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360 XLIF?? Can anyone help?

texastigerttexastiger Posts: 48
edited 06/11/2012 - 8:43 AM in Back Surgery and Neck Surgery
I see my neurosurgeon on Wednesday for my last appt before surgery. He will be fixing a spinal deformity that has caused stenosis, herniated disk and scoliosis. As for now, I am scheduled for a 360 XLIF where he will remove hardware at L4/L5-S1 that has been there for 19 years. He will then add rods from S1 to L3. Of course, remove bad disc at L3/L4 and clean it up and add plastic disc.

My question for anyone is--what do I need to ask? I have the 39 questions from the site, but I want to know everything.

If you have had experience with this type of surgery or have researched this, please give me any and all advice. I haven't seen much info on 360 XLIFs.

Thanks and Happy Easter!


  • I guess the first thing I want to mention is that in different parts of the country, procedures have slightly different names...so what I am about to say may be totally incorrect.

    The XLIF procedure is a new way of performing ALIF except for the way the spine is accessed. It is done "minimally invasively" going in from the side. In order to make it a 360, I would assume the surgeon will then also do PLIF...but, perhaps that is not the case.

    To me 360 means going in from the anterior side of the spine, and then going in from the posterior side. But a friend had surgery in England. It was called a 360 PLIF, and the surgeon just went in from the back...so I guess "360" must have more than one meaning.

    I would want to know exactly what the surgeon has planned: where will the incision be? Will there be more than one incision? Will it be an open surgery or minimally invasive?

    Frankly I would think at least part of your surgery would have to be open. I don't see how they could remove the old hardware, for one. Also, when so many levels are being done, they need to "see" more of where they are going. And, with stenosis, I would think they would need to be able to work on a wider area than MIS would allow.

    But as I already said, I am not a doctor and obviously don't know all the tricks of the trade.

    Have you had surgery with this NS previously?
  • Thank you so much for your response--I respect your opinion so much!!

    I have not had surgery with this NS before. I was sent to him by my previous NS who I have been with for years and felt like family with them. They decided I needed someone who specializes in deformities of the spine. I have sought second opinions as recent as this past wed and he said there was no way getting around the open surgery.

    Originally, my NS said he would do an ALIF/PLIF then decided to do an XLIF where he would go through the side and remove old disc and insert plastic disc that has bone grownth stimulator in it. Then turn over and do PLIF and remove old hardware and insert new longer rods and screws.

    I am in the DFW area and the new NS is board certified, fellowship trained and currently is at a teaching university and specializes in deformities of the spine.

    He said that my deformity is very much contained in one spot L3/L4 where the vertebra has turned almost on its side causing the stenosis, disc hernation, etc...

    I wish there was another option, but the deformity is getting worse. So with the pain, I am so scattered that its hard to think about all the things I need to ask him. I do know how big this surgery is since I have done it before so I don't want to miss anything.

    Thanks for all input!
  • I think I would ask if he intends to restore your spine to it's correct position, or will he fuse in situ.
    Also, will he leave the existing screws where they are and just place new screws in the extra vertebra and change the rods for longer ones?

    If you are brave enough, you could ask what colour the screws will be!!!
    There has been discussion here about colours denoting the size o f the screws.
    I would love to know the colour of mine, but am not brave enough to ask! Lol!
    My surgeon doesn't talk much, and is very serious.

    Hope that your appontment goes well. Do let us know :-)
  • Those are great questions! Thanks! He is taking out the screws. That kind of freaks me out because another NS said that since they have been in for 19 years that its hard to get out. Plus he would need to contact my previous NS in Atlanta, GA and find out what he used because they are very large and he would need to find the same size. The NS last week also said that they are steel and cause too much trouble on the MRIs for future tests so titaniums need to be put in.

    My NS that is doing the surgery said they have to come out so he can link up the L3/L4 fusion to something and he doesn't have anything that will work with them. So all new hardware from the bottom to L3/L4 unless he gets in and must fuse L2/L3 because its bad when he gets in. (The MRI doesn't offer much due to the metal in back, but in myeologram L2/L3 looks okay).

    I will ask him the color--I will have to write that down. He is such a character that he may think its funny!!

