatology of back and/or leg pain before surgery
is recommended. The main goals for treatment
of adult spinal deformity include decompres-
sion of the neural elements, establishing or
maintaining sagittal and coronal balance, and
achieving arthrodesis.
Traditionally, the adult deformity population
has been treated with open surgical techniques.
The morbidity associated with open techniques
includes excessive blood loss and deep wound
infection. Minimally invasive surgery (MIS)
techniques have gained popularity with the goal
of decreasing morbidity associated with open
surgical techniques. However, initial MIS deformity correction efforts have often demonstrated
under-corrected sagittal balance and pseudarthrosis at levels fused posterolaterally but not treated
with an interbody fusion [ 11 , 12 ]. Appropriate
patient selection may have also contributed to
early failures.
Early classifi cation and treatment recommendation systems include the Silva and Lenke
guide for adult degenerative spinal deformity
scheme [ 10 ]. This scheme used six treatment
levels to describe open techniques for the correction of adult degenerative scoliosis.
Subsequent advances in minimally invasive
techniques and adoption of their practice led to
the creation of a modifi ed scheme by
Mummaneni et al. that included a combination
of open and MIS techniques. This scheme was
refi ned to a second algorithm presented here
[ 5 ].
The minimally invasive spinal deformity
surgery (MISDEF) algorithm was created to
provide the framework for rational decision
making when considering open versus minimally invasive techniques (Table
7.2 ). The
MISDEF algorithm considers the strengths and
weaknesses of a variety of minimally invasive
techniques when compared to open techniques.
Additionally, it attempted to address the complexity and poor interobserver reliability of
previous algorithms. The MISDEF algorithm
organizes three groups to simplify the algorithm (Figs. 7.1 , 7.2 , and 7.3 ). Progressively
worse deformity leads to more aggressive correction approaches. Class I deformities in the
MISDEF algorithm may be approached with
7 Patient Selection
Table 7.2 MISDEF algorithm
55
Y
PT < 25°
Y
LL-PI mismatch
< 10°
Y
Lateral listhesis
< 6 mm
Y
Coronal Cobb
< 20°
Y
CLASS I
MIS surgery with
decompression only or fusion
of a listhetic level.
SVA < 6 cm
Y
N
N
N
N
CLASS II
MIS surgery with decompression
and interbody fusion of apex of
the curve or the entire Coronal
Cobb of the curve.
MIS or mini-open muscle-sparing decompression alone or MIS fusion of a single listhetic
level. Instrumentation, if placed, may be placed
through an expandable port tube or through a
percutaneous method. A Class II approach utilizes MIS or mini-open decompression and
interbody fusion of the curve apex or the entire
coronal Cobb angle of the major curve. This
class of patients may benefi t from a lateral
interbody fusion in combination with a posterior MIS fi xation strategy. A Class III approach
entails a traditional open surgical approach
involving osteotomies and/or extensive fusion
including extension up to the thoracic spine.
Class I patients present with symptoms of
neurogenic claudication or radiculopathy due
to central, lateral recess, or foraminal stenosis
and have relatively mild spinal deformity. They
typically have a fl exible curve on dynamic
fi lms. Radiographic parameters include a
LL-PI mismatch less than 10°, SVA less than
6 cm, a PT less than 25°, minimal, if any, lat-
N
Flexible Curve
LL-PI mismatch
< 30°
Y
Thoracic kyphosis
< 60°
Y
N
N
N
CLASS III
Open surgery with
osteotomies +/− extension of
fusion to the thoracic spine.
eral listhesis (<6 mm), coronal Cobb angle of
less than 20°, and no thoracic kyphotic deformity. Patient characteristics include minimal
back pain. These patients may have a grade 1
spondylolisthesis at a single level that may not
be at the apex of their coronal curve. A grade I
subluxation may be treated with a single interbody fusion (either lateral MIS fusion or TLIF)
as needed. Ideally, the fusion at this level
would result in direct (TLIF) or indirect (lateral MIS fusion) foramenal distraction to alleviate stenosis. The primary goal for this group
of patients is the decompression of neural elements rather than the correction of a mild spinal deformity (Fig.
7.1 ).
Class II patients typically have a more dominant back pain component as their chief complaint in addition to radiculopathy or
claudication. Patients are typifi ed by their
LL-PI mismatch of 10–30°, a lateral listhesis
greater than 6 mm, and/or a coronal Cobb
angle of the major curve greater than 20°.
56
T.D. Vogel and P.V. Mummaneni
Fig. 7.1 Class I patient. A 64-year-old M presents with
neurogenic claudication. He had severe central canal stenosis at L3/4. Preoperative long cassette x-rays demonstrated PI 55°, PT 19°, LL 22°, TK 16°, SVA 5.2 cm, and
coronal imbalance 3 cm. Note he was unable to stand pre-
A lack of bridging anterior osteophytes and
SVA less than 6 cm is important to note within
this group. Patients with fl exible deformities
that reduce to an SVA of less than 6 cm when
they are supine may be considered within this
group. Instrumentation can be performed via a
percutaneous or mini-open method. Interbody
techniques include lateral and posterior options
through a muscle splitting technique. Multiple
levels of lumbar fusion are typically required
within this technique (Fig.
7.2 ).
Class III patients have signifi cant sagittal or
coronal imbalance in addition to back and leg
pain. Patients in this group typically have an
SVA of 7 cm or greater, LL-PI mismatch greater
than 30° with PT great than 25°. Multilevel
osteotomies or a three-column osteotomy for
operatively for his x-rays. He underwent a LLIF at L3/4
with unilateral screw fi xation and central canal decompression. Postoperative long cassette x-rays demonstrated
PI 54°, PT 20°, LL 26°, TK 23°, SVA 6 cm, and coronal
imbalance 4.4 cm
realignment should probably be considered.
MIS techniques are typically not a viable option
to globally balance the spine in Class III
patients. The exception to this includes use of a
lateral approach with release of the anterior
longitudinal ligament (so-called anterior column release, or ACR). Another exception is the
patient who has a fl exible curve that reduces the
SVA to under 7 cm with positioning (Fig. 7.3 ).
The reliability of the MISDEF algorithm was
tested with a team of 11 fellowship-trained spine
surgeons who were presented with 20 representative cases from the literature. Images included
posterior/anterior and lateral 36 in. long cassette
radiographs along with select MRI views. A short
history of symptoms and measured radiographic
parameters (SVA, coronal Cobb angle, pelvic tilt