Extreme Lateral Interbody Fusion (XLIF) Surgery and Alternatives

Extreme lateral interbody fusion, or XLIF, is an approach to lumbar spinal fusion surgery. Unlike traditional spinal fusion, which involves a large incision and requires slicing through the back muscles, the XLIF procedure is minimally-invasive. 

In XLIF, no spinal bones or ligaments need to be extracted. This makes it possible to place a spinal implant without affecting the spinal cord. 

What is XLIF Surgery Used For?

XLIF surgery is used to relieve symptoms of lumbar spine conditions. Conditions that are traditionally treated with spinal fusion can often be successfully treated with XLIF. 

Examples of conditions that can be treated with XLIF include:

  • Spondylolisthesis

Spondylolisthesis occurs when a vertebra slips out of position and lands on the vertebra below it. This condition tends to occur with spinal instability and can lead to pain in the lower back and leg. Muscle spasms, stiffness, numbness, and tingling are other common symptoms of spondylolisthesis. 

  • Spinal stenosis 

Spinal stenosis is a condition involving abnormally narrow spaces in the spine. Without enough room in the spinal canal, pressure can be placed on nearby nerves. When these nerves are irritated, it can lead to muscle weakness, tingling, and pain. 

  • Slipped disc in the lumbar spine

Also referred to as a bulging or herniated disc, a slipped disc occurs when one of the discs located between each vertebra in the spine becomes damaged. Specifically, this condition involves a crack in the exterior of the disc, through which the jelly-like interior can protrude.

A slipped disc can press on spinal nerves, leading to pain, tingling, numbness, and weakness. Some patients experience no symptoms from a slipped disc. In these cases, the disc may be identified in an image of the spine taken for a different purpose. 

  • Degenerative disc disease

Degenerative disc disease occurs as a result of wear and tear on the discs in between the spinal bones. As people age, the spinal discs gradually break down, dry out, and become weaker. This can cause increased pressure on the vertebrae and irritated spinal nerves. 

While degenerative disc disease alone may not require surgery, it can lead to debilitating conditions including spinal stenosis, spondylolisthesis, and osteoarthritis.

The Benefits of XLIF Surgery

In comparison to traditional surgeries for lumbar spine disorders, XLIF surgery provides a variety of benefits, including:

  • Reduced pain and blood loss

Since XLIF is considered a minimally-invasive surgery, it causes less trauma to the tissues and reduces blood loss. By avoiding trauma to the ligaments, muscles, or bones in the back, this procedure also leads to less pain during the recovery process. 

  • Shortened time in surgery and at the hospital 

XLIF surgery can often be completed in 60 minutes, which reduces the amount of time that the patient spends under anesthesia. Additionally, many patients can leave the hospital on the same day as XLIF surgery.

  • Faster recovery

After XLIF surgery, patients generally have a recovery period that lasts for a few months. This is in contrast to conventional spinal procedures, which often require six months or longer for recovery. 

  • Walk on the same day as surgery

XLIF is often an outpatient procedure. This means that most patients can get back on their feet and walk on the same day as the procedure. Conventional spinal surgery commonly requires patients to stay in the hospital for one or multiple days after the procedure. 

The Steps of XLIF Surgery

Patients are put under general anesthesia before XLIF surgery. Additionally, throughout the procedure, your surgeon will use electromyography (EMG) to receive information on the position of nearby nerves. This is a precaution to avoid nerve damage. 

Preliminary X-Rays

XLIF surgery begins with the patient lying on one side of the body. With the patient in this position, the surgeon can perform x-rays to pinpoint and mark on the skin the location of the spinal disc that needs to be removed. 

Incision in The Flank

With the location of the disc marked, the surgeon can create an incision in the patient’s flank, which is the area on the back and sides of the abdomen. 

Reposition The Peritoneum

After the incision is made, the surgeon can shift the peritoneum away from the abdominal wall using a finger. The peritoneum serves as the lining for the abdominal wall and encloses the organs in the abdomen.  

Second Incision and Dilator Placement

Next, the surgeon creates another incision on the patient’s side and places a dilator into it. Using an x-ray, the surgeon will check the position of the dilator, ensuring that it’s right above the spinal disc. 

