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. 2021 Sep 20;22:101597. doi: 10.1016/j.jcot.2021.101597

Lateral lumbar interbody fusion in adult spine deformity – A review of literature

Dheeraj Batheja 1,∗, Bhoresh Dhamija 1, Aashish Ghodke 1, Srinath S Anand 1, Birender S Balain 1
PMCID: PMC8531858  PMID: 34722145

Abstract

Introduction

Surgery for adult spine deformity presents a challenging issue for spinal surgeons with high morbidity rates reported in the literature. The minimally invasive lateral approach aims at reducing these complications while maintaining similar outcomes as associated with open spinal surgeries. The aim of this paper is to review the literature on the use of lateral lumbar interbody fusion in the cases of adult spinal deformity.

Methods

A literature review was done using the healthcare database Advanced Research on NICE and NHS website using Medline. Search terms were “XLIF” or “LLIF” or “DLIF” or “lateral lumbar interbody fusion” or “minimal invasive lateral fusion” and “adult spinal deformity” or “spinal deformity”.

Results

A total of 417 studies were considered for the review and 44 studies were shortlisted after going through the selection criteria. The data of 1722 patients and 4057 fusion levels were analysed for this review. The mean age of the patients was 65.18 years with L4/5 being the most common level fused in this review. We found significant improvement in the radiological parameters (lordosis, scoliosis, and disk height) in the pooled data. Transient neurological symptoms and cage subsidence were the two most common complications reported.

Conclusion

LLIF is a safe and effective approach in managing adult spinal deformity with low morbidity and acceptable complication rates. It can be used alone for lower grades of deformity and as an adjuvant procedure to decrease the magnitude of open surgeries in high-grade deformities.

Keywords: Adult spine deformity, LLIF, XLIF, Lateral spinal fusion

1. Introduction

Spinal deformities in the adult population may present with spondylolisthesis, scoliosis or loss of sagittal balance. These are three-dimensional deformities and most of the patients present with chronic backache, abnormal posture, balance issues, with or without neurological symptoms which affects their activities of daily living and overall quality of life.1 Operative intervention is considered as a management option for those who are refractory to conservative treatment.2 Surgical goals include relief of leg symptoms or neural decompression which can be direct or indirect, promote fusion and preserve or correct alignment.

Over the past few years, there has been an upward trend in the number of spinal fusion surgeries worldwide. In Australia, the number of spinal fusion procedures increased significantly by up to 169%3 and a similar trend has been seen in other countries as well.4, 5, 6, 7 Provaggi et al.4 reported an increase of 63% in spinal fusion procedures in a ten-year period between 2005 and 2015 in the United Kingdom. Figures from Norway and US also suggest a continuous upward trend in both primary and complex lumbar spine surgery as reported by Grotle et al.6 and Sheik et al.7

Traditionally, these patients have been managed with open surgeries either anteriorly or posteriorly. Open surgery is often associated with high morbidity and high complication rates.8,9 Recently there has been an inclination towards minimally invasive lateral lumbar interbody fusion, which was first described by Ozgur10 in 2006. The idea of this approach aims at transferring the benefits of the classic anterior fusion technique into a minimally invasive or “less invasive mode”, which can also provide similar outcomes with fewer complications.

Some authors have raised questions on their efficacy, others have reported promising clinical results including effective decompression, better fusion rates, and deformity correction for degenerative spinal deformities.11 The scope of this paper is to review the literature on the use of lateral lumbar interbody fusion for surgical correction of deformity and to highlight the procedure efficacy and safety in adult spinal deformity.

2. Methods

2.1. Literature search and inclusion/exclusion criteria

The literature review was undertaken using Healthcare Database Advanced Search (HDAS) on NICE and NHS health education website using Medline. Search terms included “XLIF” or “LLIF” or “DLIF” or “lateral lumbar interbody fusion” or “minimal invasive lateral fusion” and “adult spinal deformity” or “spinal deformity”. In addition, we performed a manual check and cross-referencing to increase our database. Only English language articles were included in this review. Studies published before 2010, studies with less than 25 patients or less than 12 months follow up were excluded from the review. Biomechanical, cadaveric studies, case reports, conference proceedings, review articles were also excluded from this review. Studies from the same institution or the same senior author were analysed for potential overlap in the data and in such situations, series with the largest number of patients was included. Other exclusion criteria were series that did not mention at least one radiological parameter and publications that combine the other fusion approach data with the lateral fusion data.

