Lateral lumbar interbody fusion (LLIF)

Lateral lumbar interbody fusion (LLIF)

Lateral lumbar interbody fusion (LLIF) is a minimally invasive technique first described by Ozgur et al. 1). LLIF allows the surgeon to access the intervertebral space via a minimally invasive direct lateral approach through the psoas muscle. The advantage of LLIF over the traditional anterior approach is the avoidance of exposure of the abdominal viscera, large vessels, and sympathetic plexus. Injury to the nerve roots and dura, and perineural fibrosis, which can occur after PLIF or TLIF, are minimized with this technique 2)3).


Used to treat leg pain or back pain generally caused by degenerative disc disease.

LLIF has been utilized to treat a variety of pathologies including adult degenerative scoliosis, central and foraminal stenosis, spondylolisthesis, and adjacent segment degeneration

They have become an increasingly popular surgical technique due to the benefits of minimal tissue disruption, excellent disc visualization, ability to insert a large intervertebral cage to lessen subsidence, and faster recovery times 4) 5).


The LLIF procedure differs from other lumbar procedures in that the patient is positioned in the lateral decubitus position, often times utilizing bending the bed near the iliac crest region in order to facilitate access to the L4-5 disc space.

In awake volunteers, the pressure at the iliac crest or greater trochanter at the break of the bed increases by increasing the bed angle. Women with a lower BMI had high VAS pain scores when their greater trochanter was at maximal bed break. Men with higher BMI had high VAS pain scores when their iliac crest was at maximal bed break. An awareness of the iliac crest or greater trochanter at the break of the bed should be considered to prevent pain and increased pressure based on the patient’s sex and BMI 6).

As with most minimally invasive spine procedures, lateral lumbar interbody fusion (LLIF) requires the use of biplanar fluoroscopy for localization and safe interbody cage placement. Computed tomography (CT)-based intraoperative spinal navigation has been shown to be more effective than fluoroscopic guidance for posterior-based approaches such as pedicle screw instrumentation.

Use of an intraoperative cone-beam CT with an image-guided navigation system is feasible and safe and appears to be accurate, although a larger study is required to confirm these results 7).


Cost effectiveness

TLIF and LLIF produced equivalent 2-year patient outcomes at an equivalent cost-effectiveness profile 8).

Systematic reviews

Transpsoas lateral interbody fusion is one of the Lateral Lumbar Interbody Fusion minimally invasive approaches for lumbar spine surgery. Most surgeons insert the interbody cage laterally and then insert pedicle or cortical screw and rod instrumentation posteriorly. However, standalone cages have also been used to avoid posterior instrumentation.

The literature on comparison of the two approaches is sparse.

Alvi et al., performed a systematic review and meta-analysis of the available literature on transpsoas lateral interbody fusion by an electronic search of the PubMedEMBASE, and Scopus databases using PRISMA guidelines. They compared patients undergoing transpsoas standalone fusion (TP) with those undergoing transpsoas fusion with posterior instrumentation (TPP).

A total of 28 studies with 1462 patients were included. Three hundred and seventy-four patients underwent TPP, and 956 patients underwent TP. The mean patient age ranged from 45.7 to 68 years in the TP group, and 50 to 67.7 years in the TPP group. The incidence of reoperation was found to be higher for TP (0.08, 95% confidence interval [CI] 0.04-0.11) compared to TPP (0.03, 95% CI 0.01-0.06; p = 0.057). Similarly, the incidence of cage movement was found to be greater in TP (0.18, 95% CI 0.10-0.26) compared to TPP (0.03, 95% CI 0.00-0.05; p < 0.001). Oswestry Disability Index (ODI) and visual analog scale (VAS) scores and postoperative transient deficits were found to be comparable between the two groups.

These results appear to suggest that addition of posterior instrumentation to transpsoas fusion is associated with decreased reoperations and cage movements. The results of previous systematic reviews and meta-analysis should be reevaluated in light of these results, which seem to suggest that higher reoperation and subsidence rates may be due to the use of the standalone technique 9).

