Extreme Lateral Interbody Fusion (XLIF): Everything You Need to Know

Spine surgery

XLIF, or Extreme Lateral Interbody Fusion, is a minimally invasive surgical procedure used to treat spinal conditions in the lower back. It involves accessing the spine through a small incision made on the side of the patient, avoiding disruption to back muscles. The damaged intervertebral disc is removed and replaced with a bone graft to promote fusion and stability. XLIF is effective for degenerative disc disease, herniated discs, and spinal deformities, aiming to alleviate pain and restore spinal function. XLIF surgery is performed under general anesthesia and may require a hospital stay of several days and have a recovery time of several weeks to months. 

First of all, what is a fusion surgery?

Spinal fusion surgery is a procedure that involves joining two or more vertebrae together in the spine. This is typically done to alleviate pain caused by conditions such as spondylolisthesis, scoliosis, or spinal fractures. During the surgery, the surgeon will use bone grafts and/or metal hardware (such as screws and rods) to hold the vertebrae in place while they fuse together during the healing process. The goal of the surgery is to stabilize the spine and reduce pain and nerve compression.

What are the different types of spinal fusion, and how is an XLIF different?

There are several types of fusion surgery used to treat spinal conditions, and XLIF (Extreme Lateral Interbody Fusion) is one specific approach among them. Here are a few common fusion surgeries and how they differ from XLIF:

  1. Posterior Lumbar Interbody Fusion (PLIF): In PLIF, the surgeon accesses the spine through an incision in the back. PLIF allows for direct decompression of nerve roots and provides good access to the disc space, but it involves more extensive disruption of back muscles compared to XLIF.
  2. Transforaminal Lumbar Interbody Fusion (TLIF): TLIF is similar to PLIF, but the approach is slightly different. The surgeon accesses the spine through an incision on one side of the spine, approaching the disc space through the neural foramen. This approach also allows for direct decompression and fusion, with a reduced disruption of back muscles. However, compared to XLIF, the lateral access is more limited in TLIF.
  3. Anterior Lumbar Interbody Fusion (ALIF): ALIF involves accessing the spine through an incision made in the front of the abdomen. ALIF provides good access to the disc space and allows for a large interbody cage for fusion. However, it requires an abdominal approach and potential risks associated with abdominal surgery.

XLIF differs from these fusion surgeries primarily in the surgical approach. XLIF accesses the spine laterally through a small incision on the patient’s side, typically through the flank or abdomen. This approach avoids cutting through or disrupting the back muscles, reducing post-operative pain and potentially speeding up recovery. 

Which conditions can be treated with an XLIF?

Spinal fusion surgery is typically indicated for conditions that cause pain or instability in the spine. Some common indications for the surgery include:

  • Degenerative disc disease: This is a condition in which the discs between the vertebrae begin to wear down, leading to pain and instability in the spine.
  • Spinal fractures: Fractures in the vertebrae can cause instability and pain in the spine.
  • Spondylolisthesis: This is a condition in which one vertebra slips forward over another, which can lead to instability, nerve compression and pain.
  • Scoliosis: This is a condition in which the spine is curved to one side. This can lead to uneven pressure on the vertebrae and cause pain. A fusion surgery is often used to correct the deformity from scoliosis. 
  • Tumors: Spinal tumors can cause pain and instability, especially if they erode through vertebrae. 
  • Instability from Surgery: A fusion surgery is sometimes needed to stabilize the spine after a decompression surgery such as a laminectomy

What are the advantages of XLIF over other types of fusion surgery?

XLIF is a minimally invasive procedure that accesses the spine through a small incision on the patient’s side, typically through the flank or abdomen. This lateral approach avoids the need to cut or disrupt the back muscles, resulting in less muscle damage, reduced post-operative pain, and potentially faster recovery compared to procedures that involve posterior or anterior approaches.

However, not all patients or conditions may be suitable for XLIF, and the choice of fusion surgery depends on individual factors and the surgeon’s expertise.

What happens during the surgery?

