Extreme Lateral Interbody Fusion (XLIF)

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By: JOI & JOI Rehab

Extreme Lateral Interbody Fusion (XLIF)

Extreme Lateral Interbody Fusion (XLIF) can be helpful for those with chronic low back pain. Low back pain is a common condition that occurs in a significant portion of the population at some point in life. While the vast majority of low back pain resolves with non-operative treatment, it is estimated that about 5-10% of cases will develop chronic, persistent low back pain that may require surgical treatment. Improvements in spine surgical technology has aimed towards less invasive approaches in an attempt to reduce soft tissue disruption, have fewer complications, and improve time of recovery. The Extreme Lateral Interbody Fusion surgical approach is a newer approach that aims to achieve this by means of avoiding cutting through sensitive muscles of the posterior spine.

Image of MD Explaining Extreme Lateral Interbody Fusion (XLIF) Procedure

What is Extreme Lateral Interbody Fusion Procedure?

XLIF stands for Extreme Lateral Interbody Fusion surgery. This minimally invasive procedure requires two small incisions (one on the side and one in the back). A special tool is introduced through the psoas muscle as an access port, and a retractor is used to move internal tissue, giving the surgeon direct access to the spine laterally.

Extreme Lateral Interbody Fusion versus Traditional Posterior Procedure

The posterior approach achieves access to spine through an incision of about 4-8 cm long in the midline of the back. The erector spinae and multifidus muscles are divided and retracted at the level(s) of the spine that require fusion and is where implants and tools are introduced. Trauma to these muscles is the primary difference of the XLIF approach versus the Posterior approach.

Indications for Extreme Lateral Interbody Fusion

Conservative treatment is always exhausted before surgery. If conservative measures such as physical therapy and injections have failed, XLIF could be indicated for the following disorders:

• Spondylolisthesis
• Spinal stenosis
• Scoliosis
• Degenerative Disc Disease
• Recurrent lumbar disc herniation
• Painful facet disease with low back and leg pain
• Annular tear or disk disruption causing intractable low back pain
• Degenerative scoliosis

Anatomy of the Spine

If you would like to learn more about the anatomy of the spine, please watch this video.

Anatomy of the Spine

XLIF is not always an option. Some examples when this cannot be done include:

• Systemic infection
• High grade of spondylolisthesis
• Bilateral retroperitoneal scarring
• If the condition is in L5-S1, the lowest level of the spine. This area is not reachable from the side lying position that the XLIF is performed in.

Potential Risks/Complications

Potential risks. There are potential risks with any surgery the following are a few risks to discuss with your surgeon:

• Infection
• Problems with anesthesia
• Nerve damage
• Ongoing pain
• Problems with the hardware

Rehabilitation for Extreme Lateral Interbody Fusion

The benefits of an XLIF versus the traditional Posterior approach typically manifest in the early post-operative stage of rehabilitation. Because the muscles are split in the XLIF, rather than cut in the traditional posterior approach, less soft tissue disruption can result in lesser post-operative pain, and earlier functional mobility. Early mobility helps combat the effects of deconditioning from immobilization, as well as limit disuse atrophy of the lower extremity musculature, and facilitate earlier return to daily activities.

A lumbar brace will be prescribed, and will need to be worn at all times with the exception of sleeping or bathing. Bending, lifting, and twisting will still need to be avoided in the early stages of rehabilitation.

You will likely be referred to Physical Therapy to assist you in return to normal activities. This usually begins about 4 weeks after your surgery. The first few weeks of Physical Therapy will focus on protecting your lower back while learning how to use proper body mechanics for activities and transfers. Your therapist will review sleeping positions, precautions, and help you with stretches and exercises to regain your mobility. Your therapist will also help with pain control.

Back Pain 

Between 8-12 weeks, your physical therapist will help you with higher level body mechanics as you continue to improve. They will help you with bending, squatting, stair climbing, etc. PT will also help you to normalize your walking by now, and help you rid any assistive device such as a cane or a walker. One notable focus of rehabilitation is addressing the possibility of weakness in the muscles that flex the hip. Due to the nature of the lateral approach splitting through the psoas muscle, weakness or stiffness may result in the hip. Your therapist will be able to evaluate the deficits, and apply interventions that will address the limitations.

If you have a back of neck issue then you would benefit from seeking out a comprehensive spine center with a compliment of highly trained spine surgeons and rehab specialists. If you believe you may be a candidate for the XLIF procedure, please contact us at (904) JOI-2000.