**8.2 Disadvantages**

Several reviews have noted that XLIFs are associated with a far higher rate of lumbar nerve root/plexus injury compared to alternatives [59], though other studies suggest that these rates are statistically comparable in XLIFs and ALIFs [60]. Furthermore, the XLIF approach requires dissection of the psoas muscle unlike in similar alternatives such as the OLIF or ALIF. The transpsoas approach leads to traumatic soft tissue damage, and coupled with the proximity of the genitofemoral nerve, likely explains the prevalence of transient thigh numbness/weakness. However, this complication has been largely shown to be temporary and clinically insignificant. Smaller studies have cited higher rates of prolonged hospital stay or complications [61], but these findings are out of the norm and may reflect surgeon inexperience or the learning curve associated with newer MIS techniques. Finally, studies have suggested that XLIFs are susceptible to intervertebral cage settling, which may lead to poorer long-term surgical correction and necessitate wider cages [62]. Even so, however, XLIFs are at significant risk of anterior and lateral protrusion, suggesting the need to reduced cage length whenever possible [63]. The XLIF is still a procedure in its early stages of implementation and higher quality evidence is needed to further differentiate it from alternative surgical approaches.