A systematic and critical review of recent literature was conducted in accordance with PRISMA guidelines. The sources of the data were PubMed, MEDLINE, Embase, Cochrane and Scopus. Key search terms were “transpsoas”, “interbody fusion”, “LLIF”, “XLIF” and “spondylolisthesis”. Papers included in the review were original research articles in peer-reviewed journals. The articles were thoroughly examined and compared on the basis of study design, outcomes, and results. Only studies which met the eligibility criteria were included. Eight studies were included in the qualitative and quantitative analysis (three retrospective, four prospective, one randomized controlled trial). A total of 308 patients (227 females) (pooled age 64.5 years) and a total of 353 operated levels were analyzed. Mean follow up time ranged from 6.2 to 24 months. There were no reported cases of durotomies or pseudarthrosis in any study. All neurologic complications were reported to be transient with no permanent deficits. Mean improvement in ODI scores ranged between 19.5 (38.6%) to 36 (54.5%). Mean improvement in slip ranged from 47 to 67.5%. Three studies also reported that patient satisfaction and willingness to undergo the procedure again approached 90%. Minimally invasive transpsoas interbody fusion possibly leads to favorable clinical and radiological outcomes while avoiding the possible complications of its more traditional open and minimally invasive counterparts. Further studies are needed to better establish its role in the management of low grade degenerative lumbar spondylolisthesis 10).

Case series


1) , 2)

Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006;6:435–443.

Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976) 2011;36:26–32.

Rodgers WB, Gerber EJ. Outcomes of MIS spinal fusion: 12 and 24 months. The Spine Journal. 2010;10(9):S141.

Isaacs RE, Hyde J, Goodrich JA, et al. A prospective, nonrandomized, multicenter evaluation of extreme lateral interbody fusion of the treatment of adult degenerative scoliosis: perioperative outcomes and complications. Spine. 2010;15(35):S322–30.

Tatsumi RL. Lateral Pressure and VAS Pain Score Analysis for the Lateral Lumbar Interbody Fusion Procedure. Int J Spine Surg. 2015 Sep 28;9:48. doi: 10.14444/2048. eCollection 2015. PubMed PMID: 26512342; PubMed Central PMCID: PMC4610324.

Park P. Three-Dimensional Computed Tomography-Based Spinal Navigation in Minimally Invasive Lateral Lumbar Interbody Fusion: Feasibility, Technique, and Initial Results. Neurosurgery. 2015 Mar 23. [Epub ahead of print] PubMed PMID: 25812070.

Gandhoke GS, Shin HM, Chang YF, Tempel Z, Gerszten PC, Okonkwo DO, Kanter AS. A Cost-Effectiveness Comparison Between Open Transforaminal and Minimally Invasive Lateral Lumbar Interbody Fusions Using the Incremental Cost-Effectiveness Ratio at 2-Year Follow-up. Neurosurgery. 2016 Apr;78(4):585-95. doi: 10.1227/NEU.0000000000001196. PubMed PMID: 26726969.

Alvi MA, Alkhataybeh R, Wahood W, Kerezoudis P, Goncalves S, Murad MH, Bydon M. The impact of adding posterior instrumentation to transpsoas lateral fusion: a systematic review and meta-analysis. J Neurosurg Spine. 2018 Oct 1:1-11. doi: 10.3171/2018.7.SPINE18385. [Epub ahead of print] Review. PubMed PMID: 30485206.

Goyal A, Kerezoudis P, Alvi MA, Goncalves S, Bydon M. Outcomes following minimally invasive lateral transpsoas interbody fusion for degenerative low grade lumbar spondylolisthesis: A systematic review. Clin Neurol Neurosurg. 2018 Apr;167:122-128. doi: 10.1016/j.clineuro.2018.02.020. Epub 2018 Feb 16. Review. PubMed PMID: 29476935.

Oblique lumbar interbody fusion

Oblique lumbar interbody fusion

During the last 20 years several less-invasive anterior approaches to the lumbar spine have become standard, including the extreme lateral lumbar interbody fusion. Although it is associated with a lower risk of vascular injury compared with anterior midline approaches, neuromonitoring is considered mandatory to avoid neurologic complications. Interestingly, despite neuromonitoring, the reported risk of neurologic deficits with the extreme lateral transpsoas approach is greater than observed with other anterior approaches. An alternative lateral, oblique, psoas-sparing approach, named the oblique lumbar interbody fusion, uses the anatomic pathway between the abdominal vessels anteriorly and the lumbar plexus laterally to decrease the risk of neurologic and vascular injury; however, as yet, little on this new approach has been reported.


Surgeons should pay attention to the state of coupled vertebral axial rotation of lumbar degenerative scoliosis for the oblique lumbar interbody fusion procedure 1).

The oblique corridor allows access to the L1-L5 discs from both sides, but it is larger on the left side. The corridor between the iliac vessels and the psoas for L5-S1 is difficult to be applied clinically. Mild psoas retraction can moderately enlarge the oblique corridor. The genitofemoral nerve and diaphragmatic crura may be encountered in this approach and should be carefully observed 2).

