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Original Article
Extreme lateral lumbar interbody fusion. Surgical technique, outcomes and complications after a minimum of 1 year follow-up
Artrodesis intersomática lumbar extralateral. Técnica quirúrgica, resultados y complicaciones con un seguimiento mínimo de un año
I. Domíngueza,
Corresponding author
ndominguez03@gmail.com

Corresponding author.
, R. Luquea, M. Noriegaa, J. Reya, J. Aliaa, F. Marco-Martínezb
a Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid, Spain
b Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid, Spain
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surgical techniques have been developed that aim to achieve at least the same clinical outcomes in terms of interbody fusion and symptom relief but with a lower rate of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> At present we have several approach routes which enable us to perform various anterior interbody fusion techniques&#58; the anterior approach &#40;ALIF&#41;&#44; transsacral approach &#40;AxialLIF&#41;&#44; posterior approach associated with pedicle screws &#40;PLIF&#41;&#44; transforaminal approach associated with pedicle screws &#40;TLIF&#41; and finally&#44; extreme lateral interbody fusion or direct transpsoas &#40;XLIF&#41;&#46; XLIF is anterior arthrodesis of the lumbar spine performed as a minimally invasive procedure&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The XLIF technique has a series of advantages over other minimally invasive techniques&#44; because the interbody implant enables us to correct deformity&#44; restore intervertebral disc height&#44; achieve interbody fusion of the operated segment and indirectly decompress the neurological elements&#46; Complications using the XLIF technique appear to be fewer than those reported after other surgical techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">A total of 97 patients were operated from May 2012 to May 2015&#44; and 138 segments were operated &#40;1&#46;4 per patient&#41;&#46; The maximum follow-up was 44 months and the minimum 12 months&#46; The mean age was 68 years &#40;41&#8211;86&#41;&#46; The most frequent cause for intervention was disease of the adjacent segment &#40;30&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; followed by deformity &#40;22&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and lumbar discopathy &#40;21&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The surgery was performed with the patient in the lateral position &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; on a radiotransparent table with a break at the lumbosacral area&#46; When the anatomy of the lumbosacral spine and pelvis allowed&#44; we positioned the patient with the painful side upwards&#44; i&#46;e&#46;&#44; the approach was via the side where the radicular symptoms presented&#46; With the help of the imaging intensifier on lateral view&#44; we marked a vertical line crossing the centre of the intervertebral disc to be operated and another horizontal line on the centre of the disc&#46; Another incision of about three or four cm was made through which up to three levels could be reached&#46; After the skin and the subcutaneous tissue&#44; the oblique abdominal muscle fascia was opened to the retroperitoneum&#46; Through blunt dissection&#44; the transverse process of the superior vertebra&#44; the psoas muscle and the intervertebral disc were palpated using a finger&#46; The guiding needle was placed in the appropriate position under radioscopic control and a first neurophysiological check made&#46; A working window was created through the psoas muscle using a series of dilators&#46; This gesture was performed under strict intraoperative neurophysiological control at all times&#46; The Ravine<span class="elsevierStyleSup">&#169;</span> &#40;K2M&#41; separator was used and introduced through the needle located in the intervertebral disc&#59; we then proceeded to open it&#46; The site for fixing the first valve to the vertebral body with a nail of the same length was located under radioscopic control&#46; The needle was removed from the intervertebral disc and the other valve opened and fixed to the other vertebral body&#46; After setting the light sources&#44; the anterior and&#47;or posterior valve was placed with special care&#44; under neurophysiological control at all times&#44; since the femoral nerve can be compressed causing it neuropraxia&#46; Once the intervertebral disc had been located it was opened with a scalpel and the discectomy performed&#46; The vertebral discs were then prepared down to subchondral bone and dilators introduced which gave us an idea of the size&#44; length and width of the implant&#46; Once the measurements had been decided a test cage was introduced and its placement and primary stability checked under radioscopic control&#46; The definitive implant is radiotransparent because it is polyetheretherketone and has markers to check its appropriate interbody placing&#46; It is inserted filling it with demineralised bone matrix to promote interbody fusion&#46; Practically all implant models have cages with heights from 8 to 14<span class="elsevierStyleHsp" style=""></span>mm in 2<span class="elsevierStyleHsp" style=""></span>mm increments&#44; lengths from 45 to 60<span class="elsevierStyleHsp" style=""></span>mm in 5<span class="elsevierStyleHsp" style=""></span>mm increments and widths of 18 and 22<span class="elsevierStyleHsp" style=""></span>mm&#46; The interbody fusion cage was placed stand-alone in 33&#37; of our patients&#59; additional fixation was used in the remainder&#46; This fixation was achieved with unilateral percutaneous screws &#40;11&#37;&#41;&#44; bilateral percutaneous screws &#40;27&#37;&#41; or with a lateral plate &#40;62&#37;&#41;&#44; depending on the patient&#39;s anatomy and pathology&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We perform the XLIF technique under constant neurophysiological monitoring which keeps us informed of the situation of the lumbar plexus at all times&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Thanks to the use of monitoring&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> the rate of complications after this surgical technique has drastically reduced making it an inestimably valuable tool for the spinal surgeon&#46; We use four intraoperative neurophysiological monitoring techniques&#58; transcranial motor evoked potentials &#40;TcMEP&#41;&#44; somatosensory motor evoked potentials &#40;SSEP&#41;&#44; free running-EMG and triggered-EMG&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A statistical study was performed of the progress of disc and foraminal height measurement before surgery&#44; during the immediate postoperative period and in the follow-up consultations&#46; To that end&#44; a comparative study was undertaken using SPSS 15&#46;0&#44; performing the <span class="elsevierStyleItalic">t</span>-test adjusted with the Bonferroni method for multiple comparisons&#44; paired calculation of the differences and creating a linear model for paired comparison of the measurements obtained in disc and foraminal height at the different times&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">Surgery time per segment was 35<span class="elsevierStyleHsp" style=""></span>min&#44; 57<span class="elsevierStyleHsp" style=""></span>min if additional fixation was performed&#46; With regard to postoperative analysis&#44; the mean hospital stay was 3&#46;2 days &#40;2&#8211;6&#41;&#44; estimated blood loss per segment was 40<span class="elsevierStyleHsp" style=""></span>ml&#46; On analysis of outcomes with regard to pain&#44; the higher the VAS score the greater the pain&#44; the preoperative lumbar visual analogue scale &#40;VAS&#41; score reduced from 9 to 4&#46;1&#44; in the postoperative period &#40;a 53&#37; reduction&#41;&#44; and to 3 &#40;a 66&#37; reduction&#41; at 1 year&#46; The VAS of the foot reduced from 9 in the preoperative period to 5&#46;2 in the postoperative period &#40;reduction of 42&#37;&#41; and remained stable at 1 year&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">From a radiological perspective&#44; an improvement in intervertebral disc height was observed from 8&#46;4<span class="elsevierStyleHsp" style=""></span>mm in the preoperative period&#44; to 13&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#44; which constituted a gain of 65&#37;&#44; and an increase in the major diameter of the foramen from 10&#46;5<span class="elsevierStyleHsp" style=""></span>mm to 13&#46;1<span class="elsevierStyleHsp" style=""></span>mm &#40;a gain of 24&#37;&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We differentiated complications into medical or surgical and then&#44; early or delayed and major or minor complications&#46; &#8220;Early complications&#8221; were defined as those that occurred in the first month and therefore could be directly associated with the surgical intervention&#46; We defined a &#8220;major complication&#8221; as any event that required reoperation and&#47;or in which there was motor neurological impairment that had reduced by at least one point from the previous examination &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">There were no deaths&#44; injuries to the dura mater&#44; no cerebrospinal fluid fistulae or psuedomeningoceles&#44; no periradicular fibroses&#44; no major vascular injuries&#44; no visceral injuries and no infection in our series&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The major surgical complications merit more detailed mention&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Motor injuries</span><p id="par0065" class="elsevierStylePara elsevierViewall">As mentioned earlier&#44; there were three motor injuries&#46; The three were on the contralateral side at level L4&#8211;L5 and affected the femoral nerve&#46; All three were detected by the neurophysiologist and all three fully recovered in less than 6 months&#46; We attribute these injuries to over distraction of the disc space when inserting the test cage &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Retroperitoneal haematoma</span><p id="par0070" class="elsevierStylePara elsevierViewall">This was a 76-year-old patient treated with anticoagulants for valvular heart disease&#46; Five days after the XLIF the patient started with sweats&#44; tachycardia&#44; decreased haematocrit levels&#46; A large retroperitoneal haematoma was observed from 5 points due to active bleeding &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#44; left&#41; &#40;treated by the vascular surgery department and the bleeding was controlled &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#44; right&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Abdominal hernia</span><p id="par0075" class="elsevierStylePara elsevierViewall">An obese 82-year-old woman presented a painful mass at the level of the surgical scar after a fall 7 months post intervention&#46; The symptoms resolved on placing a mesh at this level&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Radicular pain</span><p id="par0080" class="elsevierStylePara elsevierViewall">Three persistent radiculopathies after the operation were recorded&#44; radiculography was performed on all of them and infiltration of corticosteroids&#44; one of them clearly improved and therefore the procedure was repeated on two further occasions and the clinical symptoms resolved&#46; In the other two cases&#44; the