Lumbar Spine Surgery:
Direct Lateral Interbody Fusion (DLIF/XLIF)
Below are some of the procedures offered by Dr. Cheng to treat lumbar spine conditions. Click the links below to learn more about the selected treatment:
eXtreme Lateral Interbody Fusion (XLIF) Lateral access is a safe and reproducible means of addressing certain spine disorders with an approach from the side of the patient, as opposed to an approach from the back (posterior) or the front (anterior). A lateral (side) approach is made safe with the use of nerve monitoring technology (NeuroVision® from NuVasive,® Inc.).
A New Avenue for Treatment
The XLIF® (eXtreme Lateral Interbody Fusion) procedure provides relief to patients who cannot tolerate a larger, open back surgery because of the increased risks of longer anesthesia time, blood loss, hospitalization, and recovery. It is also a less invasive alternative for patients who have lived with back or leg pain through years of various failed treatments, including steroid injections, physical therapy, and pain medication.
The XLIF® procedure includes the use of NeuroVision®, a technologically advanced nerve monitoring system (EMG), allows the surgeon to have accurate, reproducible, real-time feedback about nerve health, location, and function, reducing the incidence of nerve injury during surgery.
- Reduced operative time – Traditional procedures can take up to 5 hours; the XLIF procedure can be successfully completed in as little as one hour, reducing the amount of anesthesia time.
- Reduced blood loss and minimal scarring – Less-invasive procedure allows for less tissue disruption, resulting in reduced blood loss.
- Reduced postoperative pain – The XLIF procedure does not require entry through sensitive back muscles, bones, or ligaments.Many patients are usually walking the same day after surgery.
- Reduced hospital stay – Patients are typically walking the same day after surgery and require only an overnight stay in the hospital, compared to several days of immobility and hospitalization typical of traditional open approaches
- Rapid return to normal activity – Patients are usually walking the same day after surgery. Recovery is typically around 6 weeks, compared to 6 months or more.
The purpose of this surgery is to stabilize the spine and relieve leg/back pain, numbness, weakness, or lack of coordination and motor control caused by pressure on the nerves. The success rate of relieving leg pain is very high.
The surgery typically lasts two or more hours, depending on the number of discs operated upon, whether or not previous surgery has been performed, and the severity of pressure on the nerves. The likelihood of significant blood loss is dependent on the number of levels requiring surgery; if one or two level surgery is needed, blood loss can be minimal so usually no blood donations are necessary before the operation. Time spent in the hospital is short—most patients can go home three to five days after the surgery.
Risks of Surgery
Surgery and anesthesia involve stresses to many organs and tissues in the body. Incisions and handling tissues during surgery can result in many problems. The benefits of surgery must be carefully weighed against these risks. Some of the more common or serious problems are listed here.
Spinal Cord or Nerve Root Injury: Permanent injury to the spinal cord or nerve roots is extremely rare. It is not unusual, however to experience minor temporary tingling, numbness, weakness or pain which resolves over several weeks. All precautions will be taken but rarely, more serious nerve injuries can occur.
Failure of fusion: On rare occasions the bone graft does not heal properly. The likelihood of this is greatly increased by smoking or using nicotine of any kind. This can cause the hardware to fail, and the bone graft may shift. In these cases, additional surgery may be needed. For this reason, we recommend quitting smoking at least one month before surgery and refraining from smoking for at least 3 months after surgery. For high risk patients, we may check urine for nicotine by-products to ensure no tobacco is in the system prior to surgery. Smoking also causes more rapid degeneration of the spine, and continuing to smoke increases the likelihood of requiring treatment at another level of the spine.
Dural Tear: Leakage of spinal fluid can occur due to a tear in the tissue (called the “dura”) holding the spinal fluid and containing the nerves. This may require bed rest and, on rare occasions, surgical repair may be needed. This does not typically compromise the ultimate result.
Infection: Infection is always a post-operative risk and occurs in approximately 1–2% of surgical patients, varying by surgery type. Infections may be superficial or deep into the bone. You are given antibiotics before and after the surgery to help prevent this complication. Please follow the instructions for wound care to help prevent infection.
Other complications: Other possible complications include blood clots, pneumonia and complications related to the general anesthesia. Persistent hoarseness and/or swallowing problems may last for several weeks. Please call us if this persists. It is not uncommon to have temporary pain in the front of the thigh after this procedure due to irritation of nerves in the muscle through which the approach is made. This should subside over the first week or two.
Activities and Exercise / Rehabilitation
Adequate rehabilitation is crucial for a successful result. Many patients with spinal troubles have suffered from spinal pain and deconditioning for some time. This may result in considerable weakening of the spinal muscles due to lack of exercise, so you should return to normal activities slowly over several weeks. As a rule of thumb, for a healthy adult it takes about as long to get back in shape as you have been sick. So if you have been limited with back problems for 6 months, it may take that long to get back to all of your usual activities. For older persons, this time can be longer. Overall people continue to improve for one or two years after spinal fusion.
The primary form of rehabilitation after spinal fusion is an aggressive walking program. You should start immediately after discharge, walking more and more each day. In general, we recommend two to three episodes of exercise per day. The average patient undergoing single-level surgery can be walking 15 minutes twice a day by their first postoperative visit and 30–40 minutes twice a day by six weeks after surgery. This varies from patient to patient and also depends on the extent of surgery, but feel free to walk more if you are so inclined!
Patients routinely experience a dramatic, remarkable reduction in their back and leg pain; however, of the two the leg pain is more predictably alleviated. If the nerve has been irritated for a long time, then a more gradual reduction of the leg pain is to be expected. As the nerve heals, expect tingling or a warm feeling. Depending on how long the symptoms have been present, strength is usually the second symptom to improve. Numbness in the leg / foot is the last to resolve and, if present for long enough prior to surgery, may be permanent.
Back pain associated with the incision is largely improved within two to three weeks. Increased pain with prolonged sitting and driving is also expected and, for safety reasons, we recommend refraining from driving for approximately three weeks.