Contemporary

Spine Surgery
VOLUME 6 ■ NUMBER 6 ■ JUNE 2005

Transforaminal Lumbar Interbody Fusion:

Evolution and Application
Scott K. Stanley, MD, John R. Barker, MD, Eric R. Jamrich, MD, and John A. Odom Jr., MD

fusion (ALIF), posterior lumbar interbody of transient ankle weakness in a follow-up

LEARNING OBJECTIVES: After reading
fusion (PLIF), circumferential fusion, and study of 236 patients treated with posterior-
this article, the participant should be
TLIF. There are several permutations to ly inserted threaded cage devices.5
able to:
each technique that use a variety of inter- The concept of TLIF was popularized
1. Explain the history of posterior lumbar
body spacers and cages in combination by Harms et al.6 The technique involves a
interbody fusion and the development of
with allograft/autograft and bone morpho- posterior approach to the spine, where the
the transforaminal technique in response
genetic proteins. This article reviews the disc space is accessed via a path that runs
to neurologic complications.
history, technique, indications, and con- through the far lateral portion of the ver-
2. Describe the technique of transforami-
traindications to TLIF. tebral foramen. Bilateral anterior column
nal lumbar interbody fusion.
support is maintained through a unilateral
3. Describe the indications and contraindi-
HISTORY posterolateral approach. The interbody
cations for transforaminal lumbar inter-
In 1981, Blume and Rojas described component of the fusion offers several
body fusion.
a unilateral approach to PLIF.1 This advantages. It restricts movement at the
approach was developed in response to motion segment by placing the graft in the

T
he evolution of transforaminal
the neurologic complications associated center of segmental motion, which is the
lumbar interbody fusion (TLIF)
with the standard PLIF technique. PLIF shortest lever arm of the motion segment.
has resulted from a collaborative
first was attempted by Cloward in the It also surrounds the graft with a robust
effort in the spine community to provide a
early 1940s2 and later modified by Lin,3 vascular supply from the spongiosa of the
stable fusion mass across an interspace
who advocated completely filling the vertebral body. Posterior stability is
while minimizing patient morbidity and
intervertebral space
risk of pseudarthrosis. A variety of inter-
with bone graft. This
body fusion techniques is applied today.
technique requires
These include anterior lumbar interbody
retraction of the dura
and has increased risk
Dr. Stanley is a Spine Fellow, Dr. Barker is of nerve root injury,
Attending Physician, Dr. Jamrich is dural laceration, and
Attending Physician, and Dr. Odom is epidural fibrosis. The
Attending Physician, Rocky Mountain procedure is limited
Spine Clinic, 10103 Ridge Gate Parkway,
to L2–S1 because of
Suite 306, Lone Tree, CO 80124; E-mail:
drsstanley@hotmail.com. the higher probability
of neurologic injury
Dr. Barker has disclosed that he is a consul-
tant for DePuy Spine. Drs. Stanley, Jamrich,
with ascending lev-
and Odom have disclosed that they have no els. Turner reported
significant relationships with or financial cauda equina injuries
interests in any commercial organizations in 19% of patients,
pertaining to this educational activity. with permanent nerve
Wolters Kluwer Health has identified and dysfunction in three
resolved all faculty conflicts of interest patients.4 Ray report- Fig. 1 Illustration of TLIF procedure. Multiaxial pedicle screws
regarding this educational activity. ed a 10% incidence are inserted at the appropriate levels.

This continuing education activity is intended for orthopedic and neurologic surgeons and other physicians with an interest in spine surgery.
Contemporary Spine Surgery VOLUME 6 ■ NUMBER 6

