Extreme lateral interbody fusion (XLIF®): how I do it.

BACKGROUND: First introduced by Pimenta et al. in 2001, the extreme lateral interbody fusion (XLIF®) approach is a safe and effective alternative to anterior or posterior approaches to lumbar fusion, avoiding the large anterior vessels and posterior structures including the paraspinous muscles, facet joint complexes and tension bands.

METHOD: The authors provide a detailed description of the surgically relevant anatomy focusing on the close relationship among the lumbar plexus, psoas muscle and lateral spinal column. The surgical technique is detailed step by step, stressing how to avoid complications. A video clip of an XLIF is provided, and important perioperative considerations are listed in detail.

CONCLUSION: The XLIF® approach is a safe procedure allowing an approach to the lateral lumbar spine. Nevertheless, the surgeon's knowledge of anatomical landmarks, response to visual and tactile cues, and intraoperative decision-making skills remain of paramount importance.

KEY POINTS: • Correct lateral positioning with an orthogonal orientation of the corresponding lumbar vertebral body is of key importance. • Subsequent table repositioning for every level is advised in multilevel cases. • Posterior structures including the paraspinous muscles, facet joint complexes and tension bands are mostly preserved. • Meticulous preoperative planning of the psoas docking point, considering all level-specific vascular and neuronal elements, is of paramount importance. • In general, concavity is recommended for the selection of the approach side. • A careful endplate and contralateral preparation and release are mandatory in order to allow bony fusion and maximum indirect foraminal decompression. • Using a perioperative dexamethasone bolus seems to be effective at the L4/5 level to reduce postoperative plexopathy. • Overdistraction should be avoided in order to prevent cage subsidence. • A major disadvantage is the relatively high, but mostly only transient, incidence of psoas weakness as well as hip-groin-thigh pain, dysaesthesia and/or numbness. • Major advantages include indirect neurological decompression, minimal blood loss, shorter operation times, decreased overall infection rates and more surface for bony fusion.