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Purpose: The LLIF procedure is a useful stand-alone and adjunct surgical approach for many spinal conditions. One complication of LLIF is subsidence of the interbody graft into the vertebral bodies, resulting in severe pain, impaired arthrodesis and potentially fracture of the body. Low bone density, as measured by T score on DEXA scanning, has also been postulated to increase the risk of subsidence., Methods: A retrospective review of prospectively collected data was performed on all patients who underwent LLIF at this institution consisting of 712 levels in 335 patients. Patients with subsidence following LLIF were recorded. We utilized the T score obtained from the femoral neck DEXA scans, which is used to determine overall fracture risk. The T score of patients with subsidence was compared to those without subsidence., Results: 20 of 57 (35 %) patients without subsidence had a DEXA T score between -1.0 and -2.4 consistent osteopenia, one patient (1.8 %) exhibited a T score less than -2.5, consistent with osteoporosis. 13 patients of 23 (57 %) with subsidence exhibited a T score between -1.0 and -2.4, consistent with osteopenia, five (22 %) exhibited a T score of -2.5 or less, consistent with osteoporosis. The mean DEXA T score in patients with subsidence was -1.65 (SD 1.04) compared to -0.45 (SD 0.97) in patients without subsidence (p < 0.01). The area under the receiver operating characteristic curve for patients with a T score of -1.0 or less was 80.1 %., Conclusions: Patients with DEXA T scores less than -1.0 who undergo stand-alone LLIF are at a much higher risk of developing graft subsidence. Further, they are at an increased risk of requiring additional surgery. In patients with poor bone quality, consideration could be made to supplement the LLIF cage with posterior instrumentation.

Purpose: Contemporary minimally invasive techniques have evolved to enable direct access to the anterior spinal column via the extreme lateral approach. We have employed this access approach to treat selected burst fractures. We report our technique. Thoracolumbar burst fractures that require surgical intervention have traditionally been managed with anterior, posterior, or combined approaches., Methods: We have applied the minimally invasive extreme lateral approach to perform vertebral corpectomy, cage placement, and lateral instrumentation to treat burst fractures. Indications for surgery were incomplete spinal cord injury with persistent neural element compression due to ventral fracture fragments in the canal. We present the technical nuances of this surgical approach for the treatment of thoracolumbar burst fractures with two case illustrations., Results: There were no peri- or intra-operative complications. Both patients in our series remained neurologically intact at their last follow-up (11 and 29 months, respectively), and maintained their correction of kyphosis., Conclusion: The minimally invasive extreme lateral approach is an effective treatment option for the management of thoracolumbar burst fractures.

Purpose: Available studies demonstrate vertebral body fractures as a relatively rare complication following lateral lumbar interbody fusion (LLIF), with most fractures reported in association with lateral plating and vertebral screws. This study reports the occurrence of two vertebral body fractures following stand-alone LLIF in 712 levels fused in 335 patients., Methods: A retrospective review of prospectively collected data was performed on all patients who underwent minimally invasive LLIF over a seven-year period at a single institution. Patients with vertebral body fractures were recorded., Results: Two patients (0.6 %) out of 335 total patients (712 levels) were identified with vertebral body fractures following stand-alone LLIF. Both patients presented with severe back pain and return of symptoms within 2 weeks of the index surgery. Both patients were obese, had impaired bone mineral density and were managed with open posterior segmental fixation., Conclusions: The 0.6 % incidence of vertebral body fractures in our series of fusing 712 levels is in accordance with the incidence rates reported in the literature. Potential risk factors for vertebral body fractures at the index LLIF level included obesity, osteopenia, unrecognized intraoperative endplate breach, graft subsidence and oversized graft placement.