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Clinical Perspective—The Case for Adoption of LLIF

O’Brien, Joseph R. MD, MPH

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doi: 10.1097/BRS.0000000000001438


Patients undergoing open spinal fusion are at risk for proximal junctional kyphosis (PJK) requiring revision surgery; those with proximal junctional failure may experience neurologic deficits with subluxations in the upper thoracic region. Yagi et al2 compared open posterior scoliosis surgery versus anterior thoracic surgery and noted a 10-fold increase in PJK among posteriorly treated patients, while postulating that perhaps the best way for surgeons to optimize outcomes is to perform the smallest possible successful surgery while embracing MIS methods.

Lateral lumbar interbody fusion (LLIF) has been used to treat shorter segments in thoracolumbar deformity safely and with excellent results.1,3 Outcomes include trans-lateral cage placement, non-disrupted posterior muscular tension bands, lower transfusion rates, shortened hospital stay with percutaneous screws, preserved posterior musculature, and reduced use of narcotics (SDC Figure 1, Painful surgeries may have lasting psychological effects on patients. Posttraumatic stress disorder (PTSD) has been noted among cardiac surgery patients and is just beginning to be studied in those undergoing spine surgery. Efforts to provide quality health care must focus on data on pain and PTSD, in addition to ways to shorten length of stay and reduce costs and revision rates.

Preliminary data from a prospective study (O’Brien et al, unpublished data) suggest that LLIF may be an effective and beneficial procedure for treatment of degenerative spinal disorders. Investigators have observed reliable improvement in back and leg pain (Figure 1), reduced thigh pain, and steady progress, as documented by the Oswestry Disability Index.

Figure 1:
Clinical outcome data from a lateral lumbar interbody fusion study.

LLIF offers a safe, reproducible, and durable method of attaining spinal fusion. Preliminary data show a favorable complication profile, although adoption has remained slow. Future studies should examine the following. (A) Does LLIF result in less narcotic dependence at 1 year? (B) Is PTSD less with LLIF as compared with open spinal surgery? (C) Are costs reduced by LLIF as compared with open surgery? (D) Is PJK decreased by LLIF and percutaneous screw placement?


1. Anand N, Rosemann R, Khalsa B, et al. Mid-term to long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis. Neurosurg Focus 2010; 28:E6.
2. Yagi M, Akilah KB, Boachie-Adjei O. Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976) 2011; 36:E60–E68.
3. McAfee PC, Regan JJ, Geis WP, et al. Minimally invasive anterior retroperitoneal approach to the lumbar spine. Emphasis on the lateral BAK. Spine (Phila Pa 1976) 1998; 23:1476–1484.
4. Department of Health and Mental Hygiene. Maryland Board of Physicians. Overdose prevention. Available at: Accessed November 13, 2015.

fusion; lateral; minimally invasive

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