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Stand Alone XLIF: patients
selection
• Degenerative disc disease without significant sagittal or frontal
deformity, Modic ...
Stand alone XLIF: why?
• Short operative time: better for elderly patients with co-morbidities
• Minimal blood loss
• Shor...
Stand alone XLIF: FU criteria
• Pre-operative clinical assessment completed with ODI
questionnaire, VAS B/VAS L ; pre-oper...
Case collection
• October 2011-August 2013: 48 patients treated with XLIF approach: 17
male and 31 females, mean age 62 (r...
Diagnosis on admission
imaging
DDD
DDD +
stenosis
DDD + DH
Symptoms
BP
BP + RP
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9
ODI pre
ODI post
Stand alone XLIF: results
after 3-months FU
0
1
2
3
4
5
6
7
8
9
1 2 3 4 5 6 7 8 9
VB pre
VB post
Stand alone XLIF: results
after 3-months FU
0
1
2
3
4
5
6
7
1 2 3 4 5
VL pre
VL post
Stand alone XLIF: results
after 6-months FU
0
10
20
30
40
50
60
70
1 3 5 7 9 11 13 15 17 19 21
ODI pre
ODI post 3
ODI post...
Stand alone XLIF: results
after 6-months FU
0
1
2
3
4
5
6
7
8
9
10
1 3 5 7 9 11 13 15 17 19 21
VB pre
VB post 3
VB post 6
Stand alone XLIF: results
after 6-months FU
0
1
2
3
4
5
6
7
8
9
1 2 3 4 5 6 7 8 9
VL pre
VL post 3
VL post 6
Results analysis
• Most cases show good outcome with progressive improvement at six month
FU
• Unmodified or worsened ODI ...
Stand alone XLIF: pitfalls
• Radiological study at three and six months with lateral Flexion-Extension X-
Rays didn’t show...
Poor outcome analysis
• Back pain in three cases, back pain + radiculopathy in 2 cases
• Subsidence in one case (BP + RP)
...
Stand alone XLIF: implant
failure
• GR, female, 66 Years-old, previous L4-L5 PL arthrodesis in L5-S1
grade two spondylolis...
Peri-operative complications
• Right side surgical approach with MAXcess, standard fashion
discectomy, 18x55x8 mm parallel...
Stand alone XLIF
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Stand Alone XLIF One Year Outcome

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Stand Alone XLIF One Year Outcome

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Stand Alone XLIF One Year Outcome