2.2. Data extraction and outcome measures

Following data was extracted from each selected publication: first authors name, year of publication, number of patients, number of levels, level of evidence, radiological data including scoliosis or lordosis angle or disc height, surgical or medical complications, neurological deficits. In the studies that specifically mention only one radiological parameter and not others, it was presumed that the parameters were not analysed. Various patient reported outcome measures (PROMs) were also measured.

2.3. Statistical analysis

Due to variable reporting of the radiological and PROM outcome measures, we describe a narrative review format with pooled estimates for various outcomes. Descriptive statistics, i.e., the mean and standard deviation for continuous variables and frequencies with proportions for categorical variables were used to present the available information. Paired T-test was used to compare pre-operative and post-operative alignment changes and linear regression analysis was done to compare the degree of alignment change. A p-value of less than 0.05 was considered statistically significant.

3. Results

3.1. Study collection

A total of 412 studies were identified through the database screening and applying inclusion and exclusion criteria. Five further studies were identified through manual reference checks. Title and abstract screening were done for all these 417 studies independently by 2 authors. Seventy-eight studies were considered eligible and were subjected to full-text review and 34 articles were further excluded upon a full-text review. Most of these were excluded because of a lack of independent lateral fusion data. A total of 44 articles were finally included in the review paper. The search flow diagram has been depicted in Fig. 1.

Fig. 1.

Fig. 1

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Flow diagram of the literature search performed for minimally invasive lumbar interbody fusion and selected studies.

3.2. Study characteristics and demographics

A total of 44 studies including 1722 patients and 4057 fusion levels were considered for this analysis. The mean age of the patients was 65.18 years and the male to female ratio was 1:1.76. The exact level of fusion was only mentioned in 17 studies and L4/5 was the most common level fused in the pooled data (Table 1).

Table 1.

Patient demographics.

S no. Mean SD 95% CI Range
Number of Patients 42.36 27.19 34.10 to 50.63 25–140
Levels 94.34 81.30 75.62 to 128.33 27–395
Age 65.18 4.4424 63.3129 to 67.0646 58–74.2
Male 16.78 13.96 12.05 to 21.50
Female 29.58 16.72 23.93 to 35.24
Follow up 23.448 14.750 17.359 to 29.537 12–81.7
Fusion level (Total of 17 studies and 1163 levels) L1/2 80
L2/3 236
L3/4 375
L4/5 472
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SD – Standard Deviation, CI – Confidence Interval.

3.3. Radiological parameters

  • 1)

    Lumbar lordosis – Across the review of the literature, 28 study cohorts have reported lumbar lordosis including 829 patients and 1848 operated levels. There was a significant improvement in both lumbar and segmental lordosis. The weighted pre-op lumbar lordosis was 39.60° which improved to 45.74°. Segmental lordosis was commented upon in 17 studies with a total of 599 patients and 1132 levels. The pooled average segmental lordosis improved from 6.90 pre-operatively to 9.98 at the final follow-up (Table 2).

  • 2)

    Lumbar Scoliosis – Segmental scoliosis has been documented in 6 studies with a total of 175 patients and 368 levels with the average pre-op angle of 6.17°. This improved significantly to 2.87° at the final follow up. Regional scoliosis was much widely commented upon as compared to segmental scoliosis. A total of 18 studies comprising of 749 patients and 2343 levels reported the average pre-op coronal scoliosis angle of 21.86° which improved to 9.76° at the time of last follow-up (Table 2).

  • 3)

    Disc height – There has been a lot of variability in measuring disc height in literature with some studies measuring posterior disc height, some measuring central disc height while others didn't mention the site at all. For the sake of this study, all disc heights measurements were combined, and we found that 17 studies have reported a change in disk height as an outcome measure. Again, we found a significant change in disc height in reported studies (Table 2).

Table 2.

Radiological parameters in review.

