Purpose <p>This study aimed to evaluate the effectiveness of microscope-assisted modified lateral lumbar interbody fusion (micro-XOLIF) and to compare its impact on lumbar sagittal plane imaging parameters with extreme lateral interbody fusion (XLIF).</p> Methods <p>We retrospectively collected the data of patients who underwent XLIF and micro-XOLIF in our hospital. We compared general data, medical records, and imaging parameters of both groups, including lumbar sagittal balance and postoperative intervertebral height. We evaluated operative efficacy through complications, and the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) at each follow-up time.</p> Results <p>There was no significant difference in general data between the two groups. In the micro-XOLIF group, cages were predominantly placed in the anterior part of the intervertebral space, showing notable improvement in anterior intervertebral height and segmental lordosis. Postoperative ODI and VAS scores decreased significantly in both groups. VAS score of micro-XOLIF group was lower than that of XLIF group 3 days after operation, but there was no significant difference in ODI and VAS scores between the two groups in other time periods. The incidence of vertebral collapse and neurological complications in micro-XOLIF group was also lower than that in XLIF group.</p> Conclusions <p>Microscope-assisted modified lateral lumbar interbody fusion, utilizing a simple retractor, reduces the equipment needs for lateral lumbar fusion, aids in identifying crucial anatomical structures, and diminishes risks associated with lateral surgery and nerve-related complications. Additionally, micro-XOLIF effectively restores lumbar lordosis and reduces vertebral collapse rates through anterior cage placement.</p>