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Lateral Lumbar Interbody Fusion (LLIF)

 

                

What is lateral spine fusion?

When back and leg pain result from injury or degenerative changes in the spine, a lateral lumbar interbody fusion (LLIF) may be recommended. Fusion stabilizes the spine and prevents painful motion. The surgery is sometimes called DLIF, which stands for direct lateral interbody fusion, or XLIF, for extreme lateral interbody fusion. Both refer to the same technique.

During lateral fusion, an incision is made at the side of the waist. The damaged disc is removed and the space between the bony vertebrae is filled with spacer bone graft. The spacer restores the height between the bones and relives pinching of the spinal nerves. The graft becomes a bridge between the two bones to promote fusion. In some cases the graft is strengthened with a plate and screws on the side or with pedicle screws from the back.

As the body begins healing, new bone cells grow around the graft. After 3 to 6 months, the bone graft should fuse the two vertebrae, forming one solid piece of bone. Like reinforced concrete, instrumentation and fusion work together.

Depending on the symptoms, a one-level or multi-level fusion may be performed. A one-level fusion joins two bones while a two-level fusion joins three bones.

Lateral spine fusion is a unique minimally invasive surgery for several reasons. First, the small incision is only 1 inch long near the waist. Second, its path to the spine is from the side. The surgeon uses dilation tubes to create a tunnel between the patient’s abdominal organs in front and the strong spine muscles in back. Third, a nerve-monitoring probe guides the path to safely enlarge the tubular instruments without injuring the spinal nerves.

Lateral fusion can be performed in a hospital or as an outpatient same-day procedure.

Who is a candidate?

You may be a candidate for LLIF if you have:

  • Degenerative disc disease
  • Low-grade spondylolisthesis
  • Mild to moderate scoliosis
  • Spinal stenosis
  • Symptoms that have not improved with physical therapy or medication

You are NOT a candidate for LLIF if you have:

  • Damaged disc at L5-S1, because the hip bone blocks access
  • Severe spondylolisthesis or scoliosis
  • Other problems that would prevent bone fusion
  • Prior abdominal surgery near the kidneys

The surgical decision:

If you are a candidate for spinal fusion, the surgeon will explain your options. Consider all the risks and benefits as you make your decision. Fusion is performed only after other treatments have been explored. It will stop the motion in the painful area of your spine, allowing increased function and return to a more normal lifestyle – though one that may not be totally pain-free.

Your surgeon will also explain the various types of bone graft. These materials are placed within the remaining disc space and act as a kind of mortar between the bones as your body heals. Each type has advantages and disadvantages.

  • Autograft is your living bone. The marrow contains bone-growing proteins. It can be collected from drillings during the surgery or taken from the hip as an iliac crest bone graft. The harvested bone is about a half inch thick. The entire thickness of bone is not removed, just the top half layer.
  • BMA (bone marrow aspirate) is your living bone marrow, collected with a syringe from the hip (iliac bone) or vertebra. It is relatively painless compared to an iliac crest graft.
  • Allograft is bone from an organ donor, collected and stored by a bone bank. The donor graft has no bone-growing cells.
  • BMP (bone morphogenetic protein) is sometimes added to bone-graft material to stimulate bone growth naturally in the body. 

What happens before surgery?

Presurgical tests (e.g., blood test, chest x-ray, electrocardiogram) will be done several days before surgery. In the doctor’s office, you will sign consent forms and provide your medical history (allergies, medicines, vitamins, bleeding history, anesthesia reactions, previous surgeries). Inform your healthcare provider about all the medications (over-the-counter, prescription, herbal supplements) that you are taking.

Continue taking the medications your surgeon recommend. Stop taking all non-steroidal anti-inflammatory medicines (Naprosyn, Advil, Motrin, Nuprin, Aleve, etc.) and blood thinners (Coumadin, Plavix, etc.) 1 to 2 weeks before surgery as directed by your doctor. As your doctor if you are unsure.

Stop smoking and drinking before surgery

The most important way to achieve a successful spine fusion is to eliminate tobacco use (cigarettes, cigars, pipes, chewing tobacco, and snuff/dip) before surgery.

Nicotine prevents bone growth and decreases successful fusion. Smoking risk is serious: fusion fails in 40% of smokers compared to 8% of non-smokers [1]. Smoking also decrease blood circulation, resulting in slower wound healing and increased risk of infection. Talk with your doctor about ways to help you quit smoking: nicotine replacements, pills without nicotine (Wellbutrin, Chantix), and tobacco counseling programs.

You should not drink alcohol 1 week before and 2 weeks after surgery to avoid bleeding problems. 

Morning of surgery:

  • No food or drink.
  • Shower using antibacterial soap. Dress is freshly washed, loose-fitting clothing.
  • Wear flat-heeled shoes with closed backs.
  • If you have instruction to take regular medication the morning of surgery, do so with small sips of water.
  • Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
  • Leave all valuables and jewelry at home (including wedding bands).
  • Bring a list of medications (prescriptions, over-the-counter, and herbal supplements) with dosages and the times of day usually taken.
  • Bring a list of allergies to medication or foods.