An XLIF surgery typically takes several hours to complete and is performed under general anesthesia. Here is a general overview of what can be expected during the surgery:

During an XLIF (Extreme Lateral Interbody Fusion) surgery, the following steps typically occur:

  1. Anesthesia: The patient is first given anesthesia to ensure they are comfortable and unconscious throughout the procedure. The type of anesthesia used may vary depending on the patient’s specific needs and the surgeon’s preference.
  2. Incision: A small incision is made on the patient’s side, typically through the flank or abdomen. The precise location of the incision depends on the specific target area of the spine.
  3. Access to the Spine: Through the incision, the surgeon gently moves aside the muscles, tendons, and other tissues to reach the affected area of the spine. Special surgical retractors may be used to keep the surrounding tissues safely separated during the procedure.
  4. Disc Removal: The surgeon carefully removes the damaged intervertebral disc located between the adjacent vertebrae. This step is essential for alleviating pressure on the nerves and reducing pain caused by the affected disc.
  5. Bone Graft Placement: Once the disc is removed, a bone graft material is inserted into the empty disc space. The bone graft serves as a bridge between the adjacent vertebrae and promotes fusion. The graft material may be taken from the patient’s own body (autograft) or obtained from a donor (allograft). In some cases, additional bone growth-promoting substances or biologics may be used to enhance fusion.
  6. Implant Placement (if necessary): Depending on the specific needs of the patient, the surgeon may also insert metal implants such as screws, rods, or cages to provide additional stability and support during the fusion process. These implants may help maintain proper spinal alignment and prevent any movement between the vertebrae during the healing phase.
  7. Closure: After the bone graft and any implants are in place, the surgeon carefully closes the incision using sutures or staples. Sterile dressings or bandages are applied to protect the surgical site.

After the surgery, you will be taken to the recovery area to wake up from anesthesia. You may require a hospital stay for a few days for monitoring and pain management. Physical therapy and rehabilitation are typically recommended to aid in your recovery, restore strength, and improve mobility.

What is the recovery time following an XLIF?

In most cases, you can expect to spend 1 to 3 days in the hospital following a fusion surgery.  The duration of your stay will depend on your level of pain control and your ability to move around.

It is common for patients to begin standing and walking the day after surgery. Your surgeon may give you a back brace to help you feel more comfortable and to protect the surgical fusion.

During the first several weeks after the surgery, you should be able to perform basic exercises like walking but should avoid activities such as bending, twisting, or lifting heavy objects during this time.

Most patients who undergo a fusion procedure should expect to gradually resume their normal activities over a period of several months.

What are the risks of an XLIF?

As with any complex operation, there are several risks associated with spinal fusion surgery. Some of these risks include:

  • Infection: Although surgery is performed in sterile conditions, there is always a small risk of infection at the surgical site. 
  • Nerve damage: Nerves in and around the spinal cord can be damaged during the surgery.
  • Damage to other surrounding tissues: Other tissues as well as blood vessels and organs can be damaged during the procedure.
  • Non-union: The vertebrae may not fuse together properly, which may require additional surgery.
  • Adjacent segment disease: Adjacent segment disease can occur when the segments of the spine above or below the fused area become damaged or degenerate.
  • Hardware complications: There is a risk that the hardware used to fuse the vertebrae together may become loose or cause irritation.

Is an XLIF right for me?

It’s important to consult with a qualified spine surgeon to determine if an TLIF is the right option for you. 

There are many factors to be considered, including the specific condition being treated, your overall health, and your goals and expectations.

It’s also important to note that spinal fusion surgery is not always the best option for everyone. Some patients may be better served by other treatments, such as physical therapy, medications, or minimally invasive procedures.

About the Author

Dave Harrison, MD

Dr. Harrison is a board certified Emergency Physician with a part time appointment at San Francisco General Medical Center and is an Assistant Clinical Professor-Volunteer at the UCSF School of Medicine. Dr. Harrison attended medical school at Tufts University and completed his Emergency Medicine residency at the University of Southern California. Dr. Harrison manages the editorial process for SpineInfo.com.