Dott. Nicola Zullo

UF Neurochirurgia Clinica Eporediese Policlinico di Monza

SS Neurochirurgia Ospedale U. Parini di Aosta

Responsabile: dott. C. Musso

XLIF IN THE TREATMENT OF DDD

Intervertebral disc strucutre

• Central nucleus poloposus: proteoglycan + water• Peripheral anulus fibrosus: concentric rings of

collagenous lamellae intermingled with fibrous fibers• Avascular and aneural structure• Nutrients mainly diffuse through vertebral endplate

Intervertebral disc degeneration

• Losening of water content in the central NP, progressive increase in fibrous fibers

• Cracking of the peripheral anulus fibrosus (anular tears), Nitrogen incoming, nucleus polposus expansion

• Areas of air density within the disc: due to nitrogen incoming, are signs of advanced degeneration

• Possible outward extension of the nucleus polposus through anular tears: disc disruption

• Height reduction• Nerve and vascular ingrowth: discogenic back pain• Discal degeneration leads to osseus degeneration

Osseus degeneration

Progressive disc degeneration: loss of disc height and inflammatory mediators formationEndplates closer to one anotherEndplates fissuring and disruptionFormation of fibrovascular granulation tissue, vascular density and sensory nerve fibers increase Facet joint hypertrophy and cartilage lossAbnormal movement of the spinal funcional unitOsteophytes formation with central canal and neuroforamina narrowingLigamentum flavum hypertrophy

DDD:radiological calssification

DDD:MRI changes of endplates (Modic)

• Modic1: hyperintense in T2, hypointense in T1 w. Images; water content increase, inflammatory response

• Modic 2: hyperintense in T1 and T2 w. Images; conversion of BM to adipose tissue due to BM ischemia

• Modic 3: hypointense in T1 and T2 w. Images; subcondral bone sclerosis

XLIF: CASES COLLECTION• 21 patients treated with Xlif in one year• Diagnosis: 19 DDD and 2 degenerative scoliosis• Pre-operative clinical evaluation, ODI, VAS back and VAS leg administration• Follow up criteria: diagnosis of DDD, clinical evaluation at 1 month post-op,

ODI, VAS back and VAS leg at three and six month post-op., X-ray films in a-p and l-l at three month post-op.

• 15 patients matched the FU criteria and were enrolled in the study (8 males, 7 females).

XLIF: CASES COLLECTION

11

1

1 2

Construct

Xlif stand aloneXlif + LPXlif + bilateral PSFXlif + ILIF

XLIF: CLINICAL SYMPTOMS

15

5

Clinical symptoms

LBP

Radicular symptoms

XLIF: CLINICAL SYMPTOMS

ODI Vas Back Vas Leg0

2

4

6

8

10

12

14

16

18

20

pre36

XLIF: complications• Ipsilateral transitorial muscular strength reduction: 6• No major nerve injury, no wound infection, no spondylitis• Numbness of the ipsilateral lower limb: 7 cases• Numbness of controlateral lower limb: 2 cases • Transitorial ipsilateral lower limb vasodilatation• Implant disruption: 4 cases (3 8mm cages, 1 10 mm cage)• Subsidence: 3 cases (1 patient worsened, two improved)

Remember the trajectory during the cotrolateral anulus fibrosus realease manoeuvre

XLIF: complications

• Overall complication rate: form 2 to 30,4%• Minor complications: about 20%• Major complications: about 8.6%• Most frequent complications: thigh symptoms from 0.7 to

60.1%

XLIF: INDICATIONS

• DDD with disc bulging causing lumbar pain and/or raduclopaty• After microsurgical erniectomy for recurrent disc erniation• Alternative to PLIF:: prevention of muscular injury and denervation• Alternative to TLIF: ligament sparing• Alternative to ALIF: large surface and bone graft volume, with ALL

integrity, reduced risk of vascular injury• Spondylolistesis less than grade 2.

Minimal access surgery: decrease blood loss, shorter operative time, reduce post-op. pian, shorter recovery, rapid mobiization. low major complication rate

Stand alone XLIF