1905 Clint Moore Rd. Suite #309
Boca Raton, Florida 33496
Phone: (561) 988-8988
Fax: (561) 988-7075
MINIMALLY INVASIVE SPINAL SURGERY
EXTREME LATERAL INTERBODY FUSION

As a spine surgeon, We have developed a specialized interest in these new (MIS) Minimally Invasive Surgical Techniques for several years, offering completely new advantages of spinal surgery, while minimizing the pain and rehabilitation. Importantly, these now comprise the vast majority of the surgical procedures we currently perform.

WHAT IT IS:

Extreme lateral interbody fusion (XLIF or DLIF) surgical procedures now offer a minimally invasive procedure to insert plastic spacers and bone graft into the collapsed degenerated disk, indirectly decompressing the spinal nerves and also stabilizing the spine performed through a minimal 1- inch incision directly on the side of the waist above the pelvis bone. This approach does not involve a large incision over the low back any longer with the associated muscle stripping and extensive scar tissue surrounding the nerves involved with previous larger lumbar laminectomy operations with pedicle screws and instrumentation for stabilization and fusion. This newer and minimally invasive approach also typically uses bone grafting substitutes and/or bone morphogenic protein (BMP) to stimulate a bony fusion, precluding the necessity for painful harvesting of the bone graft from the hip area. This type of fusion is done through a lateral incision, by a nearly complete removal of the disk and then replacement with a plastic or ceramic spacer to stabilize the spine rather than through the back, where previous fusion surgeries were performed involving more muscle pain, substantially more bleeding, higher risk of infection, spinal fluid leak and scar tissue surrounding the lumbar nerve roots and sciatic nerve. This procedure is performed under live neurological monitoring to avoid any disruption or injury to nearby nerves passing alongside the spine through the psoas muscles. The nerve injury rate is low with this technique, but not zero percent. The fusion rates appear to be equal or better than previous surgical methods and involve much less pain postoperatively. Rehabilitation and mobilization are much quicker after these surgeries, since it does not involve violation of the extensive back musculature, and achieves straighter and more anatomical realignment of the spine.

Notably, this new technique yields a more rigid fixation, particularly in elderly, with weaker bone via screws that are placed in the back through small percutaneous tubes requiring approximately ½ - inch incisions, the tubes are placed between the muscles rather than involving stripping muscles from the back.

INDICATIONS:

XLIF interbody fusion technique is utilized for patients with predominance of back pain with or without associated leg pain, sciatica from nerve compression in the central spinal canal or foramen. It is also an excellent technique for straightening scoliosis deformity, curvature of the spine, spondylolisthesis or kyphosis, where there has been collapse of the disk spaces with or without other deformity. The XLIF techniques is superior for correcting deformity immediately stabilizing the spine when stabilization and decompression are desired without the need for direct decompression discectomy, laminectomy, etc.
ADVANTAGES:

1. Minimally invasive means much smaller incisions and less pain from the incision and surgical approach. Timing and duration of the operation is typically shorter due to the approach, since the small muscles on the side of the back are divided, rather than stripped off the bones which is what occurs when the approach through the middle of the back is utilized.

2. Substantially less bleeding. Typically only a few tablespoons of blood is lost during the entire XLIF operation. Blood transfusion is needed very rarely from this type of operation.

3. Due to the substantially less blood loss and need of blood transfusion, there is much less fatigue after surgery, and one can resume their normal activities, particularly walking and activities of daily living, much quicker after such surgery, compared to posterior laminectomy and traditional fusion methods.

4. Substantially lower infection rate. Since the operation is performed through a much smaller incision, there is less surface area exposed to bacteria, and the wound heals much quicker.

5. Additional levels can be added on later with much more ease.
POTENTIAL COMPLICATIONS:

These newer minimally invasive techniques with surgery performed through tubes rather than through a large open incision have many advantages, but also have some potential, infrequent complications such as:

1. Potential Bleeding, requiring an open incision to control by using smaller incisions and operating through a tube means less exposure to correct any complications such as bowel or urological injury. If an injury occurs, a separate incision is required to manage it. A potential secondary infection may occur if the bowel is damaged as a portion of the procedure is blind involving tissue mobilization with blunt dissecting assuming the patient has normal anatomy.

2. Potential vertebral body collapse, especially in older and weaker bone. This is particularly true if the person has osteopenia or osteoporosis. The spacers do have a large surface area, but the plastic may be harder than the underlying vertebral bone quality, and if any settling occurs, it can involve fracturing of the end plates of the bone. It usually heals like a normal fracture, but additional bracing may be necessary until healing occurs. Additional surgery for decompression may be necessary if painful compression of nerves results.

3. Inadequate decompression. These procedures rely on indirect decompression of nerves by distracting the disk space and correcting the spinal canal, which usually takes the disk and bone spur pressure off the exiting nerve routes, reducing sciatic pain. However, if this does not result in enough indirect nerve decompression then a midline small central incision over the central spine area may still be necessary later to directly remove the bone spurs or disk pressing on the nerve roots.

4. Patients may experience a new pain in the front of the thigh, particularly on the approach side, either left or right, depending on the side chosen for the XLIF procedure. Since this procedure involves dissection through the psoas muscle, there can be muscle pain which travels down into the front of the thigh or small nerves inside the muscle which, despite careful nerve monitoring during the operation, can still be damaged by stretching or injury, and result in either numbness, tingling, pain or even weakness of the thigh. This nearly always resolves by 6 or 8 weeks, but could possibly be permanent in a very small percent of cases.

5. This operation involves placing the patient on their side during the operation, enabling the opening of the side most desired to be distracted to correct any curvature or asymmetrical disk collapse. Unfortunately, only at the time of the surgery under anesthesia can this be definitively determined. There are rare cases where the patient may be asleep and positioned, and then the surgeon realizes that the patient is not amenable to the XLIF minimally invasive procedure approach to decompression and fusion.

6. Non-union. This procedure generally involves bone morphogenic protein or bone substitute, rather than harvesting of one’s own bone. However, there is still a small percentage who develop a non-union for known reason such as cigarette smoking, diabetes, or systemic chronic diseases precluding normal bone healing, or idiopathic unknown reasons.