Glenn R. Buttermann, MD

XLIF vs ALIF Combined with PSF Results in a

Community Practice

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Introduction• XLIF combined with posterior spinal fusion has increased in

popularity for patients with advanced degenerative spinal conditions as well as selective deformity conditions.

• Prior studies have predominantly been from academic institutions or by authors who had a financial relationship to a manufacturer with the potential for bias in reported outcomes.

• The purpose of this study was to assess outcomes of an XLIF cohort and compare to a previous prospective cohort of traditional 2-level anterior/posterior spinal fusion patients treated for advanced degenerative disc disease.

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Present Study• Indications for XLIF patient (n=41) were primary surgical fusion

for lumbar DDD, adjacent segment degenerative condition, or as part of a hybrid procedure for spinal deformity.

• Prospective study: Visual Analog Scale for back pain and leg pain, pain drawing, ODI.

• Follow-up periods were at six-month to one year intervals with minimum two-year follow-up.

• Comparative anterior/posterior spinal fusion cohort (n=50) had similar prospective outcomes evaluation.

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XLIF/PSF vs ASF/PSF

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Age (mean +/- SD) 59.1 ± 18.8 44.0 ± 11.5Female (%) 78 68Smokers (%) 10 50Work Comp/Lit (%) 5 48Osteoporosis (%) 24 36EBL (ml, mean +/- SD) 283 ± 188 498 ± 297

XLIF/PSF ASF/PSF

Major XLIF Dx• Primary Degenerative condition

Example: L45 post-lami DDDPreop Postop

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Major XLIF Dx• Adjacent segment degenerative condition

Example: L23 Adj DDD/stenosis/retrolisthesisPreop Postop

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Major XLIF Dx: Adult DeformityExample: AIS lumbar motion segment sparing method

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Major XLIF Dx: Adult Deformity• Degenerative scoliosis, spondylolisthesis &

stenosis

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Low Back & Leg Pain Outcomes

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0

2

4

6

8

10

PRE-OP 7-12 MONTH 1-2 YEARS 2-4 YEARS

VA

S

FOLLOW-UP PERIOD

Fig. 1, BACK PAIN

XLIF/PSF (n=41)

ASF/PSF (n=50)

0

2

4

6

8

10

PRE-OP 7-12 MONTH 1-2 YEARS 2-4 YEARS

VA

S

FOLLOW-UP PERIOD

Fig. 2, LEG PAIN

XLIF/PSF (n=41)

ASF/PSF (n=50)

Pain Drawing & ODI Outcomes

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02468

101214161820

PRE-OP 7-12 MONTH 1-2 YEARS 2-4 YEARS

PA

IN

AR

EA

FOLLOW-UP PERIOD

Fig. 3, PAIN DRAWING

XLIF/PSF (n=41)

ASF/PSF (n=50)

0

10

20

30

40

50

60

70

80

PRE-OP 7-12 MONTH 1-2 YEARS 2-4 YEARS

Deg

ree

of

Dis

abili

ty

FOLLOW-UP PERIOD

Fig. 4, OSWESTRY DISABILITY

XLIF/PSF (n=41)

ASF/PSF (n=50)

Results• Most common indication for XLIF was adjacent level

degenerative condition s/p prior lumbar fusion (29 of 41 patients).

• Both XLIF/PSF and ASF/PSF groups had significantly improved outcomes at all follow-up periods.

• There was no significant difference in outcomes between XLIF/PSF and ASF/PSF groups, however demographics differ between cohorts.

• Patients in both XLIF and AP fusion groups who had interbody device subsidence were found to have osteoporosis.

• Transient neurological deficits were most common at L4-5 in the XLIF cohort.

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Discussion• The outcomes of XLIF combined with PSF were

statistically similar to ASF/PSF outcomes in patients undergoing primary fusion.

• The XLIF approach avoids potential complications related to revision ASF approach in patients who have adjacent level conditions yet obtains similar clinical success.

• Patients with osteoporosis require additional individualized treatment:

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Subsidence in osteoporotic pt.