Establishing Access to The Spine

A probe can then be used to separate the psoas muscle and a retractor can be positioned to establish entry to the spine. 


Once the surgeon has access to the spine, they can remove the interior (also called the nucleus) of the damaged disc. This process is known as discectomy and gets the surrounding vertebrae ready for spinal fusion. 

Spacer Placement 

Next, a spacer containing a bone graft is inserted into the area that was previously occupied by the disc nucleus. The spacer keeps the vertebrae aligned and works with the bone graft to stimulate fusion. The surgeon will check the position of the spacer using an x-ray. 

Posterior Fixation

The surgeon may also choose to perform posterior fixation involving facet screws or pedicle screws. Posterior fixation can help the patient maintain spinal alignment and stability after the procedure.  

The XLIF surgery process can vary somewhat depending on the patient’s unique needs. Before the procedure, your surgeon can provide the details of the procedure for your circumstances. 

Alternatives to XLIF

Non-Surgical Treatments

Lumbar spine conditions are usually first treated with non-surgical methods before surgery is considered. The most common non-invasive treatment approaches for spinal conditions include rest, lifestyle changes, medications, injections, and physical therapy. 

  • Rest

Rest can prevent strain on the lumbar spine to relieve inflammation and pain. Your doctor may recommend that you rest for days or weeks, depending on the severity of your condition. While you’re resting, make sure to avoid motions that put pressure on the spine, including lifting, bending, and poor posture. 

  • Lifestyle changes

Smoking, a sedentary lifestyle, and being overweight are examples of lifestyle factors that can contribute to spinal conditions. Your physician may work with you to develop a healthier lifestyle for relief from pain and stiffness in the spine.

If you have an occupation that involves repetitive motions that strain the spine, your physician may recommend that you take more frequent breaks at work. 

  • Medications

Anti-inflammatory medications, such as NSAIDs, acetaminophen, and muscle relaxants may help treat lumbar spine pain. Make sure to consult with your doctor before taking medications to prevent side effects and complications. 

  • Injections

Epidural steroid injections can prevent the transmission of pain signals from inflamed spinal nerves. While it’s important not to exceed three to six steroid injections per year, this non-surgical treatment option may help you achieve relief from spinal pain. 

  • Physical therapy 

Physical therapy can support your recovery from a spinal condition by improving your posture, enhancing the strength of muscles that support the spine, and devising a personalized exercise program. Other therapeutic methods, including massage and heat/cold therapy, may be provided during physical therapy. 

  • Alternative therapies

For some patients, alternative therapies including acupuncture and chiropractic care can provide relief from spinal symptoms. These methods can release tension and improve spinal alignment. 


ALIF stands for anterior interbody fusion. It’s a surgical method of spinal fusion during which the spine is accessed from the front of the body.

By reaching the spine from the front of the body, the surgeon must move aside large blood vessels and abdominal organs. This is in contrast to XLIF, which doesn’t require moving blood vessels or vital organs because the spine is accessed from the patient’s side. With this in mind, XLIF is generally considered to be a lower-risk procedure with the same result. 


PLIF stands for posterior interbody fusion. This approach to spinal fusion involves accessing the spine from the patient’s back. In order to do so, the surgeon must cut large muscles in the back, leading to an extensive recovery process and postoperative pain. 

Similar to ALIF, PLIF is considered to present a higher risk of complications than XLIF and involves a longer recovery period.  

TOPS Spinal Surgery

Although it’s less invasive than either ALIF or PLIF, XLIF is still a method of spinal fusion. So, it comes along with the downsides of spinal fusion, including a reduced range of motion in the spine and a significant recovery process. 

Spinal implants like the TOPS System provide an alternative to fusion in spinal surgery. Unlike fusion, the TOPS device allows patients to retain their full range of motion right after the procedure. Additionally, by opting for an implant, patients can enjoy a quicker recovery period after surgery.

The TOPS spinal implant can help you avoid a lengthy recovery process and stiffness from spinal fusion. To learn more about this treatment option, contact Premia Spine.