Juan was showing some XLIFs, and Chris Shaffrey and I mentioned, “You know, Juan, your coronal balance is incredible, but your sagittal, not so much.” To Juan’s credit, he went back and looked at it, and that was before sectioning the anterolateral ligament (ALL). As Joey alluded, unless you section the ALL with a lateral approach, you could not obtain optimal sagittal, lordotic balance. With ALIF, you section the ALL and put in a big spacer and you’re able to create great lordosis. An XLIF does not give the best sagittal alignment but gives phenomenal coronal alignment. I do a lot of ALIFs at 3-4, 4-5, and 5-1 where I can really get great height and lordosis. I do a preoperative CAT scan looking for calcification of vessels. If you see calcification of the vessels, you may need to do an XLIF, or a TLIF, if you prefer interbody techniques, like most of us do. It’s important for the surgeon have a variety of techniques to employ.
When listening to these talented surgeons, I thought about Joey representing Juan Uribe and Avery representing Chris Shaffrey. Avery trained with Chris and is a highly skilled, technical surgeon that trained at the foot of the master of TLIFs. Chris Shaffrey is the best TLIF-er I know. Avery is right behind him. As Chris and I teach around the world, we quickly find that not everybody has the same approach that we do. What Avery’s talking about is a deformity lift; you go in, do osteotomies, place screws, distract, and use a spinous process distractor or a distraction rod. You do a very thorough discectomy, then slide a spacer in anterior. This is not new. This was taught to me by Dr. Ogilvy, who was a deformity orthopedic surgeon at Minnesota. His young associate named Polly who later became president of the Scoliosis Research Society (SRS), also described this in several papers. To get the deformity correction that Avery talked about, bilateral facetectomies, extraction, complete discectomy, and an anterior placed device followed by posterior compression are absolutely critical.
I agree with everything said with the exception of Joey saying this is technically simple. I don’t think it is. I’ve spent decades learning these techniques, visiting other surgeons, and cadaveric labs. My recommendation is to visit surgeons, do clinical observations, do live cadaveric, and to do remote lab visits.
Since NuVasive sponsored this debate, I can tell you that they’re very proactive in teaching people open techniques, minimally invasive techniques, anterior, lateral, et cetera. You can always contact your local rep for that. I’d like to thank Avery and Joey for doing an excellent job. It’s obvious that the future of spine surgery is in great hands. With an industry partner like NuVasive, I think we’ll serve our patients well. Thank you so much.
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