ALPA Approach or XLIF?

[mmglobal]

I had a wonderful surprise yesterday. I got a message from Dr. Bertagnoli saying that he was going to be a LAX for a 5 hour layover on his way back from the MIIST conference in Hawaii. 4 hours of his undivided attention is tough to come by... there was no problem canceling other plans (was going to see David Beckham play for LA Galaxy... 5 goal game... would have been fun, but this was better!) So instead of Dr. Bertagnoli sitting in the airport for 5 hours, I picked him up and we had a wonderful afternoon and evening. (Manhattan Beach is great!)

This post comes along with all the standard "I'm not a doctor" disclaimers. I'm just posting my layperson's recollection of our conversations. Take everything I say with a grain of salt.

Unfortunately, several of my clients are dealing with ADR revisions. I asked him a question about the XLIF approach. He corrected me... XLIF is not an approach, it's the name of some devices and is frequently used in describing systems that support the ALPA (AnteroLateral transPsoas) Approach. I didn't realize it when we were speaking, but I've seen him do it. It was truly one of the most amazing surgeries I've seen... not because of the lateral approach step, but this was a very extreme case. The ALPA approach seemed so easy, it was a very small part of this procedure. Even so... I think you'll find Ken's story is VERY interesting.

Today, I've been looking around for info on ALPA and XLIF. Both are written up in a new book that I bought at SAS last month. (Motion Preservation Surgery of the Spine, Yue, Bertagnoli, McAfee, An) This book is amazing and seems to have everything in new spine tecnologies... very well presented. Both ALPA and XLIF are written up. Bertagnoli Pioneered ALPA back in the late 90's as a minimally invasive approach for prosthetic disc nucleus implantation. It turns out that the term XLIF is frequently used to refer to the approach in addition to the hardware. In any case... ALPA, XLIF look like excellent alternatives for procedures that can be performed from these minimally invasive lateral approaches.

Whenever Dr. Bertagnoli and I get together, there is never time to just relax... we played dueling laptops as I showed him a few of the extreme clients I'm working with. It never ceases to amaze me when I will show a case to 5 different surgeons (not just a quick look... often very extensive discussions... ordering more tests... more discussions), then... showing the same case again to the same surgeons, or to a new surgeon, something JUMPS out... significant findings. That happened yesterday for a couple of clients... Dr. Bertagnoli made some incredible finds.

[JeffreyD]

I just read Ken's story...That is really something. I've been studying this stuff for many years now, and am not usually surprised, but this entire surgical plan of attack and apparent solution is an eye opener!
I have been struggling for the last 1-1/2 years with intense pain and worsening problems in my low back. I have 3 artificial discs in my lumbar spine (and 2 in my cervical spine; those are great!), and my top-most lumbar Charite (L-3/4) is rotated and tilted.
My functionality is still better than before the ADR surgery, but the back and leg pain has become a nightmare. I work 40 hours per week as a graphic designer (praise God!!!), but the rest of the time, I'm pretty much laying on the floor or in bed.
Revision surgery may possibly be for me at some point in the future, so this intrigues me very much, as it may have some application to my problems.
Thanks Mark, for bringing this to light. I hope Ken continues to improve!
God Bless,
Jeff

[B13s]

Originally Posted by mmglobal

Unfortunately, several of my clients are dealing with ADR revisions.

It would be interesting to know how many % this is from all your clients. I hope it's not the usual 99% success rate you get from surgeons...

[mmglobal]

B13, that number might be interesting, but it would not be meaningful. These forums, like my client base have artificially inflated numbers of failures. A highly successful patient does not seek me out to tell me that they are doing wonderfully. The successful patients are not spending their days on the internet posting their woes.

I'm reviving the paremeterized surgical outcomes thread that I started 5 years ago and that will produce some interesting data. Even with that, the data should not be used for decision making process unless there is a way to 'grade' the patients. If a surgeon is unwilling to take a difficult patient and only 'cherry picks' his results will appear better. The surgeon who is willing to take the 'basket cases' may have results that don't look as good, but are actually far better in many ways.

