XLIF interbody cage reduces stress and strain of fixation in spinal reconstructive surgery in comparison with TLIF cage with bilateral or unilateral fixation: a computational analysis

In treating recalcitrant low back pain, extreme lateral lumbar interbody fusion (XLIF) with a large cage is reported to have better stability compared to approach of transforaminal lumbar interbody fusion (TLIF) using a small cage. In addition, bilateral pedicle screw fixation (PSF) in comparison with unilateral fixation achieved no inferior fusion rate, but with a significant reduction in operation time and blood loss. The aim of the study was to understand the mechanism underpinning the stability of lumbar interbody fusion using different cage sizes with unilateral or bilateral PSF. A computer model of human lumbar vertebrae L4 and L5 with implants was reconstructed based on CT scans and simulated in Ansys Workbench. Simulation results demonstrated that for either XLIF or TLIF cages, the maximum values of rod stress were comparable with bilateral and unilateral PSF. However, the stability was considerably reduced with unilateral PSF for TLIF due to significantly increased facet joint strain for TLIF; whereas for XLIF with left unilateral PSF, the max facet joint strain was comparable to bilateral PSF, possibly due to facet tropism of this specific subject.