radiculopathy had been caused by facet compression&#46; After imaging studies a posterior decompression was performed using a minimally invasive technique and the symptoms resolved&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Movement of the implant</span><p id="par0085" class="elsevierStylePara elsevierViewall">The implant moved more than 10<span class="elsevierStyleHsp" style=""></span>mm in a 75-year-old woman who had undergone a stand-alone procedure who&#44; after 2 asymptomatic months and after indirect trauma&#44; started to experience severe lumbar pain radiating to her lower left limb&#46; The imaging study showed movement greater than 10<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; The cage was changed via the same transpsoas route for another of a greater height &#40;12<span class="elsevierStyleHsp" style=""></span>mm rather than 10<span class="elsevierStyleHsp" style=""></span>mm&#41; and four percutaneous screws were placed at that level&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The total major complication was 9&#37; and minor complications 13&#37;&#46; The sum of all these complications gives us an incidence of 22&#37;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The incidence of pain&#44; discomfort&#44; paresthesia and symptoms to the proximal third of the thigh on the side of the approach route deserves separate mention&#46; There are many reports &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; of this circumstance&#46; These events presented in 30&#37; of cases in our series&#46; All of them resolved in less than 6 months&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The statistical study found statistically significant differences in the difference in disc and foraminal height&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The complete series comprised 138 implants using the clinical criteria used in most of the literature&#44; the preoperative period&#44; immediate postoperative period and at follow up at 6&#44; 12&#44; 18 and 24 months were considered the appropriate times for measuring the disc and foraminal heights&#46; The progress of both radiological parameters was similar&#44; both the discs and the foramens recorded a statistically significant increase&#46; The mean height of the discs was 7&#46;2<span class="elsevierStyleHsp" style=""></span>mm and after surgery it was 12&#46;58<span class="elsevierStyleHsp" style=""></span>mm&#44; therefore the improvement was 5&#46;44<span class="elsevierStyleHsp" style=""></span>mm &#40;75&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span> 0&#46;0001&#41;&#46; The foramens improved by 6&#46;74<span class="elsevierStyleHsp" style=""></span>mm &#40;63&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span> 0&#46;001&#41;&#44; since they went from 10&#46;6<span class="elsevierStyleHsp" style=""></span>mm to 17&#46;34<span class="elsevierStyleHsp" style=""></span>mm&#46; During the follow-up consultations statistically significant differences were recorded in the reduction in disc and foraminal height increase&#46; Both parameters decreased during the first 6 months&#44; the mean reduction was approximately 1<span class="elsevierStyleHsp" style=""></span>mm &#40;discs&#58; 0&#46;73<span class="elsevierStyleHsp" style=""></span>mm and foramens 1&#46;03<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; During subsequent follow-up &#40;at 12&#44; 18 and 24 months&#41; a reduction of less than 0&#46;5<span class="elsevierStyleHsp" style=""></span>mm was recorded &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">The XLIF technique is an anterior arthrodesis technique via a lateral transpsoas approach&#44; first described by Pimenta<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in 2001 reporting more than 100 transpsoas operations at that time since 1998&#46; Several authors have reported their results &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; since the publication of the surgical technique by Ozgur et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> until the present date&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">With regard to clinical results&#44; because this is a general review of patients with different disorders it is true that the final outcomes are difficult to evaluate&#46; We consider this review interesting because&#44; despite the persistent VAS score in the leg&#44; there was improvement of 42&#37;&#46; This appears to us a hopeful outcome&#44; despite the diversity of diseases&#44; because we believe that patients with a VAS score of 5 or less usually decide not to undergo an operation&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">With regard to the analysis of our major surgical complications&#44; it is worth mentioning that there are several authors that report motor injury in the side ipsilateral to the approach side&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;11</span></a> All due to retraction and&#47;or compression of the nerve in approaching the disc &#40;especially at level L4&#8211;L5&#41;&#46; However&#44; injuries occurring on the contralateral side appear less likely&#44; at least in theory&#46; Nevertheless&#44; Taher et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> report up to 3&#46;4&#37;&#59; they attribute these to over distraction&#44; or displacement of a disc fragment towards the foramen&#46; Although not common&#44; vascular injuries<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;19</span></a> can occur&#44; especially if there are large deformities in the spine&#46; Vascular complications after the transpsoas XLIF procedure are rare since the approach used means that the vessels are relatively distant from the approach route&#46; The abdominal hernia