Transforaminal lumbar interbody fusion (TLIF)

Transforaminal lumbar interbody fusion (TLIF) is a spinal fusion procedure performed as an alternative to posterior lumbar interbody fusion (PLIF) when posterior decompression of the spinal canal is not required ¹. 

Indications

See: lumbar interbody overview (overview).

Contraindications

• extensive epidural fibrosis
• arachnoiditis
• infection
• conjoined nerve roots
• osteoporosis ²

Procedure

This procedure can be performed with an open (OTLIF) or minimally invasive (MITLIF)  approach for surgery at the L1-to-S1 levels.

Open approach

Via a paramedian incision and after dissection the posterior elements are exposed and pedicle screws are placed. Traditionally, a unilateral laminectomy and facetectomy are usually performed although there can be variation depending on clinical indication and the laminectomy/facetectomy may be unilateral or bilateral, and/or complete or partial. Rods are then placed to distract the disc space and a discectomy and endplate preparation is performed followed by insertion of the interbody cage and graft ^1-3. 

Minimally invasive approach

Using intraoperative fluoroscopy, pedicle screws are placed percutaneously above and below the surgical level. Via a paramedian incision, access to the surgical is gained via a tubular retractor after serial dilatation and decompression, discectomy, endplate preparation and interbody cage and graft insertion are similar to the open approach ⁴.

Complications

Compared to PLIF, TLIF has reduced rates of nerve root injury, dural tears and epidural fibrosis due to reduced thecal sac retraction ^2,3. TLIF-specific complications include:

• increased lumbar plexus injury (typically transient) from psoas retraction ^3,4
• postoperative contralateral radiculopathy ³

There may be higher rates of pedicle screw misplacement and cage migration in MITLIF compared to OTLIF ⁴. 

Outcomes

Compared to OLIF, MITLIF has less intra-operative blood loss, less postoperative pain and a shorter rehabilitation period ⁴. 

History and etymology

The TLIF technique was first described by Harms and Rolinger in 1982 ³, and the minimally invasive approach described by Foley et al in the early 2000s ⁴.