Extreme Lateral Interbody Fusion (XLIF) in the Thoracic and Thoracolumbar Spine: Technical Report and Early Outcomes

Abstract

Background: Previous studies have demonstrated the distinct advantages of thoracoscopically assisted spinal fusion compared to traditional open thoracotomy. However, these techniques are limited by a steep learning curve, prolonged operative time, and lack of three-dimensional visualization of the surgical field.

Objective: The objective of this study was to describe our initial experience with an adaptation of the extreme lateral interbody fusion (XLIF) technique allowing access to the anterior aspect of the thoracic and thoracolumbar spine with specific reference to (1) early pulmonary complications, (2) non-pulmonary complications, and (3) ability of this technique to successfully achieve spinal decompression and fusion at the operative level.

Methods: Clinical and radiographic data were reviewed for the entire perioperative period. A total of 18 patients (72% females; mean age, 56.8 years) underwent a thoracic XLIF procedure for spinal pathologies including disc herniation, fracture, tumor, pseudoarthrosis, and proximal junctional kyphosis. A total of 32 levels were treated, with the majority located at the thoracolumbar junction. Twelve of the procedures were done as part of a combined anterior/posterior surgery.

Results: The mean estimated blood loss was 577 ml and the mean length of stay was 12 days. At a mean follow-up of 14 months, all patients except for one (who died of widely metastatic disease) had achieved radiographic evidence of fusion. Two patients developed pulmonary effusions requiring medical intervention. Six patients had seven non-pulmonary complications: incidental durotomy (two), infection (one), instrumentation pullout (one), cardiac arrhythmia (two), and death from metastatic disease (one).

Conclusions: The XLIF technique can be utilized for access to the anterior column of the thoracic and thoracolumbar spine. The advantages of this minimally invasive technique include avoidance of the need for an access surgeon and for lung deflation during surgery as well as excellent visualization of the spinal pathology.

Keywords: XLIF; lateral access surgery; spine; thoracolumbar spine.

Fig. 1

Distribution of fused spinal levels.

Fig. 2

Twenty-four-year-old male with myelopathy. a Sagittal T2 MRI demonstrating disc herniations at T11-12 and T12-L1 causing cord compression. b Intraoperative fluoroscopic images demonstrating retractor positioning and localization of the interspace. c, d AP and lateral radiographs demonstrating Nuvasive PEEK cages with a lateral thoracic spine locking plate. e Sagittal CT at 8 months after the index surgery shows completed fusion of the instrumented levels.

Fig. 3

Nineteen-year-old female with chronic T12 burst fracture and painful progressive local kyphosis. a Preoperative sagittal CT scan demonstrating collapse with local kyphosis and retropulsion of fragments into the canal. b Preoperative sagittal fat saturation inversion recovery MRI demonstrating a chronic fracture and cord compression. c Intraoperative fluoroscopic image demonstrating retractor placement and localization of the affected spinal level. d, e Postoperative AP and lateral radiographs demonstrating Synex expandable cage and thoracic spine locking plates in place with restoration of normal alignment.