related to defective closure of the abdominal fascia and was associated with major obesity&#46; Injury to the ilioinguinal nerve when making the abdominal muscle incision can cause paralysis of the musculature at this level triggering bulging&#46; We had no case in the series presented&#46; There are few published articles that refer to complications&#46; Apart from the series by Rodgers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> reporting 2&#37; of total complications and the study by Tormenti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> with 150&#37;&#44; the remainder report complications<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;22&#8211;29</span></a> ranging around 25&#37;&#46; This is consistent with the abovementioned experience of HCSC&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">On analysis of the clinical&#8211;radiological outcomes&#44; the statistical study of the progress of the disc and foraminal heights shows that after surgery all levels operated gained in height enabling the indirect decompression of the posterior elements&#44; which is consistent with the literature and with the clinical outcomes obtained&#46; It is worth highlighting that considering movement of the implant as pseudoarthrosis&#44; the failure rate of the arthrodesis was 1&#37;&#44; this figure is similar to that of the most recent series published&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#8211;35</span></a> We found no references on this point&#46; We believe that the infradimension of the implant size in terms of both its height and its width plays a key role in the onset of this complication&#46; It is nonetheless remarkable that movement with clinical repercussions and six paucisymptomatic implant movements presented even when percutaneous screws via a posterior route were used&#46; It appears clear that the only situation where we found no movement was when we used a &#8220;mini-plate&#8221; via a lateral route&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">The XLIF procedure is an anterior arthrodesis technique via a lateral transpsoas approach&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">An approach surgeon is not needed for the procedure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Intraoperative neurophysiological monitoring is essential to reduce the rate of complications that derive from the approach route&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">Clinical improvement is important from a clinical and a radiological perspective&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">The rate of major complications is low compared to that of other lumbar arthrodesis procedures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">The major complications can be resolved relatively easily&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">The XLIF procedure constitutes a safe and reliable alternative when planning a minimally invasive lumbar arthrodesis&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Level of evidence</span><p id="par0170" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">II</span>&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ethical responsibilities</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Protection of people and animals</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that neither human nor animal testing have been carried out under this research</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data confidentiality</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with their work centre protocols for the publication of patient data&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Right to privacy and informed consent</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that no patients&#8217; data appear in this article&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#8220;Minimally invasive&#8221; techniques have been recently been developed in order to achieve good clinical results with a low incidence of complications&#46; The extralateral interbody fusion or direct transpsoas is a minimally invasive anterior arthrodesis&#46; A total of 97 patients with 138 segments received surgery between May 2012 and May 2015&#46; The follow-up was from 12 to 44 months&#46; The mean age was 68 years &#40;41&#8211;86&#41;&#46; The most common cause of intervention was the adjacent segment &#40;30&#37;&#41;&#44; deformity &#40;22&#37;&#41;&#44; and lumbar disc disease &#40;21&#37;&#41;&#46; The interbody cage was implanted as&#58; single &#40;stand-alone&#41; in 33&#37;&#44; and additional fixation was used in the others&#58; Screws&#44; percutaneous unilateral &#40;11&#37;&#41;&#44; bilateral &#40;27&#37;&#41;&#44; or with a lateral plate &#40;62&#37;&#41;&#46; The mean stay was 3&#46;2 days &#40;2&#8211;6&#41;&#46; The score on a lumbar visual analogue scale decreased from 9 to 4&#46;1&#44; and dropped to 3 after 1 year&#46; The improvement in disc height was from 8&#46;4<span class="elsevierStyleHsp" style=""></span>mm to 13&#46;8<span class="elsevierStyleHsp" style=""></span>mm&#44; and a larger increase in the foramen diameter from 10&#46;5 to 13&#46;1<span class="elsevierStyleHsp" style=""></span>mm&#44; which were statistically significant&#46; The early major complications recorded were&#44; three motor femoral nerve injuries and retroperitoneal haematoma &#40;4&#37;&#41;&#44; and the early minor were&#58; two fractures &#40;2&#37;&#41;&#46; As major late complications there was an abdominal hernia&#44; a mobilization of 10<span class="elsevierStyleHsp" style=""></span>mm and three radiculopathy &#40;5&#37;&#41;&#44; and as minor late&#44; three fracture&#44; two mobilisations greater than 10<span class="elsevierStyleHsp" style=""></span>mm&#44; four mobilisations of less than 10<span class="elsevierStyleHsp" style=""></span>mm&#44; and one mobilisation of a screw plate &#40;10&#37;&#41;&#46; The extralateral interbody fusion technique is a safe and reliable when performing a lumbar fusion by an alternative minimally invasive route&#46;</p></span>"