Parameter Number of studies Number of patients Number of levels Average pre-op value Average post op value standard error of difference P value
Lumbar Lordosis 28 829 1848 39.6 45.74 1.565 <0.0006
Segmental Lordosis 17 599 1132 6.9 9.9 1.214 0.0143
Scoliosis 18 749 2343 21.86 9.76 2.423 <0.0001
Segmental Scoliosis 6 175 368 6.17 2.87 1.072 0.0066
Disc Height 17 746 1059 5.43 9.03 0.711 <0.0001
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3.4. Patient reported outcome measures

Many studies have reported different patient-reported outcome measures (PROM). Only 3 PROMs have used uniformly and were considered for this review. These include Oswestry Disability Index (ODI), Visual analogue score (VAS) for leg pain and VAS for back pain. Some authors have just reported VAS score without specifying back or leg. For the sake of this review, they have been evaluated separately from back or leg VAS. Findings have been tabulated in Table 3. We have found a significant improvement in patient reported outcome measures in this review.

Table 3.

Patient reported outcome measures.

Parameter Number of studies Number of patients Number of levels Average pre-op Average post op value standard error of difference P value
ODI 22 1059 2248 50.18 28.03 1.457 <0.0006
VAS for Leg pain 15 673 1281 6.29 3.06 0.284 <0.0001
VAS for Back Pain 13 609 1157 7.43 3.24 0.295 <0.0001
VAS (not specified) 7 384 980 7.7 3.37 0.391 <0.0001
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3.5. Complications

There was again variable reporting of the complications in the LLIF procedure. Due to this heterogeneity, most complications were analysed for fewer patients than the overall study. Transient neurologic symptoms and cage subsidence were the two most common complications in our review, reported by 9 studies each. Most of these patients had thigh numbness or pins and needles/paraesthesia in the post-op period. Other complications reported by various authors include hip flexion weakness, wound complications, hernia, failed indirect decompression, and adjacent segment disease. These findings and percentages have been summarised in Table 4.

Table 4.

Complications.

Parameter Number of studies Number of patients Number of levels Number of events % of total patients % of total levels
Hip flexion weakness 11 516 1291 54 10.46 4.1
Thigh sensory symptoms 9 501 1312 111 22.15 8.4
Subsidence 9 384 848 86 22.39 10.1
Wound complications 8 436 1180 24 5.50 2.03
Incisional hernia 2 57 191 2 3.50 1.04
Failed indirect decompression 4 157 553 11 7.0 1.98
Adjacent segment disease 5 338 995 13 3.84 1.30
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4. Discussion

The management of adult spinal deformity remains a challenging issue for both orthopaedic and neurosurgeons. Operative intervention is considered for those who are refractory to conservative treatment.2 The primary goals of the treatment are to manage pain, halt the progression of deformity, obtain harmonious correction of coronal or sagittal balance, and improve the overall quality of life. The importance of restoring sagittal balance and lumbar lordosis has been increasingly recognised in the world of spinal deformity surgery.12

Lateral lumbar interbody fusion (LLIF) has gained widespread acceptability due to its potential in minimizing complications. Anecdotal perception is that these techniques are not able to alter the lumbar sagittal or coronal balance and hence, don't have much impact on overall alignment.13 Acosta et al.14 and Johnson et al.15 have been proponent of this theory. At the same time, it has been refuted by many other authors. Dawkar et al.16 in 2010, reported significant improvement of sagittal balance after LLIF procedure and were probably amongst the first authors to do so. Over the last few years, there have been numerous case series on the success of LLIF for spondylolisthesis, adjacent segment disease, scoliosis, stenosis and kyphosis.17, 18, 19, 20

LLIF surgery can only be successful if it addresses all the goals as described above. One just cannot propose a lateral surgery to reduce the complication rates without addressing the main issue at hand. Evaluation of XLIF results can provide an insight into its technical potential in deformity correction and disc height reconstruction. The current study, thus, aims to provide objective evidence in the radiological and functional outcome of lateral fusion surgeries and look into possible management protocols and algorithms as described in the literature.

