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Maintenance of Segmental Lordosis and Disk Height in Stand-alone and Instrumented Extreme Lateral Interbody Fusion (XLIF)

Malham, Gregory M. MB ChB, FRACS; Ellis, Ngaire J. MB ChB, FRACGP; Parker, Rhiannon M. PhD; Blecher, Carl M. MBBS, FRANZCR, DDU; White, Rohan MBBS, FRANZCR; Goss, Ben PhD; Seex, Kevin A. MB ChB, FRACS

doi: 10.1097/BSD.0b013e3182aa4c94

Study Design: A prospective single-surgeon nonrandomized clinical study.

Objective: To evaluate the radiographic and clinical outcomes, by fixation type, in extreme lateral interbody fusion (XLIF) patients and provide an algorithm for determining patients suitable for stand-alone XLIF.

Summary of Background Data: XLIF may be supplemented with pedicle screw fixation, however, since stabilizing structures remain intact, it is suggested that stand-alone XLIF can be used for certain indications. This eliminates the associated morbidity, though subsidence rates may be elevated, potentially minimizing the clinical benefits.

Materials and Methods: A fixation algorithm was developed after evaluation of patient outcomes from the surgeon’s first 30 cases. This algorithm was used prospectively for 40 subsequent patients to determine the requirement for supplemental fixation. Preoperative, postoperative, and 12-month follow-up computed tomography scans were measured for segmental and global lumbar lordosis and posterior disk height. Clinical outcome measures included back and leg pain (visual analogue scale), Oswestry Disability Index (ODI), and SF-36 physical and mental component scores (PCS and MCS).

Results: Preoperatively to 12-month follow-up there were increases in segmental lordosis (7.9–9.4 degrees, P=0.0497), lumbar lordosis (48.8–55.2 degrees, P=0.0328), and disk height (3.7–5.5 mm, P=0.0018); there were also improvements in back (58.6%) and leg pain (60.0%), ODI (44.4%), PCS (56.7%), and MCS (16.1%) for stand-alone XLIF. For instrumented XLIF, segmental lordosis (7.6–10.5 degrees, P=0.0120) and disk height (3.5–5.6 mm, P<0.001) increased, while lumbar lordosis decreased (51.1–45.8 degrees, P=0.2560). Back (49.8%) and leg pain (30.8%), ODI (32.3%), PCS (37.4%), and MCS (2.0%) were all improved. Subsidence occurred in 3 (7.5%) stand-alone patients.

Conclusions: The XLIF treatment fixation algorithm provided a clinical pathway to select suitable patients for stand-alone XLIF. These patients achieved positive clinical outcomes, satisfactory fusion rates, with sustained correction of lordosis and restoration of disk height.

*Neuroscience Institute, Epworth Hospital

Greg Malham Neurosurgeon, Melbourne

Radiology Department, Epworth Hospital

§NuVasive Australia & NZ Pty Ltd, Kew, VIC

Neurosurgery Department, Macquarie University, Sydney, NSW, Australia

B.G. provided statistical advice and is employed by NuVasive Australia & NZ Pty Ltd. The remaining authors declare no conflict of interest.

Reprints: Gregory M. Malham, MB ChB, FRACS, Suite 2, Level 1, 517 St. Kilda Road, Melbourne, VIC 3004, Australia (e-mail:

Received May 17, 2013

Accepted August 28, 2013

© 2017 by Lippincott Williams & Wilkins, Inc.