Lumbar Fusions – ALIF, PLIF, XLIF

Anterior Lumbar Interbody Fusion (ALIF)

Anterior lumbar interbody fusion (ALIF) is a surgical procedure to correct the spinal problems from the front of the vertebral body by removing disc or other bone material from in between two adjacent lumbar vertebrae. The surgery can be implemented either as an open surgery or minimally invasive techniques.

Anterior lumbar interbody fusion (ALIF) is a spinal surgery that involves removal of all or part of a herniated disc from in between two contiguous vertebrae (interbody) from the front of the vertebral body in the lower back region (lumbar spine) and fusing or joining the two vertebrae together so that they heal into a single, solid bone. A bone graft or a substitute bone graft can be used on both sides of the remaining disc space of the vertebrae.

The graft material binds the two vertebrae together and promotes bone healing, facilitates the fusion and helps to preserve the normal disc height as the body heals. Along with the vertebral bone, the bone graft also grows and stabilizes the spine. An ‘internal cast' made up of certain instruments such as rods, screws, plates, cages, hooks and wires can be used to support the vertebral structure during the healing process.   

Your condition and your surgeon’s experience, training or preferred methodology may determine the performance of ALIF surgery alone or in combination with another spinal fusion approach.  Discuss the options of surgical approach thoroughly with your doctor and depend on their decision for the most suitable approach for your condition.

Indications

The recommendation of spinal fusion by a surgeon depends on various reasons and the procedure is most commonly used to treat conditions such as one or more fractured vertebra, spondylolisthesis or slippage of one vertebra over another, presence of abnormal curvatures of the spine such as scoliosis or kyphosis, any protrusion or degeneration of the disc (the cartilaginous structure that ‘cushions’ between vertebrae) and instability of the spine or excessive motion between two or more vertebrae.

Patients with certain symptoms such as low back or leg pain due to degeneration of disc, spondylolysis or spondylolisthesis, scoliosis or any spinal instability that have not responded to other non-surgical treatment measures such as rest, physical therapy or medications may be appropriate candidates for an ALIF surgery.

The best candidate for ALIF surgery include the patients who are suffering from excessive amount of spinal instability or slippage of vertebra and patients with little to no spinal stenosis or nerve compression over the lower back of the spine. Though ALIF is the most useful technique, it is not recommended for the patients who are suffering from osteoporosis or softening of bone and arthritis or patients with instability.

Before prescribing the ALIF surgery your surgeon considers various factors such as the condition to be treated, your age, health, lifestyle and your expected level of activity after the surgery. Have a complete discussion with your spinal care provider regarding the available treatment options.

Procedure

The ALIF surgery is usually performed under general anaesthesia and the patient is positioned in supine lying r on their back. The surgeon makes an incision in the abdomen and retracts abdominal muscles, organs and other vascular structures including major blood vessels such as aorta and vena cava to get a clear view of the front of the spine and accessibility to the vertebrae. Usually this part of the surgery may be executed by a general surgeon or vascular specialist. The surgeon removes the whole or a portion of the degenerated disc from the affected disc space and inserts bone graft or bone graft substitute into the disc space between the vertebral bodies, to promote bone healing and support the disc space. After the completion of the procedure, the abdominal organs, blood vessels and muscles are realigned and the incision is closed.

ALIF is a traditional form of open surgical procedure commonly performed by surgeons. However, there is another option to access the spine through application of minimally invasive (endoscopic) technologies. These applications help the surgeon to access the affected vertebrae through small incisions and create intramuscular tunnels to accommodate the surgical tools with special guidance and illumination.

Recovery

The recovery period after ALIF surgery depends on the surgical procedure and ability of your body to heal and firmly fuse the vertebrae together. The advantage of ALIF is that the back muscles and nerves are not troubled during the surgery.

Patients may expect several days of post-surgical hospitalization. The post-surgical hospitalization also includes the rehabilitation program. If required your surgeon may prescribe pain medications or a brace and follow-up physical therapy upon discharge.

The period of your rest or inactivity depends on a few factors such as the type of surgical procedure and the approach used to access your spine, the size of the incision and presence of any complications. Another consideration for returning to work or normal activity depends on the type of work or activity you plan to perform. Usually 3 to 6 weeks of healing time is needed. Within the last few years many innovations and advancements have been developed that helps to improve fusion rates, reduce hospital stays and deliver more active and rapid recovery period.

Seek the consultation of your spinal surgeon to establish the appropriate recovery protocol and follow post-operative instructions to augment the healing process.

Risks and Complications

Each patient has a treatment plan and outcome result which vary from individual to individual.  The complications of the ALIF surgery include infection, nerve damage, blood clots or blood loss or bowel and bladder problem and any problem associated with anaesthesia. The underlying risk of spinal fusion surgery is failure of fusion of vertebral bone and bone graft which usually requires an additional surgery.

Please refer to your physician to obtain a list of indications, adverse effects or precautions, clinical results and other significant medical information related to the ALIF surgical procedure.

Posterior Lumbar Interbody Fusion (PLIF)

A posterior lumbar interbody fusion (PLIF) is a surgical technique that involves correction of the spinal problems at the base of the spine by placing bone graft between two vertebrae. Minimally invasive surgical techniques may be used to perform the procedure.

Posterior lumbar interbody fusion (PLIF) is a spinal surgery that involves placement of bone graft material between two adjacent vertebrae from the back of the spine. The bone graft material works as a bridge or platform that binds or fuses two vertebrae together and promotes new bone growth. The ultimate purpose of the procedure is to re-establish the spinal stability.

