Another study [21] noted two L4 nerve root injuries (3.4%) in a series of 58 lateral fusion cases (and a 22.4% complication rate). This paper reported cases using both XLIF selleck chem inhibitor and direct lateral interbody fusion (DLIF) without delineating the number of each type of procedure or distinguishing the complications by procedure. Since the recommended technique is somewhat different in the two procedures and the duration of hospitalization was so prolonged (XLIF: 6 days; DLIF: 4 days), one might argue that this study was a learning curve comparison and should not be cited as definitive. In the largest published series to date, 600 patients treated with XLIF experienced a length of hospitalization averaging 1.21 days and a 6.2% complication rate (rate of transient motor deficit��0.7%) [18].
Nonetheless, neurologic deficits associated with lateral approaches are an area of great discussion. As has been documented anatomically and radiographically, the lumbar plexus migrates ventrally as one descends caudally from L2-3 to L4-5 [8, 22�C27]. This places the plexus at greatest risk in a transpsoas approach at the L4-5 level. In addition, anterolisthesis of the superior vertebral body carries the plexus even more ventral, heightening safety concerns. However, as shown by our data, in the presence of real-time neurologic monitoring and with attention to the details of the technique mentioned above, grade 2 listhetic segments, especially at L4-5, can be treated successfully without neurologic injury. The importance of monitoring and technique cannot be overemphasized.
Clinically, surgery for spondylolisthesis has been shown to yield better patient outcomes than nonoperative treatment in large randomized trials [2�C4]. Multiple techniques have been employed��decompression alone, [32] PLF, [6] instrumented PLF [33] PLIF [34], ALIF [35], Dacomitinib TLIF [9], as well as MIS ALIF [10], or MIS TLIF [19] procedures��without a clear consensus emerging [5]. In addition to clinical effectiveness, recent results of a randomized controlled trial have shown that instrumented fusion for the treatment of degenerative spondylolisthesis is substantially cost effective compared to conservative care [32]. This study noted a quality-adjusted life-year (QALY) gain of 0.39 in the fusion cohort at a cost of $54,500 (down from 0.23 QALY and $115,600 cost per QALY gained at two years postoperative) per QALY gained.