Grade 2 Spondylolisthesis at L4-5 treated by XLIF

Overview 

Spondylolisthesis, a condition where one vertebra slips forward over the one below it, is a common reason for spinal surgery. Degenerative spondylolisthesis, often resulting from aging and wear and tear, is particularly prevalent. Patients with this condition frequently require spinal fusion surgery to alleviate pain and stabilize the spine. Recent data has underscored the long-term benefits and cost-effectiveness of surgical treatment for spondylolisthesis, making it a preferred option over non-surgical care for many patients.

One of the most frequent reasons for spinal surgery is still spondylolisthesis. Patients with degenerative spondylolisthesis are often advised to undergo fusion.

Although the advantages of surgical treatment compared to non-surgical care for this condition have been demonstrated in the long run, it is only in recent high-quality data that the cost-effectiveness of this procedure has been established.

Modern developments in minimally invasive surgical technology are currently being utilized to treat spinal conditions. An approach known as extreme lateral interbody fusion (XLIF) has been proposed as a secure and minimally invasive substitute for conventional open fusion surgeries.

Surgical Techniques and Innovations

Modern advancements in minimally invasive surgical technology have revolutionized the treatment of spinal conditions. One such technique, extreme lateral interbody fusion (XLIF), offers a less invasive alternative to traditional open fusion surgeries. XLIF is particularly suited for treating spondylolisthesis up to grade 2, although it comes with potential risks, especially at the L4-5 level where the lumbar plexus is most vulnerable.

Advantages of XLIF

Patients undergoing XLIF typically experience shorter hospital stays, averaging 1.2 days, and a minimal drop in hemoglobin levels (about 1.4 g). Despite some initial postoperative symptoms, such as transient pain in the upper thigh and hip flexion weakness due to psoas muscle trauma, the overall recovery is swift. The majority of biologic materials used in these procedures contain demineralized bone matrices, which aid in bone healing and stability.

Clinical Outcomes and Patient Satisfaction

Studies show that patients undergoing XLIF for grade II spondylolisthesis, particularly at the L4-5 level, exhibit no radiographic instability after 12 months, with successful bone growth spanning the interbody space. Factors such as age, BMI, preexisting comorbidities, previous surgeries, the number of levels treated, and the type of fixation do not significantly impact the outcomes. Most patients report high satisfaction levels, with nearly all willing to undergo the procedure again.

Complications

Literature reports indicate an occurrence of groin numbness (without motor deficits) when using an endoscopic transpsoas approach without neurological monitoring. There is a lot of debate around the neurological deficits linked to lateral approaches.

The L4-5 level poses the highest risk for the lumbar plexus in a transpsoas approach, as per the anatomical and radiographic documentation. Furthermore, the plexus is placed at even greater risk with anterolisthesis of the superior vertebral body, as it is pushed even more ventrally, further increasing safety concerns.

Nevertheless, if proper attention is given to the technique details mentioned above, and real-time neurologic monitoring is conducted, successful treatment of grade 2 spondylolisthesis segments, particularly at L4-5, can be achieved without any neurologic damage.

Surgery has been demonstrated in large randomized trials to result in better patient outcomes than nonoperative treatment for spondylolisthesis. Various techniques have been utilized to treat spondylolisthesis, including decompression alone, instrumented PLF, PLIF, ALIF, TLIF, as well as minimally invasive procedures like MIS ALIF or MIS TLIF.

However, there is no clear consensus on which technique is the best. Substantially cost-effective compared to conservative care, instrumented fusion for the treatment of degenerative spondylolisthesis has been demonstrated to be clinically effective. MIS XLIF fusion for spondylolisthesis is associated with significantly fewer complications compared to traditional open approaches, according to the reported literature. Additionally, traditional open spinal fusions have been reported to result in much longer hospital stays.

The use of XLIF has been demonstrated to be a secure and efficient method to manage grade 2 spondylolisthesis specifically at the L4-5 level. This technique leads to significant clinical and radiographic improvement that is sustained over a period of time. Real-time neurologic monitoring and meticulous technique are essential.

Comparative Effectiveness of Surgical Techniques

Large randomized trials have demonstrated that surgery offers better outcomes than nonoperative treatment for spondylolisthesis. Various techniques, including decompression alone, instrumented posterolateral fusion (PLF), posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF), and minimally invasive procedures like MIS ALIF or MIS TLIF, have been used. However, there is no consensus on the best approach. Instrumented fusion has been shown to be both clinically effective and cost-effective compared to conservative care, with MIS XLIF fusion presenting fewer complications and shorter hospital stays than traditional open approaches.

Conclusion

XLIF has emerged as a safe and effective method for managing grade 2 spondylolisthesis, particularly at the L4-5 level. The technique offers significant clinical and radiographic improvements that are sustained over time. The success of XLIF underscores the importance of real-time neurologic monitoring and meticulous surgical technique in ensuring patient safety and optimal outcomes.

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