I had a very long discussion today with a surgeon to get the pros and cons of XLIF. What a great lesson in why it's so difficult to know exactly what to do... who to go to... I had eluded to it above (before I got the private lesson today) when I said that more talented and experienced surgeons will minimize the risks.
I've seen this with many other surgeries. For example: some endoscopic techniques are difficult to learn. Some surgeons will never learn them because they require great dexterity and the ability to visualize 3D while looking at a monitor instead of looking directly at their hands, tools and surgical field. Some surgeons will try to adopt these techniques and fail. They may fail because they don't have the talent. They may fail because they don't have the stomach to get through their learning curve. They may fail because their practice won't support dozens of these types of surgeries each month... maybe you have to do a lot and continue to do a lot to be proficient. There are huge trade offs between less invasive surgery and learning to deal with being less able to visualize the field. Those who fail to adopt the technique successfully will blame it on the technique. Maybe it's good that they don't keep on with something they are not successful with. However, that does not mean that the technique is bad... it just means that it's not very good in the hands of someone without the great experience, and/or without the talent. It may be magic in the hands of someone who knows how to use it... knows how to avoid the pitfalls...
Apparently, XLIF is easier down the the lumbar spine where the discs are larger, access is easier and vascular structures can be more readily avoided. (Tim's correct that L5-S1 cannot be accessed via XLIF.) As you transition into the thoracic spine, the disc spaces are much smaller and there are vascular structures that can 'get you into trouble'. There are also trade-offs with how well you can see... how well you can manipulate the tools, etc.; through the minimal access that they are trying to achieve.
So, a well done ALPA or XLIF approaches done in the appropriate circumstances may a wonderful way to avoid the issues associated with the alternative, bigger surgeries. But, as the surgeon's field sorts itself out... who can do it... who can't... who knows when to say when... The patients will have to deal with risks of being on the learning curve, issues of informed consent, and all the other issues and risks we take as spine patients.
Interesting stuff. As we learn more, "It's getting curiouser and curiouser!"
All the best,
Mark
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