    When I asked him if my legs are different lengths and if that is why my back was crooked. He said my back was crooked due to a neuromuscular imbalance. But what if my legs are different lengths? Is that something that I should look into?
  • Told me that I had one leg longer due to muscle imbalane too.
    I also had one hip higher and one shoulder higher. Having a dress made 4 years ago for my daughter's wedding, the dressmaker said one shoulder was higher. I didn't think it was important at the time. I wonder if they will all sort themselves out.
    I am over an inch taller since my surgery! I knew I was getting shorter as I was struggling to reach things.
  • I can tell you what I know about one leg being longer...or is it one leg is shorter? @)

    Very often is it a result of your posture. I will use myself as an example since that is the one I know best. I was completely unaware of any of these issues prior to going to the guy I call my "rearranger."

    The first thing he did when he met me was watch me walk. He immediately mentioned my pronation -- how my feet pointed out when I walked. I was always under the impression that I had a straight-forward stance and didn't toe out or in, so was surprised by this. Anyway, it changes the entire posture...because my feet pronated, it meant that I had a slight inward lean at the ankle...which in turn affected the knee position, which affected the hip position, which causes the pelvis to tip slightly forward. This continue on up my spine.

    It turns out that I was twisted from the years of compensating for the pain in my right leg...and without realizing it, was standing and sitting with more of my weight on the left side. This resulted in one hip being higher, and thus one leg longer (or shorter, depending on how you look at it!!) This also created a posture that made one shoulder higher and my chin thrusting just slightly forward.

    I have spent the past year working with Doug to get things properly aligned. At the very least it will help to prevent further damage to my remaining discs and vertebrae due to improper alignment.

    Prior to meeting up with Doug I would have told you I had great posture and used my body wisely. I studied dance for years and was aware of proper alignment...but as I had pregnancies and put on some additional weight, etc. and then developed sciatic pain, I began overcompensating and posture changed.

    The body automatically causes these compensations in an attempt to protect an injured part. If there is a weak link in the spine, the surrounding muscles, ligaments, etc. will stiffen up in an attempt to "guard" that area. That's one reason we develop muscle cramps along the spine.

    This can go on for years because we are not aware we are doing it -- and it can cause unnatural wear and tear on the bones of the spine. I could go on and on as it is a topic that interests me greatly...but, I will stop for now! I hope that what I did write makes sense!!

    Gwennie ;)
  • You will ultimately be better off having an open surgery. With such a complex situation as you have, the surgeon will need to visually eyeball everything to see how one segment is relating to the next.

    I think MIS is great, but I think they miss things sometimes, that they would have taken care of if it had been an open procedure.

    It sounds like you have a real expert in the field operating on you. You will be in good hands.

    I was supposed to have something similar, except just from the back. I am fused at L4-5, but we are adding on at L3-4 and L5-S1. The planned surgery is to leave the screws intact at L4-5, remove the old rods and add new, longer rods that will run from L3 to S1.
    But my insurance company had another opinion...so I am filing an appeal and waiting to hear back. Bah!!
  • for all the info. I have been following your case for a while and we have so many things similar. I even talked to my nurse when I found out about your insurance denial. I am still waiting to find out about my insurance. So my fingers are crossed.

    I know that I must have the open back. The surgeon wants to do both side and back so my back will have support from both. I do like him alot; my problem is that I have had two fusions (one lumbar--19 years ago and one cervical--2years ago) and so I know what I am up against. This time I am older with 4 kids and its no cake walk! I wish they could leave the old hardware in but they can't link up to it since its so old. However, I will ask him on wed if he can leave the screws and just put in longer rods--thanks for that info.

    After your surgery, do you still plan on seeing the guy who "tries to straighten you out?" :)

    What is the latest on your insurance saga--if you don't mind me asking?

    Thanks again for your help and time!
  • Gwennie, I expect that I have been lopsided for a long time. Your re-aligner Doug sounds great and you are very lucky to have found him.