4.1. LLIF in adult spinal deformity

Many authors have reported LLIF as an excellent management option for adult spinal deformity.17, 18, 19, 20 Sembrano et al.21 in their study of 147 patients with spinal deformity and sagittal imbalance, compared four approaches ALIF, LLIF, TLIF and posterior spinal fusion, PSF. They concluded that LLIF can improve sagittal balance as well as the other approaches and is better than the posterior approach in improving the disc height. ALIF, however, could provide greater segmental and lumbar lordosis correction.

In our study, we found that both lumbar lordosis and segmental lordosis can be significantly improved with lateral interbody fusion surgery. Also, the amount of correction achieved by this approach is directly proportional to the pre-operative lumbar lordosis. A simple linear regression analysis revealed a significant inverse relationship between pre-operative lumbar lordosis and change in lumbar lordosis wherein a lower pre-operative lumbar lordosis predicted a greater increase in post-operative lumbar lordosis (Fig. 2). Segmental lordosis, however, did not show the same inverse relationship between pre-operative values and post-operative change (Fig. 3). Correction of scoliosis was seen directly proportional to pre-operative scoliotic deformity, suggesting that correction can be achieved in severe deformities as well (Fig. 4).

Fig. 2.

Fig. 2

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Linear regression diagram showing inverse relationship between pre-operative lumbar lordosis (x-axis) and change in lumbar lordosis (y-axis).

X-axis – lumbar lordosis, y-axis- change in lumbar lordosis.

Fig. 3.

Fig. 3

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Linear regression diagram showing relationship between pre-operative segmental lordosis (x-axis) and change in segmental lordosis (y-axis).

X-axis – Segmental lordosis, y-axis- change in segmental lordosis.

Fig. 4.

Fig. 4

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Linear regression diagram showing positive relationship between pre-operative scoliosis (x-axis) and change in scoliosis (y-axis), indicating that correction can be achieved in severe deformities as well.

X-axis –Scoliosis, y-axis- change in scoliosis.

Significant improvement in clinical outcomes has been reported with both open and percutaneous posterior fixation following lateral fusion. Open procedures, however, were found to have a better radiographic correction as compared to percutaneous fixation.22

4.2. LLIF in severe deformity and elderly

The use of lateral fusion techniques in one or two-level disease has been well established.22, 23 While dealing with severe deformities, multiple level LLIF can be, therefore, used to decrease the magnitude of deformity.24 This can be then combined with multiple level grade 2 osteotomies24,25 to improve the correction. If greater correction is desired, an anterior column realignment (ACR) or a higher-grade osteotomy (PSO) should be taken into consideration.26,27 However, ACR is associated with a higher risk of blood vessel damage and therefore, caution must be exercised.28 Higher grade osteotomies25 increase the surgical insult and is associated with greater blood loss and morbidity. In our review, we found 5 studies19,20,29, 30, 31 treating severe deformity with the use of lateral lumbar fusion. In each of these five studies, all the patients underwent more than 3 levels of lateral lumbar fusion with a combined 197 patients and 898 operated level. Out of these, 4 studies demonstrated a significant correction of lumbar scoliosis and 2 studies showed a significant correction of lumbar lordosis, signifying the role of LLIF in severe deformities as well.

In a retrospective study, Rodgers et al.32 compared the advantages of the XLIF technique to the open PLIF technique in a group of over 80-year-old patients. The XLIF had statistically superior results in terms of the earlier discharge of patients from the hospital, the lower transfusion rate and the lower complication rate. The reported clinical result of lateral fusion was significantly better than PLIF for a comparable indication. Another study by Paterakis et al.33 concluded that lateral fusion is an effective alternative in adult deformity cases and could be considered as the treatment of choice in the elderly in whom there is a higher risk of complications due to underlying co-morbidities.

4.3. Management algorithms

Adult spinal deformity comprises of miscellaneous conditions. There is a paucity of literature on the classification or management protocol for adult spinal deformity patients using lateral fusion techniques. Berjano et al.34 in 2012 classified adult deformity into 4 types depending upon radiological parameters and suggested surgical options for the same. They concluded that lateral fusion surgery along with posterior intervention helps in attaining satisfactory curve correction while reducing the number of levels fused. Malham et al.35 proposed a management flowchart in adult deformity patients regarding the use of stand-alone LLIF or concomitant use of posterior fixation. Osteoporosis, more than 2 levels, facet arthropathy, and instability were considered as a risk factor for adding posterior fixation.