Mark

[Tim]

Hi all
Remember the ALPA/XLIF approach is not applicable to the L5/S1 level. I assume revision at this level either involves a risky 2nd anterior approach to remove the offending ADR or a posterior gutter fusion with rods and screws leaving the ADR in place.
The XLIF is an exciting innovation either for straight fusion or ADR revision - unfortunately as it's pretty new there seems to be a shortage of real life cases on the web to read about. Hopefully over the next year we'll start to see some cases filtering through and then we'll get a real idea of how much of a step forward this really is.
If you visit the Nuvasive site or any of the sites provided by clinics using the XLIF you get the real impression this surgery is a walk in the park..
Here in the UK there are currently only 2 doctors who are trained in this procedure (although more are signed up to go over to the states for training in the near future). The doc I saw recently had at that time only done 1 procedure and I don't fancy being part of his learning curve. There seem to be far more surgeons in the US who are well practiced in this procedure.
Jeff I'm so sorry to hear of your ongoing problems. Have you talked to Dr Zeegers or any other surgeons to discuss your options?
Tim

[johnb]

I believe Job13 had this procedure done to remove her prodisc. Her experience is detailed in her thread. I also understand that there in a nerve that runs through the psoas and damage to that nerve is a potential complication during the procedure though it seems this literature points to a small chance percentage. http://www.spineuniverse.com/display...ticle4227.html

Johnb

[mmglobal]

Thanks John... great article.

At SAS in Miami last month, Diane and I attended the XLIF breakout session... 2 hours including unlimited Q&A... it was excellent. There was some discussion about how to minimize the risks of this complication. More talented and experienced surgeons will be able to reduce these risks.

Mark

[mmglobal]

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

[Tim]

Hi all

Here are some intresting links regarding XLIF - if they've been posted before then apologies..

1. Recorded movie of live XLIF procedure at or.com :
http://www.or-live.com/tgh/2330/#

2. Experience and Early Results with a Minimally Invasive Technique for Anterior Column Support Through eXtreme Lateral Interbody Fusion (XLIF®):
http://www.touchbriefings.com/pdf/2814/rodgers.pdf

3. Charité lumbar artificial disc retrieval: use of a lateral minimally invasive technique:
http://thejns.org/doi/pdf/10.3171/spi.2006.5.6.556

OK - so if outcome success is largely dictated by surgeon experience how many procedures is enough to become proficient and who are the surgeons who are good at this now?

All the best
Tim

[ans]

Thank you for this information! - Allan

[Roblin]

Great information! Who is the most experienced surgeon in the States and the world at removing ProDisc L4/5 with this method?
Roblin

[mmglobal]

Roblin,

I may very well be wrong about this, but my impression is that we'd be talking about numbers that could be counted on a finger or two.

I believe that if you are talking a 2-level revision, it would be a moot point. They can't do L5-S1 with a lateral approach. The XLIF approach includes an osteomoty to remove the bone on one side of the keel. That may be easier to do with anterior approach, eliminating the need for lateral approach. Another advantage of already being there for anterior approach is that it may be possible to safely expose L4-5 enough so that the prosthesis may be removed without osteotomy.

Obviously, this comes with all the "I'm not a doctor" disclaimers... this is just my 'laypersons' understanding based on my experiences.

Mark

[B13s]

Originally Posted by mmglobal

B13, that number might be interesting, but it would not be meaningful. These forums, like my client base have artificially inflated numbers of failures. A highly successful patient does not seek me out to tell me that they are doing wonderfully. The successful patients are not spending their days on the internet posting their woes.

I'm reviving the paremeterized surgical outcomes thread that I started 5 years ago and that will produce some interesting data. Even with that, the data should not be used for decision making process unless there is a way to 'grade' the patients. If a surgeon is unwilling to take a difficult patient and only 'cherry picks' his results will appear better. The surgeon who is willing to take the 'basket cases' may have results that don't look as good, but are actually far better in many ways.

Mark

What I mean how many of out your clients that had ADR's with you need revision, not counting the ones that contacted you just because of the revision having their ADR's implanted before.

[mmglobal]

That is a great question and will require some research. Off the top of my head, Off the opt of my head, I know 2 people who were my clients before their ADR surgery who had revisions. There may be more, but I'll have to look. My guess is that I know approximately 20 revision patients. Most would not have required revision had they done something different (gone to more careful/experienced surgeon.)

Give me some time to do research... if I haven't updated this in a couple of weeks... hunt me down.

[mmglobal]

I had breakfast yesterday with an XLIF surgeon from Los Angeles; Larry Khoo, co-director of spine at UCLA. One of the things we discussed was XLIF. Very interesting contrasts... he describes XLIF as "mini-ALPA" The instrumentation that Nuvasive has developed allow even smaller access.

I like Dr. Khoo. He got on my radar at SAS with excellent presentations about several minimally invasive procedures that have nothing to do with ADR. Also, I was researching a very complex FBSS case that includes AXIALIF and he came highly recommended. He's pretty amazing. I'm looking forward to spending more time with him.

All the best,

Mark

Mark