Now-a-days minimally invasive spine surgical techniques may be used to perform PLIF which permits the surgeon to make small incisions and gently separate the surrounding muscles of the spine rather than cutting. The aim of the minimally invasive approach is to preserves the surrounding muscular and vascular function for faster recovery and reduced scarring.   

Indications

Patients with spinal instability in their lower back due to degenerative disc disease, spondylolisthesis or spinal stenosis that has not responded to other non-surgical treatment measures such as rest, physical therapy or medications may be recommended for surgical treatment of spinal fusion procedure such as PLIF. Patients with lumbar spinal instability may experience pain, numbness and muscle weakness in the lower back, hips and legs.

Before prescribing the PLIF surgery your surgeon considers various factors such as the condition to be treated, your age, health, lifestyle and your expected level of activity after the surgery. Have a complete discussion with your spinal care provider regarding the available treatment options.

Procedure

In this procedure, the surgeon makes a small incision in the lower back over the vertebra (e) to be treated. The size of the incision depends on the bone graft to be used and can be as small as approximately 3 centimetres. Usually 3- to 6- inches of incision is required in a traditional open PLIF surgical procedure. 

The surgeon dilates the surrounding muscles of the spine to access the section of the spine to be stabilized. Next, the lamina, the roof of the vertebra, is removed to visualize the nerve roots. The facet joints that are directly over the nerve roots are trimmed to provide the nerve roots with more space.

Bone Graft Placement

To place the bone, graft the nerve roots are shifted to one side and disc material is removed from the front (anterior) of the spine. Now the bone graft is implemented into the disc space. Screws and rods are used to stabilize the spine for better healing and fusion.

After the completion of the procedure the small incision is closed and leaving behind a minimal scar.

Recovery

This minimally invasive procedure typically permits most of the patients to be discharged the day after surgery but some patients may require a longer hospitalization. Usually most of the patients observe immediate improvement of some or all their symptoms but sometimes the improvement of the symptoms may be gradual.

Contribution of a positive approach, realistic expectations and compliance with your doctor's post-surgical instructions help bring a satisfactory outcome of the surgical procedure. Most patients can resume their regular activities within several weeks.

Have a conversation with the doctor to determine if you are a candidate for minimally invasive PLIF surgery.

Risks and Complications

Every patient has a treatment plan and outcome result. Sometimes outcome results vary from individual to individual.  The complications associated with PLIF surgery include infection, nerve damage, blood clots or blood loss, bowel and bladder problems and problems associated with anaesthesia. The primary risk of spinal fusion surgery is failure of fusion of vertebral bone and bone graft which may require an additional surgery.

Please refer to your physician to obtain an ample list of indications, warnings or adverse effects or precautions, clinical results and other significant medical information related to the minimally invasive PLIF surgical procedure.

X-LIF Extreme Lateral Interbody Fusion

Extreme lateral interbody fusion (XLIF) is a minimally-invasive surgery that involves the fusing of two degenerative spinal vertebrae. The procedure is conducted to relieve painful motion in the back caused by spinal disorders.

Spinal problems occur primarily between vertebrae, where they are packed with a cushioning material called intervertebral disc. Over the years, the discs undergo wear and tear, allowing the vertebrae to painfully rub against each other every time we move and degenerate.

Fusing of degenerated vertebrae maintains the optimal disc space between them, aligns and stabilizes the spine, and protects the spinal cord and nerves from further damage.

Indications

XLIF is considered when the patient does not respond well to pain killers, physical therapy and steroid injections. It is indicated for leg and back pain that are caused by any of the lumbar or lower spine disorders listed below.

• Degenerative disc disease (damaged discs between two vertebrae)
• Degenerative scoliosis (sideways curve of spine)
• Degenerative spondylolisthesis (one vertebra moves away from the normal spine alignment)
• Recurring disc herniation (ruptured disc)
• Posterior Pseudarthrosis (previous failed fusion surgery)
• Post-laminectomy syndrome (spinal instability following non-fusion surgery)
• Adjacent level syndrome (condition that occurs next to previous fusion surgery)

Contraindications

XLIF may not be an option for the following conditions:

• Degenerative spondylolisthesis of greater than grade 2
• Presence of scarring behind the abdominal cavity, on either side of the spine because of previous surgery or abscess

Procedure

XLIF adopts a lateral approach when compared to traditional methods of spinal fusion techniques, and in doing so, spares the disruption of major back muscles, ligaments and bones. Since the procedure is done in close proximity with several important nerves in the spinal column, your surgeon will continuously monitor them with electromyography (EMG) to avoid any damage to the nerves.

The surgery takes about one hour and is performed under general anaesthesia. You will be positioned onto one side. Using X-ray, your surgeon will locate and mark off the affected region. Through a small incision made in your back, your surgeon will hold back the peritoneum (outer covering of abdominal organs) and will make a second incision on your side for instruments called tubular dilators to pass through. The affected disc is then removed, and replaced with an implant filled with bone graft, which will aid in the fusion of the adjacent vertebrae. The instruments are removed and incision stitched and bandaged. Additional support with the help of plates, rods or screws may be inserted.

Recovery

XLIF ensures a quick recovery and lets you return to normal activities. As this approach, does not damage muscles, ideally you will be able to walk the evening of the surgery and will be discharged the next day. Following your discharge, you will be prescribed medication for pain.

Risks and complications

The surgery may be associated with infection, damage to nerves, spinal cord or blood vessels, muscle weakness and enduring pain at the site of bone graft. There are chances of the implant failing to fuse the vertebrae and a progression in the existing disease. Other conditions such as deep vein thrombosis or clotting, urinary tract infection, stroke and pneumonia may develop following the procedure.