    If you hear of anyone doing the same thing in the UK, please let me know
  • is that a chiropracter with certain training? how do you find a re-aligner?
  • j.howiejj.howie Brentwood, Ca., USAPosts: 1,730
    I've had a ant., post. 360. And a plif. And most recently a XLIF.
    It sounds to me like he'll do the ant. work laterally. And the rest post. That would be a less painful, less invasive. By eliminating the ant. surgery. Much easier to recover from! I'd go for it if he has had a good deal of experience doing the XLIF procedure.
    P.S. Less nerve and muscle damage.
    Hoe that makes sense.
    Click my name to see my Medical history
    You get what you get, not what you deserve......I stole that from Susan (rip)
    Today is yours to embrace........ for tomorrow, who knows what might be starring you in the face!
  • I'm sorry to call him my "rearranger." I never know how to refer to him as he has a crazy background. The degree that pertains to what he does now is in acupuncture and a master's degree in Chinese medicine. He participates in extreme sports...used to be a ski racer, had a serious injury and was dissatisfied with the type of PT he was getting, so started developing a system. As it evolved it was designed for athletes that participate in the ultra-long distance sports like the 100 mile runs, Ironman, etc. to help them preserve the condition of their bodies.

    One orthopedic surgeon I went to used to send his patients after surgery. Now he sends them prior to surgery to see if they can avoid having surgery. I met him after having fusion two years ago. For me, he first does acupuncture and then he does some "bodywork" if I am out of alignment. It is a hands on sort of gentle manipulation, but not like a chiropractor would do.

    I just call him my rearranger because I can't really describe what he does. But I love him because he knows so much about body mechanics, kinesiology, alignment, etc. Surgeons are only interested in discs and bones. They get a blank look when you start asking about soft tissue, muscle imbalances, etc. and whether they are contributing to the pain.
    He also answers all my questions and is very good at explaining things in a way that is easy for me to understand. He teaches classes in Boulder and Santa Cruz, CA several times each year. I wouldn't know how to replace him or where to begin looking -- he is a combination of various techniques, modalities, etc.

    He is the one that really figured out where the source of my pain was coming from when two spinal surgeons and two pain management doctors wanted me to have a SCS trial.

    Oh, he also managed my scar tissue after my second surgery. There is an acupuncture technique that is done in China where a tiny piece of tissue is picked up by a long needle and it is twirled...it somehow causes the tissue to organize itself so the fibers are all running in the same direction and it does not adhere to anything. I started that treatment at three weeks and went twice per week for the time when the tissue is most actively growing.

    Well, that's way more than you wanted to know, I am sure.

    I have my materials gathered together for the appeal and am awaiting a letter from my surgeon which I will get on Friday. I will mail it out Friday. They will receive it Monday and then have 30 days in which to reply. So I suppose I will spend the following month feeling in limbo. I wish I'd scheduled the surgery in Dec. Then I would not be having these problems. Bah!!
  • Its never too much info--I am soaking up everything like a sponge with a foggy brain :)

    Jim--I believe that is why he is goind through the side. Tomorrow, I will ask more questions and there is a good chance that he will want another mri, myelogram and standing xray before the surgery since the spine is changing weekly :(. I just hope that it doesn't change so much that it changes his gameplan! You have been through so much--I am very sorry for all your pain.

    Gwennie-- There is a guy sounds similar about 30 minutes away which around here is not too bad. I will see if I can get an appt before the surgery and see if I like him. The scar tissue thing is very interesting. One of my best friends is my chiro; I keep her two boys 3x a week so she can work. She has helped me a lot with pain control but its nothing like what you described.

    As for your insurance, it sounds like you could write an instruction manual on how to fight the insurance companies. That is so unfortunate and I pray that it will all work in your favor. My mom works as a benefit rep for a large company and she represents the employees when they have insurance problems. She says that the employee almost always wins when they fight the insurance company its just that most don't fight it. So keep fighting!!

    And thanks for the continue advice.
  • Since you were interested in my "rearranger," I just wanted to tell you about my experience today, which is fairly typical. I had an uncomfortable night with constant pain in my right leg. By noon I had terrible pain in my right hip. I lay down for awhile with my infrared heating pad. When I got up to drive downtown for my appointment, I felt really uncomfortable.

    We always chat a bit before he begins the treatment. I was telling him how uncomfortable I was and I assumed it was a pain I often get that seems to me like it could be right piriformis pain. Turns out I was worse than usual...my LEFT hip was hiked up higher...and it is because the left psoas muscle contracts...which causes some rotation of the pelvis and puts pressure on the ligaments on the right side, which resulted in the pain I was feeling.

    Then the more I hurt on the right side, the more I compensate and lean or use the left side more, which causes the psoas to tighten up even more. The psoas is a really important muscle that causes all kinds of problems that people can interpret as disc pain, etc.