In 2013, Mummaneni et al. proposed a management algorithm36 and classified patients into six groups depending upon the clinical and radiological findings. The surgical options included minimally invasive (MIS) decompression to open surgeries and osteotomies depending upon the deformity. In 2019, a modified algorithm37 was developed by the same authors depending upon similar parameters and divided them into 4 treatment plans ranging from basic to advanced MIS techniques to open deformity surgery with osteotomies. The MISDEF-2 algorithm incorporates recent advances in MIS surgery and has good intra and inter-observer agreement. This algorithm aims to provide guidance to surgeons aiming at MIS surgeries.

4.4. Complications

Open deformity correction procedures are associated with a higher complication rate. A retrospective review of 306 primary lumbar adult degenerative scoliosis patients, by Charosky et al.,38 showed an overall complication rate of 39% with a 44% chance of new operation within 6 years of primary surgery. Another study by Worley et al.39 showed higher complication rates as well. Rodgers et al.40 compared traditional open approaches with minimally invasive spine surgeries using lateral approach and concluded that these are associated with lower incidence of infection, less chance of neurologic or visceral injuries, lesser transfusion rates and overall lesser hospital stay. LLIF is, thus, gaining popularity among spinal surgeons. However, it brings a unique set of complications along with it.

The occurrence of neurologic complications with lateral surgery is a predominant concern among many surgeons. Some studies have suggested that transient numbness and mild flexion weakness happen due to the trans-psoas approach and should not be considered as a complication. This has led to significant heterogenicity in reporting neural complications with deficits ranging from 0.7% to 78.8%.41, 42, 43 In Isaac's study,44 a total of 33.6% of the patients had mild motor weaknesses with the majority of them (77.8%) had grade one loss of strength.

Hijji et al.45 reviewed 63 articles and reported transient motor deficit was 14.11%, transient thigh symptoms 26.51% and persistent neurologic deficit of 3.98%. Similar findings were reported by Gammal et al.46 with post-operative thigh symptoms reported as high as 60.7% with a motor deficit of 9.3%.

Uribe et al.47 suggested the use of EMG during the procedure and to minimize the retraction time as well. Tohmeh et al.48 reported 27.5% of hip flexion weakness and 17.6% of thigh sensory symptoms in a study of 102 patients undergoing LLIF with neuromonitoring. None of the cases had a significant long-lasting weakness. The review article by Joseph et al.49 highlighted the complication rate was not lower in the studies which use EMG. Therefore, there is no clear answer, but the authors prefer to use EMG while performing LLIF surgery.

There are several limitations in our study. Firstly, the use of different operative techniques by various authors presents diverse data when compared. Some of the authors have used stand-alone lateral fusion cages, while others have done pedicle fixation either percutaneously or open. This heterogenicity in surgical methods can lead to different radiological correction and complication rates. Secondly, our analysis did not include the studies which didn't mention at least one radiological outcome measure. Therefore, there is a possibility that some of these studies didn't find any correction in a specific parameter and hence did not analyse them. This could have led to a bias in our study. Lastly, our review is impacted by the level of evidence of various studies included with most of them being retrospective level 4 studies and only 3 being prospective studies and one a randomised control trial.

5. Conclusion

The current study is a comprehensive evaluation of LLIF results over the past decade. In summary, it can be said that LLIF is a safe and effective approach in managing adult spinal deformity with improvement in PROMs. It can be used alone for lower grades deformity and as an adjuvant procedure to decrease the magnitude of open surgeries in high-grade deformities. Across the individual studies, transient paraesthesia, thigh pain and transient motor weakness were the most common complications. A large well-designed randomised controlled trial comparing different fusion techniques are required to provide stronger evidence.

Declaration of competing interest

The authors declare no conflict of interest.

Contributor Information

Dheeraj Batheja, Email: drdheerajmamc@gmail.com, Dheeraj.Batheja2@nhs.net.

Bhoresh Dhamija, Email: bdhamija1@doctors.org.uk.

Aashish Ghodke, Email: aashish.ghodke@nhs.net.

Srinath S. Anand, Email: dr.srinath05@gmail.com.

Birender S. Balain, Email: bbalain@nhs.net.

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