The Lateral Lumbar Interbody Fusion (LLIF) procedure is a minimally disruptive surgical technique in which the surgeon approaches the spine from the side of the patient’s body, rather than the front or back as in traditional spine surgeries. This side (lateral transpsoas) approach can reduce the risk of injury to muscles, nerves, and blood vessels.
There are several systems from various manufacturers that will allow for an MIS lateral retroperitoneal transpsoas approach. The two most common are the eXtreme Lateral Interbody Fusion/XLIF® (NuVasive, San Diego, CA) and Direct Lateral Interbody
Fusion/DLIF® (Medtronic, Memphis, TN).
What are the XLIF and DLIF procedures?
The XLIF and DLIF are types Lateral Lumbar Interbody Fusion, or LLIF, which is a category of fusion in which the disc in the front of the spine is removed and replaced with an implant containing a bone graft to set up the condition for the two vertebrae to fuse together through the disc space.
XLIF uses a minimally invasive, transpsoas approach to the spine. The surgeon uses his or her finger to perform blunt dissection through a posterior paraspinal incision to escort dilators and a guide wire into position directly over the psoas muscle. Using his or her finger the surgeon is able to create a retroperitoneal space and protect the viscera and prevent possible injury.
With the DLIF technique, some surgeons have chosen to perform this procedure through a single miniopen lateral approach without the use of the posterior incision to create the retroperitoneal space. With the single incision, the layers of the abdominal wall are directly visualized, and the retroperitoneal space is created under direct vision with passage of instruments through the psoas. In addition, the use of electrophysiological monitoring, including triggered and freerunning electromyography (EMG), reduces the likelihood of injury to the lumbosacral plexus when accessing the disc space through the psoas muscle. Dilators, which contain insulated tips allow for EMG monitoring as they are introduced via the transpsoas approach to the disc space. If a dilator passes in proximity to the lumbosacral plexus, the surgeon is warned both visibly on a graphic display and also via auditory feedback. The surgeon can then adjust his or her trajectory to reduce the likelihood of neural injury.
The major advantage of XLIF/DLIF is the fact that the procedure does not require a second access surgeon. Other advantages are reduced incidence of ileus, the anterior longitudinal and posterior longitudinal ligaments remain intact, the lack of need for bony resection as performed when posterior approaches for interbody fusion are being used, reduced operative time in comparison to other anterior approaches, and reduced postoperative hospital stay and analgesic requirements. In deciding to use this approach over others, a flowchart is included to assist the reader in decision making versus other
techniques. Source; http://media.axon.es/pdf/87399_2.pdf
What do those procedures need?
Lateral interbody fusion (e.g., Extreme Lateral Interbody Fusion [XLIF] or Direct Lateral Interbody Fusion [DLIF]) uses specialized retractors in a minimally invasive, lateral approach to the anterior spine through the psoas and also nerve monitoring.Because nerves exiting the spinal column are close to the psoas muscle and can even run right over the surface of it, it is critical that the surgeon be provided with real-time information about the position of the nerves relative to his instruments. Neuromonitoring, the testing of the nerves during surgery to make sure that they are not harmed or irritated during the process, is a critical part of this procedure. This type of nerve monitoring is known as electromyography or EMG.Nuvasive,was the first Company to fully support this technique developing and promoting with Dr Luiz Pimenta this retroperitoneal transpsoas minimally invasive lateral interbody fusion (MIS LIF) as an effective alternative to anterior or posterior approaches for lumbar fusion. Nuvasive named this procedure as XLIF (eXtreme Lateral Interbody Fusion) designing an specific neuromonitoring system (NeuroVision, NuVasive, Inc.) and also a retractor tool
How is the Procedure?
Which are the Benefits of Lateral Interbody Fusion Procedures?
- Minimal tissue damage
- Minimal blood loss
- Small incisions and scars
- Minimal post-operative discomfort
- Relatively quick recovery time and return to normal function.
- Because of the above factors, it is one of a number of options for spinal fusion that are relatively minimally invasive.
- Axial lumbar interbody fusion (AxiaLIF®, also called anterior para-axial, trans-sacral or paracoccygeal interbody fusion) is a minimally invasive technique designed to provide anterior access to the L4-S1 disc spaces for interbody fusion. It is performed percutaneously, under fluoroscopic guidance via the pre-sacral space. Theoretically, this approach avoids the viscera, blood vessels and nerves; preserves normal tissue at the treatment site; provides access to the disc space without interrupting the annulus; and allows for percutaneous longitudinal access to the anterior spine.
- Anterior Lumbar Interbody Fusion (ALIF). In this procedure, the spine is approached from the front of the body. This approach spares the back from trauma but requires delicate manipulation of the major blood vessels in front of the spine.
- Posterior Lumbar Interbody Fusion (PLIF). This procedure is performed through the middle back, which allows direct access to the area being treated. The downside is that this approach also requires significant disruption to the muscles, bones, and ligaments of the back, which can lead to pain and desensitization after surgery.
- Transforaminal Lumbar Interbody Fusion (TLIF):This approach is similar to PLIF; the difference is that only one side of the back is accessed and affected. Like PLIF, significant disruption to the muscles, bones, and ligaments of the back can occur, although these are limited to one side of the back.