Standard treatment protocols for lumbar degenerative lesions in the setting of rheumatoid arthritis (RA) are lacking. The purpose of a study of Akbary et al., from St. Mary’s Hospital, was to evaluate the clinical and radiologic outcomes of minimally invasive oblique lumbar interbody fusion(MI-OLIF) in RA patients having degenerative lumbar spine lesions.

This was a retrospective hospital-based case series (evidence level 4). Eight patients with degenerative lumbar disease with significant back painand neurologic claudication underwent MI-OLIF with polyetheretherketone cage insertion and posterior pedicle screw instrumentation. The clinical outcomes were measured by the numerical rating scale (NRS) for back and leg pain and the Oswestry Disability Index (ODI), and radiologic outcomes were studied on radiographs, computed tomography, and magnetic resonance imaging. Minimum follow-up duration was 1 year.

Mean NRS results for back and leg pain preoperatively were 6.3 and 7.1 that improved to 2.6 and 2 for back and leg pain, respectively, at last follow-up. The mean ODI scores preoperatively were 58.02 that improved to 39.06 at last follow-up. All patients had good functional outcomes, good fusion rates, and were able to continue their activities of daily living without much disability at last follow-up.

MI-OLIF in patients with symptomatic lumbar spine degenerative lesions with RA seems to provide good short-term clinical and radiologic outcomes 3).

Twenty-two patients with degenerative lumbar disease who underwent OLIF between October 2016 and January 2017 were included. Radiography, computed tomography (CT), and magnetic resonance imaging (MRI) were performed pre- and postoperatively. The cross-sectional area (CSA) of the dural sac, disc height (DH), cross-sectional height of the intervertebral foramina (CSH), and intervertebral foramina CSA (CSAF) were measured. Scores from the Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Medical Outcome Study 36-Item Short-Form Health Survey (SF-36), obtained preoperatively, 1 week and 3 months postoperatively, and at the final follow-up, were compared.

Forty-five segments were fused in 22 patients using OLIF. Postoperatively, CSA increased from 0.79±0.32 cm2 to 1.40±0.37 cm2, DH increased from 0.67±0.24 cm to 1.15±0.31 cm, CSH increased from 1.51±0.25 cm to 2.01±0.31 cm, and CSAF increased from 1.11±0.28 cm2 to 1.86±0.38 cm2 (P <0.01). The VAS, ODI, and SF-36 scores of all patients significantly improved postoperatively (P<0.05). There were no complications involving injuries to spinal nerves, great vessels, abdominal viscera, or ureters. Only one patient experienced injury to the psoas major.

OLIF is a safe and effective minimally invasive procedure for the treatment of degenerative lumbar disease 4).

Fukaya and Hasegawa presented their early experience with circumferential MIS(cMIS), which involves oblique lumbar interbody fusion(OLIF)with percutaneous pedicle screw(PPS)fixation using a rod cantilever technique to enhance lumbar lordosis(LL)for ASD.

Twenty-one thoracolumbar ASD cases in which surgical correction was performed from the lower thoracic spine corresponded to class IIIa in the modified minimally invasive spinal deformity surgery(MISDEF)algorithm. Patients with a rigid curve and prior fusion were excluded. Surgery was performed in 2 stages. During the first stage, OLIF was performed from L1/2 or Th12/L1 to L4/5. After 4 to 7 days, the patients were re-imaged with standing radiography, and the second-stage surgery was performed with L5/S1 posterior lumbar interbody fusion(PLIF)and percutaneous instrumentation from the lower thoracic spine to the pelvis. Radiological deformity correction at 4 weeks and perioperative complications were evaluated. Scatter plots were created for comparison of preoperative and postoperative sagittal spinopelvic parameters.

The patients’ mean age was 75 years. The mean operative time was 488 min, and the blood loss was 901 mL. Significant improvement in the spinopelvic parameters were found on the preoperative images of the sagittal vertical axis(SVA)(108mm to 33.5 mm), lumbar lordosis(LL)(18° to 48°), pelvic tilt(PT)(31.8° to 19.2°), and Cobb angle(CA)(21.1° to 11.9°). The change from the preoperative to the postoperative sagittal spinopelvic parameters(SVA, PI-LL, and PT)strongly correlated with preoperative values.

As cMIS resulted in improvement in spinopelvic parameters and no major complications, this technique could provide a safe and effective strategy to manage ASD even with severe sagittal imbalance 5).