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      "es" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Durante los &#250;ltimos a&#241;os se han desarrollado t&#233;cnicas &#171;m&#237;nimamente invasivas&#187; de artrodesis que pretenden alcanzar los buenos resultados cl&#237;nicos con una baja incidencia de complicaciones&#46; La artrodesis intersom&#225;tica extralateral o directa transpsoas es una artrodesis anterior m&#237;nimamente invasiva&#46; Se han intervenido desde mayo de 2012 hasta mayo de 2015&#44; un total de 97 pacientes con 138 segmentos intervenidos&#46; El seguimiento fue de 44 a 12 meses&#46; La edad media fue de 68 a&#241;os &#40;41-86&#41;&#46; La causa m&#225;s frecuente de intervenci&#243;n fue el segmento adyacente &#40;30&#37;&#41;&#44; la deformidad &#40;22&#37;&#41; y la discopat&#237;a lumbar &#40;21&#37;&#41;&#46; La caja intersom&#225;tica se implant&#243;&#58; sola &#40;&#171;stand-alone&#187;&#41;&#44; en el 33&#37; y se utiliz&#243; fijaci&#243;n adicional en el resto&#58; tornillos percut&#225;neos unilaterales &#40;11&#37;&#41;&#44; bilaterales &#40;27&#37;&#41; o con placa lateral &#40;62&#37;&#41;&#46; La estancia media fue 3&#44;2 d&#237;as &#40;2-6&#41;&#46; La puntuaci&#243;n de la escala anal&#243;gica visual lumbar pas&#243; de 9 a 4&#44;1 bajando a 3 a partir del a&#241;o&#46; La mejor&#237;a de la altura del disco fue de 8&#44;4<span class="elsevierStyleHsp" style=""></span>mm a 13&#44;8<span class="elsevierStyleHsp" style=""></span>mm y un aumento del di&#225;metro mayor del foramen de 10&#44;5 a 13&#44;1&#46; Dichas diferencias son estad&#237;sticamente significativas&#46; Se registraron complicaciones precoces mayores&#58; tres lesiones motoras del nervio femoral y un hematoma retroperitoneal &#40;4&#37;&#41;&#59; y precoces menores&#58; dos fracturas&#47;hundimientos &#40;2&#37;&#41;&#46; Como tard&#237;as mayores&#58; una hernia abdominal&#44; una movilizaci&#243;n de 10<span class="elsevierStyleHsp" style=""></span>mm y tres radiculopat&#237;as &#40;5&#37;&#41;&#59; y como tard&#237;as menores&#58; tres fracturas&#47;hundimiento&#44; dos movilizaciones mayores de 10<span class="elsevierStyleHsp" style=""></span>mm&#44; cuatro movilizaciones menores de 10<span class="elsevierStyleHsp" style=""></span>mm y una movilizaci&#243;n de un tornillo de una placa &#40;10&#37;&#41;&#46; La t&#233;cnica artrodesis intersom&#225;tica extralateral constituye una alternativa segura y fiable a la hora de plantear una artrodesis lumbar por v&#237;a m&#237;nimamente invasiva&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Dom&#237;nguez I&#44; Luque R&#44; Noriega M&#44; Rey J&#44; Alia J&#44; Marco-Mart&#237;nez F&#46; Artrodesis intersom&#225;tica lumbar extralateral&#46; T&#233;cnica quir&#250;rgica&#44; resultados y complicaciones con un seguimiento m&#237;nimo de un a&#241;o&#46; Rev Esp Cir Ortop Traumatol&#46; 2017&#59;61&#58;8&#8211;18&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Most common reason for intervention&#58; disease of the adjacent segment &#40;30&#37;&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Second and third most common reasons for intervention&#58; deformity &#40;22&#37;&#41; and lumbar discopathy &#40;21&#37;&#41;&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Surgery undertaken with the patient in a lateral position&#44; on a radiotransparent with a break at the lumbosacral area&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Over distraction of the disc space on inserting the test cage&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Imaging study showing movement greater than 10<span class="elsevierStyleHsp" style=""></span>mm&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Major early surgical &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Minor early surgical &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Major late surgical &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Minor late surgical &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Major early medical &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Minor early medical &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Three motor injuries to the femoral nerve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Two fractures&#47;depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">One abdominal hernia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Three fractures&#47;depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paralytic ileus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">One retroperitoneal haematoma</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Three radiculopathies&#46; One movement of the cage greater than 10<span class="elsevierStyleHsp" style=""></span>mm</td><td class="td" title="table-entry  " align="left" valign="top">Two movements greater than 10<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Four movements less than 10<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">One movement of a plate screw&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="6" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Comparison of disc height measurements pre-Sx with progress</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Standard deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lower&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Higher&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sign&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 