    So Doug used a few more needles today, to bring blood flow to the area, and then he had to work on me a bit more than usual. He knows I spend a lot of time on the computer. He asked me today if I always got out of my computer chair on the same side. I answered affirmatively and told him it was the left side...so from now on, I am supposed to turn my chair to the point where I can stand up straight, use both hands on the arms of the chair to push up and stand up with weight on both feet....this will save wear and tear on that side. It is a small thing, but when you multiply it by how many times each week I get in and out of the chair, it can make a difference.

    It's this type of thing that happens all the time that I would never be aware of if it weren't for Doug. I would just be in pain and think it was my back....

    Doug was telling me that he's had a number of patients recently that have all had surgeries denied...from a variety of insurance companies...and it's all since Jan 1st.

    What happened with the doctor today?? The last NS I went to would not even look at my standing MRI. He proclaimed it a "gimmick."


    Do you live in Texas?
  • SpineAZSpineAZ WiscPosts: 1,084
    I'm 43 and just had an L3-S1 fusion on 2/3/10. It was done via a side incision (horizontal incision) and a posterior incision. They took out the 17 yr old hardware from 1993 that was L4-S1.

    I'm going to be out of town for a few days this week (in our RV nearby but at least a chance to get out of the house) and then I see my surgeon the 12th and see if he'll let me fly to Chicago on the 15th. So please feel free to send me a Private Message if there's anything I can answer for you.

    Ask your doctor if the side incision will be vertical or horizontal. My incision was horizontal so not a true XLIF procedure. They used the side incision to put a "spacer" in between L3-L4. My prior fusion had straightened my low back to much so when they removed the disc at L3-4 they wanted to try to retain the natural spinal curve by using a "spacer" insert where the disc had been. I think, from what I've heard, the XLIF is usually a vertical incision (but I don't know too much about the true XLIF type procedure). I had thought it was XLIF until I started describing it here and then found out it was not, just a horizontal hip incision (this was done so they would not have to do a full ALIF).

    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • Gwennie--you seem to have an awesome "rearranger." Its amazing what he is able to figure out. Are you out of more pain? I will be asking my NS about the neuromuscular imbalance. He has already said that is what has caused my problem, but I would like to know how it can be "fixed" from his perspective. I do live in Texas--Dallas Fort Worth area. Where are you?

    Karin--wow! I can't believe that you have had all that done in February. I have thousands of questions to ask :) but I will wait until after I see my NS today. I don't have any idea if its vertical or horizontal but I will ask also. I don't think its a true XLIF--like you, I think he is just going on the side so he doesn't have to go through the front. But I will find out more.

    Thanks again!!
  • I'll be eager to hear what your NS tells you today about upcoming surgery.

    My son is in grad school at UT in Austin. I was just curious where you were!
  • Hook 'em Horns!! I have lots of UT friends, althought I am a bayou girl and blend purple and gold for them LSU Tigers! :) UT is a great school and I would be proud to have any or all of my boys there one day!

    I really like my NS so that is a plus. (I am trying to look at the positives since I hurt like crazy.) The surgery is scheduled for June 11. I am his only surgery for the day since it will be approx 4-6 hours. The first incision will be on the left side (XLIF) and will be lateral. He will remove the disc at L3/L4 and replace it with a plastic wedge that has BMP in it. Once the wedge is in place he will be able to determine how much the spine straightens. Then he will flip me over and do a PLIF. He will remove the old hardware. He would like to take all old hardware out--stainless steel--but if its too difficult, he will only remove what he can. Then he will replace all with titanium from the initial fused spot starting at S1 and go to L3/L4 unless there is still too much instability and the crookedness. Then he will have to fuse up to L2/L3. We did bending xrays today that will aid in determining if he needs to fuse up to L2/L3 also.

    25% chance I will need a blood transfusion. Also chance for ICU but hopefully not. :) I will be in hospital for 5-7 days approx if I progress as he wants. They will have my up walking the next day. No doing anything for 2 weeks except self care and then its a week to week progression.

    He does not like his patients in any pain so he said he is aggressive with pain management.

    Whew--lots to take in. I am trying to look at all the positives.

    Oh and one more thing, they are sending to insurance and they don't see any reason for denial, but I am praying that it all goes through.

    Hope your day is great! Off to put my car under cover because I hear hail!

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