  1. 1. Stand Alone XLIF: patients selection • Degenerative disc disease without significant sagittal or frontal deformity, Modic changes 1 or 2 of endplates • No segmental instability at pre-op imaging, including LS flexion- extension X-Rays • Good chance to improve radiculopaty with indirect decompression (no facet joint arthrodhesis) • No wide posterior decompression needed (severe narrowing of spinal canal with claudicatio spinalis) • No diagnosis of severe osteoporosis
  2. 2. Stand alone XLIF: why? • Short operative time: better for elderly patients with co-morbidities • Minimal blood loss • Shorter hospitalization • Good cost/effectiveness Stand alone XLIF: handicaps • Persistent radiculopaty : indirect decompression alone insufficient • Risk of subsidence of the cage (in particular 18 mm cages) • Amount of bone growth: biomechanical stability of cage alone less than circumferential constructs • Risk of two stages surgery
  3. 3. Stand alone XLIF: FU criteria • Pre-operative clinical assessment completed with ODI questionnaire, VAS B/VAS L ; pre-operative imaging with LS MRI + LS lateral and a-p flexion-extension Radiographs • Clinical evaluation + LS lateral and a-p X-Ray at one month • ODI/VAS evaluation + LS lateral Flexion-extension X-Ray at three months • ODI/VAS evaluation + LS lateral flexion-extension X-Rays at six months • In poor grade outcomes, LS MRI was performed
  4. 4. Case collection • October 2011-August 2013: 48 patients treated with XLIF approach: 17 male and 31 females, mean age 62 (range 39-81) • Of the 48 patients, 37 were treated with stand alone XLIF, 10 with circumferential approach and one with XLIF + Lateral Plating • In 3 cases stand alone XLIF + posterior decompression without instrumentation • 31 out of 37 patients completed the FU and were enrolled for the study • 21 patients single level procedure, 10 patients double level procedure livelli trattati L1-L2 L2-L3 L3-L4 L4-L5 L1-L2/L2-L3 L2-L3/L3-L4 L3-L4/L4-L5
  5. 5. Diagnosis on admission imaging DDD DDD + stenosis DDD + DH Symptoms BP BP + RP
  6. 6. 0 10 20 30 40 50 60 70 80 1 2 3 4 5 6 7 8 9 ODI pre ODI post
  7. 7. Stand alone XLIF: results after 3-months FU 0 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 VB pre VB post
  8. 8. Stand alone XLIF: results after 3-months FU 0 1 2 3 4 5 6 7 1 2 3 4 5 VL pre VL post
  9. 9. Stand alone XLIF: results after 6-months FU 0 10 20 30 40 50 60 70 1 3 5 7 9 11 13 15 17 19 21 ODI pre ODI post 3 ODI post 6
  10. 10. Stand alone XLIF: results after 6-months FU 0 1 2 3 4 5 6 7 8 9 10 1 3 5 7 9 11 13 15 17 19 21 VB pre VB post 3 VB post 6
  11. 11. Stand alone XLIF: results after 6-months FU 0 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 VL pre VL post 3 VL post 6
  12. 12. Results analysis • Most cases show good outcome with progressive improvement at six month FU • Unmodified or worsened ODI and VAS scores are classified as poor outcome • Limited improving of scores at three-six months FU that doesn’t lead to category shifting is considered as no satisfactory (poor outcome) • After 3 months FU, 4 out of 9 patients did not significantly improve; of these, three had limited improvement but didn’t change ODI category, one had bad outcome with ODA/VAS scores worsening. • After six month, 1 out of 22 patients didn’t improve significantly • Data matching at three and six months shows progressive outcome improving
  13. 13. Stand alone XLIF: pitfalls • Radiological study at three and six months with lateral Flexion-Extension X- Rays didn’t show significant bone formation • 8 out of 23 patients (34,8%) showed radiological evidence of subsidence of the cage at six months FU • 3 out of 9 patients (33%) showed radiological evidence of subsidence of the cage at three months FU • 7 out of 11 cages were 18 mm wide. • Subsidence was identified in one case of poor outcome at three month FU (22mm CoRoent XL) • No subsidence in the case of poor outcome after 6-months FU • In 10 cases subsidence was clinically silent
  14. 14. Poor outcome analysis • Back pain in three cases, back pain + radiculopathy in 2 cases • Subsidence in one case (BP + RP) • Single level (L3-L4) interbody fusion in two levels degenerative disc disease (L3-L4/L4-L5): procedure aborted in L4-L5. • Persistent foraminal stenosis in one case • No clear causes of persistent symptoms in two cases
  15. 15. Stand alone XLIF: implant failure • GR, female, 66 Years-old, previous L4-L5 PL arthrodesis in L5-S1 grade two spondylolishtesis, osteoporosis • Symptoms: invalidating low back pain, lower limbs radicular pain with cladicatio spinalis, walking severely restricted • Clinical examination on admission: segmental paresis in extension of left foot, Lasegue + 40° in left lower limb • Pre-op LS MRI: L5-S1 grade II spondylolisthesis with spontaneous fusion, L4-L5 pedicle screws with left L5 screw malposition, adjacent level discopaty with Modic 1 changes of the endplate, right convex scoliosis with L3-L4 apex. • Surgical planning: L3-L4 stand alone XLIF to achieve mild coronal deformity correction and treat adjacent level discopathy, L4-L5 laminectomy to decompress left L5 nerve root
  16. 16. Peri-operative complications • Right side surgical approach with MAXcess, standard fashion discectomy, 18x55x8 mm parallel trial followed by 18x50x10 mm parallel trial then 22x50x10 mm lordotic trial • No evidence of subsidence during the discectomy and trial introduction, but significant bleeding from the disk space started after last steps • Cage dislocated in the cranial third of L4 vertebral body (22x50x10 lordoticl); bleeding stopped just after cage insertion, the implant was tightly positioned in the L4 body • We decided to leave the implant there and go on with posterior decompression
  17. 17. Stand alone XLIF

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