1 Disc&#46; Pre-disc&#46; Post Sx&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;440&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;738&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;5&#46;908&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;4&#46;972&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 2 Disc&#46; Post Sx&#8211;Disc-Post&#95;6m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;739&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;527&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;950&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 3 Disc&#46; Pos&#95;6&#8211;Disc&#46; Post&#95;12m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;350&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;730&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;205&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;495&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 4 Disc&#46; Post&#95;12&#8211;Disc post&#95;18m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;394&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#44;782&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;202&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;586&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top" style="border-bottom: 2px solid black">Pair 5 Disc&#46; Post&#95;18&#8211;Disc Post&#95;24m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">0&#46;438&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">0&#46;619&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">0&#46;214&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">0&#46;661&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top" style="border-bottom: 2px solid black">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="6" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Comparison of largest foraminal diameter height measurements pre Sx with progress</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lower&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Higher&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sign&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 1 Foramen&#46; Preforamen&#46; Post Sx&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;6&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;157&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;7&#46;449&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;6&#46;029&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 2 Foramen&#46; Post&#46;QX&#8211;Foramen-Post&#95;6m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;030&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;687&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;373&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 3 Foramen&#46; Post&#95;6&#8211;Foramen&#46; Post&#95;12m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;470&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;915&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;288&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;652&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 4 Foramen&#46; Post&#95;12&#8211;Foramen&#46; Post&#95;18m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;364&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;797&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;168&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;560&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pair 5 Foramen&#46; Post&#95;18&#8211;Foramen&#46; Post&#95;24m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;336&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;246&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;044&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">During subsequent follow-up &#40;at 12&#44; 18 and 24 months&#41; a reduction of less than 0&#46;5<span class="elsevierStyleHsp" style=""></span>mm was recorded&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Series&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Conclusions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rodgers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Degenerative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A safe technique&#44; with a really low rate of complications &#40;2&#37;&#41; and significant clinical improvement on the VAS scale &#40;68&#37; improvement&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anand et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Deformity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Minimally invasive procedures &#40;XLIF&#41; less blood loss and greater pain improvement compared to conventional techniques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Knight et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Degenerative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rate of complications of 22&#46;4&#37; half of which were associated with the approach route&#46;<br>They describe 3&#46;4&#37; motor neurological injury with improvement at 1 year and other &#8220;major&#8221; complications&#46; They indicate that mortality using the extreme lateral technique was less than that of other traditional techniques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rodgers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adjacent segment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Report excellent results with a complications rate of 9&#37; and only 1&#37; symptoms related to dysesthesia and weakness at the level of the upper third of the thigh ipsilateral to the approach side&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oliveira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Stand- alone XLIF using BMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low