Mehren et al performed a chart review of intra- and perioperative complications of all patients who had undergone minimally invasive anterior lumbar interbody fusion through a lateral psoas-sparing approach from L1 to L5 during a 12-year period (1998-2010). During the study period, the oblique, psoas-sparing approach was the preferred approach of the participating surgeons in this study, and it was performed in 812 patients, all of whom are studied here, and all of whom have complete data for assessment of the short-term (inpatient-only) complications that we studied. In general, they performed this approach whenever possible, although it generally was avoided when a patient previously had undergone an open retro- or transperitoneal abdominal procedure, or previous implantation of hernia mesh in the abdomen. During the study period, posterior fusion techniques were used in an additional 573 patients instead of the oblique lumbar interbody fusion when they needed to decompress the spinal canal beyond what is possible through the anterior approach. In case of spinal stenosis calling for fusion in combination with a high disc space, severe endplate irregularity, or severe biomechanical instability, they combined posterior decompression with oblique lumbar interbody fusion in 367 patients. Complications were evaluated by an independent observer who was not involved in the decision-making process, the operative procedure, nor the postoperative care by reviewing the inpatient records and operative notes.

A total of 3.7% (30/812) of patients who underwent the oblique lumbar interbody fusion experienced a complication intraoperatively or during the hospital stay. During the early postoperative period there were two superficial (0.24%) and three deep (0.37%) wound infections and five superficial (0.62%) and six deep (0.86%) hematomas. There were no abdominal injuries or urologic injuries. The percentage of vascular complications was 0.37% (n = 3). The percentage of neurologic complications was 0.37% (n = 3).

The risk of vascular complications after oblique lumbar interbody fusion seems to be lower compared with reported risk for anterior midline approaches, and the risk of neurologic complications after oblique lumbar interbody fusion seems to be lower than what has been reported with the extreme lateral transpsoas approach; however, they caution readers that head-to-head studies will need to be performed to confirm our very preliminary comparisons and results with the oblique psoas-sparing approach. Similarly, future studies will need to evaluate this approach in terms of later-presenting complications, such as infection and pseudarthrosis formation, which could not be assessed using this inpatient-only approach. Nevertheless, with the results of this study the oblique psoas-sparing approach can be described as a less-invasive alternative for anterior lumbar fusion surgery from L1 to L5 with a low risk of vascular and neurologic damage and without costly intraoperative neuromonitoring tools 6).



Kim DB, Shin MH, Kim JT. Vertebral Body Rotation in Patient of Lumbar Degenerative Scoliosis; Surgical Implication for Oblique Lumbar Interbody Fusion (OLIF). World Neurosurg. 2018 Dec 26. pii: S1878-8750(18)32896-1. doi: 10.1016/j.wneu.2018.12.073. [Epub ahead of print] PubMed PMID: 30593961.

Kai W, Can Z, Hao W, Zan C, Chou D, Jian F. The Anatomic Characteristics of the Retroperitoneal Oblique Corridor to the L1-S1 Intervertebral Disc Spaces. Spine (Phila Pa 1976). 2018 Nov 20. doi: 10.1097/BRS.0000000000002951. [Epub ahead of print] PubMed PMID: 30475333.

Akbary K, Quillo-Olvera J, Lin GX, Jo HJ, Kim JS. Outcomes of Minimally Invasive Oblique Lumbar Interbody Fusion in Patients with Lumbar Degenerative Disease with Rheumatoid Arthritis. J Neurol Surg A Cent Eur Neurosurg. 2019 Jan 24. doi: 10.1055/s-0038-1676301. [Epub ahead of print] PubMed PMID: 30677786.

Zhang C, Wang K, Jian F, Wu H. Efficacy of oblique lateral interbody fusion in the treatment of degenerative lumbar disease. World Neurosurg. 2018 Nov 24. pii: S1878-8750(18)32698-6. doi: 10.1016/j.wneu.2018.11.139. [Epub ahead of print] PubMed PMID: 30481626.

Fukaya K, Hasegawa M. [Oblique Lumbar Interbody Fusion Combined with Minimally Invasive Percutaneous Posterior Instrumentation for Adult Spinal Deformity]. No Shinkei Geka. 2018 Sep;46(9):771-781. doi: 10.11477/mf.1436203812. Japanese. PubMed PMID: 30262681.

Mehren C, Mayer HM, Zandanell C, Siepe CJ, Korge A. The Oblique Anterolateral Approach to the Lumbar Spine Provides Access to the Lumbar Spine With Few Early Complications. Clin Orthop Relat Res. 2016 May 9. [Epub ahead of print] PubMed PMID: 27160744.

