Lumbar interbody fusion (overview)

Lumbar interbody fusion is a common technique that aims for osseous fusion after discectomy. 

There are anterior and posterior approaches (relative to the transverse process), some of which require additional instrumentation, and none of which have been demonstrated to be clinically superior with limited high-quality research comparing techniques ^1,3,4:

• anterior approach
  • anterior lumbar interbody fusion (ALIF)
  • lateral/eXtreme/direct lumbar interbody fusion (LLIF/XLIF/DLIF)
  • oblique lumbar interbody fusion (OLIF)
• posterior approach
  • posterior lumbar interbody fusion (PLIF)
  • transforaminal lumbar interbody fusion (TLIF)
• circumferential approach: combined lumbar interbody fusion and posterolateral lumbar fusion

Indications

• discogenic low back pain
• spondylolisthesis, e.g. pars interarticularis defect, degenerative, traumatic
• degenerative scoliosis/kyphoscoliosis
• adjacent segment degeneration 
• lumbar non-fusion ⁴

Generally, there is a lack of strong evidence for which procedure is best for which indication but speaking very generally for selected indications ⁴:

• discogenic low back pain: ALIF, TLIF
• spondylolisthesis
  • ​pars interarticularis defect: PLIF, ALIF or TLIF and/or posterolateral lumbar fusion (PLF)
  • degenerative: LLIF/TLIF may have lower complication rates than PLIF or PLF
• degenerative scoliosis: LLIF

Procedure

Lumbar interbody fusion essentially comprises of discectomy, vertebral endplate preparation, bone graft +/- interbody cage or spacer to restore intervertebral disc space height ^3,4.

Complications

Radiographic complications include ²:

• graft subsidence
• pseudarthrosis
• hardware loosening and/or migration

History and etymology

The first lumbar interbody fusion technique described was the PLIF by Briggs and Milligan in 1944 ⁴.