Arrive at the hospital 2 hours before (surgery center 1 hour before) your scheduled operation to complete the necessary paperwork and pre-procedure work-ups. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks. An intravenous (IV) line will be placed in your arm.

What happens during surgery?

This surgery generally takes 1 to 2 hours, depending on how many spine levels are treated.

  • Step 1: Prepare the patient
  • Step 2: Make the incision
  • Step 3: Locate the damaged disc
  • Step 4: Remove the disc
  • Step 5: Prepare the disc space
  • Step 6: Insert the bone graft
  • Step 7: Insert plate and screws (optional)
  • Step 8: Close the incision

What happens after surgery?

Most patients will go home the same day. However, if any difficulty in breathing or unstable blood pressure occurs, the patient can be transferred to a hospital.

Discharge instructions

Discomfort

  • Take pain medication as directed by your surgeon. Narcotics can be addictive an are used for a limited period of time.
  • Narcotics can also cause constipation. Drink lots of water and eat high-fiber foods. Laxatives and stool softeners such as Dulxolax, Senokot, Colace, and Milk of Magnesia are available without a prescription.
  • Do NOT take anti-inflammatory pain relivers (Advil, Aleve) without surgeon’s approval. They prevent new bone growth and may cause your fusion to fail.
  • You may take acetaminophen (Tylenol).
  • Ice your incision 3-4 times per day for 15-20 minutes to reduce pain and swelling.

Restrictions

  • Avoid bending, lifting or twisting your back for the next 6 weeks.
  • Do not lift anything heavier than 5 pounds for 2 weeks after surgery.
  • No strenuous activity for the next 2 weeks, including yard work, housework and sex.
  • DO NOT SMOKE, vape, dip, chew or use nicotine products. It prevents new bone growth and may cause your fusion to fail.
  • Do not drive until after your follow-up appointment. You may ride in the car for short distances of 45 minutes or less if necessary.
  • Do not drink alcohol for 2 weeks after surgery or while you are taking narcotic medication.

Activity

  • You may need help with daily activities (e.g., dressing, bathing), for the first couple days.
  • Get up and walk 5-10 minutes every 3-4 hours. Gradually increase your walking time, as you are able.

Bathing/Incision Care

  • Wash your hands thoroughly before and after cleaning your incision to prevent infection.
  • If you have Dermabond (skin glue) covering your incision, you  may shower the day after surgery. Gently wash the area daily with soap and water. Pay dry.
  • If you have staples, steri-strips, or stitches, you may shower 2 days after surgery. Remove the gauze dressing and gently wash the area with soap and water. Replace the dressing or completely remove it if no drainage. Inspect and wash the incision daily.
  • Do not submerge or soak the incision in water (bath, pool or tub).
  • Some drainage form the incision is normal. A large amount of drainage, foul smelling drainage, or drainage that is yellow or green should be reported to your surgeon’s office immediately.
  • Staples, steri-strips, and stitches will be removed at your follow-up appointment.

Bracing

  • If you were given a brace, wear it at all times unless you are sleeping or showering.

When to call your doctor

  • Call if your temperature exceeds 101.5° F. Call if the incision begins to separate or show signs of infection, such as redness, swelling, pain, or drainage.
  • Swelling and tenderness in the calf or one leg.

New onset of tingling or numbness in the legs or numbness in the groin area.

Recovery and Prevention

Schedule a follow-up appointment with your surgeon for 2 to 4 weeks after surgery. Recovery to resume daily activities is usually 2 to 4 weeks. Several weeks later, X-rays may be taken to ensure the fusion is occurring. At your follow up, the surgeon will decide when you may return to work.

Pain recurrences are common. The key to avoiding recurrence is prevention by:

  • Proper lifting techniques
  • Good posture during sitting, standing, moving, and sleeping
  • Appropriate exercise program
  • An ergonomic work area
  • Healthy weight and lean body mass
  • A positive attitude and relaxation techniques
  • No smoking

What are the risks?

General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to LLIF spinal fusion may include [1]:

  • Thigh weakness and/or pain
  • Injury to abdominal organs
  • Nerve damage or persistent pain
  • Vertebrae fail to fuse
  • Hardware fracture – Metal screws and plates break before the bones are completely fused.
  • Bone graft migration and settling – in rare cases, the bone graft moves from its correct position.
  • Transitional syndrome – Fusion causes extra stress and load transferred to the discs and bones above or below the fusion segment. The added wear and tear can eventually degenerate the adjacent level and cause pain.

If you have questions or would like to schedule an appointment with one of our Spine Center specialists, please call 515.875.9560.

Sources:

  1. Bose B: Anterior cervical instrumentation enhances fusion rates in multilevel reconstruction in smokers. J Spinal Disord 14:3-9, 2001.