Neurologic Injury after Lateral Lumbar Interbody Fusion

Since the first description of LLIF in 2006, the indications for LLIF have expanded and the rate of LLIF procedures performed in the USA has increased. LLIF has several theoretical advantages compared to other approaches including the preservation of the anterior and posterior annular/ligamentous structures, insertion of wide cages resting on the dense apophyseal ring bilaterally, and augmentation of disc height with indirect decompression of neural elements. Favorable long-term outcomes and a reduced risk of visceral/vascular injuries, incidental dural tears, and perioperative infections have been reported. However, approach-related complications such as motor and sensory deficits remain a concern. In well-indicated patients, LLIF can be a safe procedure used for a variety of indications 1).

Hijji et al. published a systematic review analyzing the complication profile of LLIF. Their study included a total of 63 articles and 6819 patients. The most commonly reported complications were transient neurologic injury (36.07%). The clinical significance of those transient findings, however, is unclear since the rate of persistent neurologic complications was much lower (3.98%) 2)

The risk of lumbar plexus injury is particularly concerning at the L4-5 disc space. Although LLIF is associated with an increased prevalence of anterior thigh/groin pain as well as motor and sensory deficits immediately after surgery, our results support that pain and neurologic deficits decrease over time. The level treated appears to be a risk factor for lumbosacral plexus injury 3).

Interestingly, the use of rhBMP-2 was associated with higher rates of persistent motor deficits, which might be explained by a direct deleterious effect of this agent on the lumbosacral plexus 4).

In a retrospective chart review of 118 patients, Cahill et al. determined the incidence of femoral nerve injury, which is considered one of the worst neurological complications after LLIF. The authors reported an approximate 5% femoral nerve injury rate of all the LLIF procedures performed at L4-5. There were no femoral nerve injuries at any other levels 5).

During a 6-year time period of performing LLIF Aichmair et al., noted a learning curve with a decreasing proportional trend for anterior thigh pain, sensory as well as motor deficits 6)

Le et al. also observed a learning curve with a significant reduction in the incidence of postoperative thigh numbness during a 3-year period (from 26.1 to 10.7%) 7).

Levi AD from the University of Miami Hospital, adopted an exclusive mini-open muscle-splitting approach in LLIF with first-look inspection of the lumbosacral plexus nerve elements taht may improve motor and sensory outcomes in general and the incidence of postoperative groin/thighsensory dysfunction and psoas-pattern weakness in particular 8).



Salzmann SN, Shue J, Hughes AP. Lateral Lumbar Interbody Fusion-Outcomes and Complications. Curr Rev Musculoskelet Med. 2017 Dec;10(4):539-546. doi: 10.1007/s12178-017-9444-1. Review. PubMed PMID: 29038952; PubMed Central PMCID: PMC5685966.

Hijji FY, Narain AS, Bohl DD, Ahn J, Long WW, DiBattista JV, Kudaravalli KT, Singh K. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J. 2017 Oct;17(10):1412-1419. doi: 10.1016/j.spinee.2017.04.022. Epub 2017 Apr 26. Review. PubMed PMID: 28456671.

Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014 May 1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 24012428.

Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014 May 1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 24012428.

Cahill KS, Martinez JL, Wang MY, Vanni S, Levi AD. Motor nerve injuries following the minimally invasive lateral transpsoas approach. J Neurosurg Spine. 2012 Sep;17(3):227-31. doi: 10.3171/2012.5.SPINE1288. Epub 2012 Jun 29. PubMed PMID: 22746272.

Aichmair A, Lykissas MG, Girardi FP, Sama AA, Lebl DR, Taher F, Cammisa FP, Hughes AP. An institutional six-year trend analysis of the neurological outcome after lateral lumbar interbody fusion: a 6-year trend analysis of a single institution. Spine (Phila Pa 1976). 2013 Nov 1;38(23):E1483-90. doi: 10.1097/BRS.0b013e3182a3d1b4. PubMed PMID: 23873231.

Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976). 2013 Jan 1;38(1):E13-20. doi: 10.1097/BRS.0b013e318278417c. PubMed PMID: 23073358.

Sellin JN, Brusko GD, Levi AD. Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach. World Neurosurg. 2019 Jan;121:e647-e653. doi: 10.1016/j.wneu.2018.09.180. Epub 2018 Oct 3. PubMed PMID: 30292030.
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