rate of complications &#40;6&#46;7&#37;&#41;<br>100&#37; fusion demonstrated by CAT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rodgers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">300 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">XLIF obese and non-obese&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">They did not find significant differences between the two groups and concluded that patient satisfaction exceeded 89&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ozgur et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62 patients&#44; 113 segments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Degenerative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#37; minor complications and none considered major&#46;<br>Fusion was achieved in 91&#37; of cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oliveira et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Degenerative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highlight the indirect decompression of the neurological elements&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anand et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Degenerative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All the patients maintained the correction with 57&#37; improvement on the VAS scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dakwar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adult deformity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Both the surgery time &#40;a mean of 108<span class="elsevierStyleHsp" style=""></span>min&#41; estimated blood loss per patient &#40;53<span class="elsevierStyleHsp" style=""></span>ml&#41; were extremely low&#44; with a 20&#37; rate of minor complications and major complications of 4&#37; and a reduction in the VAS score of 70&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wang and Mummaneni<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adult deformity using XLIF bilateral percutaneous screws and BMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The incidence of problems in the anterior face of the thigh ipsilateral to the XLIF surgery was 30&#37; and the fusion rate confirmed by CAT was 100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tormenti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adult scoliosis XLIF with posterior percutaneous screws compared to subsequent techniques alone &#40;PLIF or TLIF&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Confirming a much greater correction capacity with the XLIF procedure &#40;70&#46;2&#37; compared to 44&#46;7&#37;&#41;&#46;<br>However the high rate of complications is noteworthy&#58; 75&#37; of the patients experienced symptoms in the proximal third of the thigh and 25&#37; presented motor injuries&#46; They also reported the onset of other major complications such as&#58; intestinal perforation&#44; pleural effusion&#44; paralytic ileus and pulmonary thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rodgers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">600 patients&#44; 741 levels operated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Degenerative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The reported rate of complications was 6&#46;2&#37;&#46; The low rate of neurological complications &#40;0&#46;7&#37;&#41; is worthy of note&#44; all of which were transient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sharma et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Degenerative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Concluding that after 1 year follow-up a gain of 3&#46;7&#176; on the coronal plane and 2&#46;8&#176; on the sagittal plane per segment operated with 25&#37; of symptoms in the proximal third of the thigh&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Uribe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Experimental&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Achieving good correction of the deformity exposing the necessity to use more aggressive procedures such as Smith Petersen and&#47;or pedicle subtraction osteotomy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pimenta et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prospective and randomised prospective study stand-alone XLIF with tricalcium phosphate compared with BMP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fusion was achieved in both groups with only one case where the bone formation in the BMP group made reoperation necessary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meredith et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 patients and 32 levels operated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">XLIF in the thoracic and thoracolumbar area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#37; fusions&#46;<br>The authors agree that at this level this procedure offers two very significant advantages&#58; an approach surgeon is not necessary for the operation neither is selective pulmonary intubation to enable access to the disc space&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Malham et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">XLIF prospective&#44; non-randomised study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Significant improvement in intervertebral disc height with a 100&#37; fusion rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Several authors have reported their results &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; since the publication of the surgical technique by Ozgur to the present date&#46;</p>"
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Article information
ISSN: 19888856
Original language: English
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