Standalone EXLIF

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Status

Done

Parent item

Extreme Lateral EX Interbody Fusion

General

• Standalone Exlif (without posterior instrumentation).

• Use of lateral plate does not add much biomechanical benefit.

• Good for Degen grade 1 listhesis without instability and not signficant central canal stenosis. However, if there is not central canal stenosis why are we doing this surgery in the first place.

 

 

Indications

Radiographic and Biomechanical Criteria:

• Neutral sagittal and coronal balance.

• Mild to moderate facet arthropathy.

• Stable grade 1 spondylolisthesis without a pars defect
• Confirmed via dynamic radiographic imaging.

• Absence of severe central canal stenosis that would necessitate direct decompression.

• Normal to mildly reduced bone mineral density (BMD).
• A Hounsfield unit threshold > 120 is recommended to mitigate the risk of subsidence.

• Discogenic disease only (a condition primarily seen in younger patients and considered ideal for this approach).

Patient and Clinical Risk Criteria:

• Presence of comorbidities or risk factors where the additional operative time, increased blood loss, extended hospital stay, increased tissue damage, and/or increased perioperative pain associated with supplemental posterior fixation would pose greater risks for the patient.

• Older age (e.g., > 65 years of age) may lead a patient to be considered a suitable candidate due to the heightened risk associated with additional surgery.

Pros and cons

Pros of Stand-Alone EXLIF (Compared to LLIF with Posterior Instrumentation)

• Suitability for High-Risk Patients:
• High risk
• Preferable option for older patients (e.g., > 65 years of age) OR
• Significant comorbidities or risk factors
• Due to
• Reduced Operative Time: 131.4 minutes vs 242.5 minutes
• Reduced Blood Loss: 60.5 mL vs 145.4 mL
• Shorter Hospital Stay: 1.9 days vs 3.2 days

• Favorable Clinical Outcomes: Non inferior postoperative patient-reported outcomes (such as ODI, VAS-back, and VAS-leg scores)

• Comparable Stability/Cage Migration Rate: Stand-alone cohort (7%) and the Posterior instrumentation + EXLIFcohort (5%) was not statistically significant.

• Cost Reduction
• Abstaining from the use of a lateral plate (if considered for fixation) helps reduce the overall costs of patient care.

Cons of Stand-Alone LLIF (Risks and Limitations)

• Biomechanical Limitations:
• Biomechanical studies suggest that while stand-alone constructs offer mechanical stability at the instrumented segment, they may be limited in controlling flexion and extension compared to constructs supplemented with posterior fixation.
• Supplemental posterior instrumentation traditionally enhances the stiffness and stability of the construct.