achieved with pedi-

Editor-in-Chief cle screw fixation.
Gunnar B.J. Andersson, MD, PhD* In contrast to
Chairman, Department of Orthopedic Surgery
Rush-Presbyterian—St. Luke’s Medical Center
the wider decom-
Chicago, IL pression required for
PLIF, TLIF pre-
Associate Editor serves the interlami-
Alexander J. Ghanayem, MD* nar surface of the
Associate Professor and Chief, Division of
Spine Surgery, Department of Orthopaedic contralateral side,
Surgery which can be used
Loyola University Medical Center as additional surface
Maywood, IL
area for the fusion
Editorial Board mass. It also does
Howard S. An, MD not require retrac-
Chicago, IL tion of the dura.
Edward C. Benzel, MD Humphreys et al.
Cleveland, OH compared the tech-
Scott D. Boden, MD niques and did not Fig. 2 Illustration of TLIF procedure. Decompression is per-
Decatur, GA
find any significant formed by removing the entire inferior articular process and supe-
Steven R. Garfin, MD difference between rior articular process of the spinal segment to be fused.
San Diego, CA
one-level TLIF and
Kenneth B. Heithoff, MD
St. Louis Park, MN
PLIF in blood loss,
operative time, or duration of hospital frame. A standard midline approach is
Neil Kahanovitz, MD
Arlington, VA stay. However, there was an 11% rate of used. Care is taken to preserve the supra-
nerve root traction injury with PLIF.7 spinous and interspinous ligaments. The
Joel Saal, MD
SOAR Physiatry Group TLIF can be performed through a paraspinous muscles are elevated from
Menlo Park, CA standard open incision or mini-approach. the dorsal surface of the lamina and dis-
Volker K.H. Sonntag, MD Recently, this technique has been com- sected out to the transverse processes. A
Phoenix, AZ bined with minimally invasive technolo- separate fascial incision is made over the
Thomas A. Zdeblick, MD gy to minimize soft tissue stripping and posterior iliac crest, and a cortical win-
Madison, WI blood loss further. dow is made between the tables of the
*Dr. Andersson has disclosed that he ilium. Cancellous bone is removed with
receives grant/research support from Wright
Medical and Stryker; and he is a consultant TECHNIQUE gouges and curettes, and then the fascia
for Smith & Nephew, Zimmer, and Orthofix. The following technique is described is closed. Bone wax or thrombin sponges
Dr. Ghanayem has disclosed that he receives
grant support for resident reseach from as the standard open technique. The may be used to control bleeding between
Medtronic and DePuy. patient is placed prone on a Jackson spine the iliac tables prior to wound closure.
The cortical window has proven to be an
adequate source of bone graft for one
Contemporary Spine Surgery (ISSN 1527-4268) is published monthly by Lippincott level. If more than one level is required
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Contemporary Spine Surgery is independent and not affiliated with any organization, vendor, or company. ulation of each screw. After pedicle
Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A
mention of the products or services does not constitute endorsement. All comments are for general guid- screw insertion, decompression is per-
ance only; professional counsel should be sought for specific situations. formed by removing the entire inferior

2
JUNE 2005 Contemporary Spine Surgery

Fig. 5 Illustration of TLIF procedure. Proper rod length is neces-

Fig. 3 Illustration of TLIF procedure. An 11-blade scalpel is used sary to avoid impingement on adjacent facets.
to incise a posterolateral rectangular annular window.

Fig. 4 Illustration of TLIF procedure. The iliac crest cancellous

bone graft is inserted into the posterior half of the disc space after
the anterior cage is placed.

articular process and superior articular process of the spinal

segment to be fused. These cuts can be made with a 3/8-inch
straight osteotome followed by a 4- or 5-mm Kerrison rongeur
(Fig. 2). Next, the rods and locking plugs are seated, and the Fig. 6 Preoperative x-ray of a 45-year-old man with L3–L4,
disc space is distracted bilaterally via pedicle screws. L4–L5 degenerative disc disease.
3
Contemporary Spine Surgery
A B
Fig. 7 The patient in Figure 6 at 1 year postoperatively. A, lateral x-ray, lumbar spine. B, anteroposterior x-ray, lumbar spine.
The exiting nerve root inferior to the upper pedicle is the key
to anatomic orientation and should be protected with a nerve root
retractor. This root hugs the inferomedial surface of the pedicle.
Epidural bleeding is brisk with exposure of the disc space and
should be controlled with bipolar cautery or a thrombin carrier.
An 11-blade scalpel is used to incise a posterolateral rec-
tangular annular window (Fig. 3). This window is caudal to
the exiting nerve root. This root rarely requires retraction
with the transforaminal approach. A discectomy is performed
using shavers, chondrotomes, straight and offset curettes,
and pituitary rongeurs. After endplate decortication is accom-
plished, the disc space is measured for the cage. Local bone
graft is inserted into the appropriate sized cage and is impact-
ed into the anterior half disc space. The iliac crest cancellous
bone graft is inserted into the posterior half of the disc space
(Fig. 4). The remaining bone graft is ground up in a bone mill.
Lordotic rods are placed into the pedicle screws, and com-
pression is applied across the disc space. Final tightening of
the locking plugs is performed. Proper rod length is necessary
to avoid impingement on adjacent facets (Fig. 5).
The contralateral facet, interlaminar space, and bilateral trans-
verse processes are decorticated, and the remaining bone graft is
packed into the posterolateral gutters. The wound is copiously irri-
gated with saline and closed in layers over a drain (Figs. 6 and 7).
4
VOLUME 6 ■ NUMBER 6
The technique described herein involves placement of bilat-
eral pedicle screws. Various instrumentation techniques are
available to use in TLIF, including contralateral facet screws,
unilateral pedicle screw fixation, and bilateral pedicle screw fix-
ation. Harris et al. determined that TLIF with bilateral pedicle
screws most closely approximates segmental flexibility of the
intact spine. In their biomechanical cadaveric study, the overall
flexibility was within 10% of the intact specimen in all motions.8
Technical highlights of the TLIF approach include spar-
ing the laminar arch and contralateral facet. Preserving these
structures provides a revision strategy that may not exist
with PLIF due to bilateral epidural scarring. By accessing the
disc space through a far lateral approach and avoiding retrac-
tion of the dura, nerve root injuries are minimized.
INDICATIONS AND CONTRAINDICATIONS
Operative indications for TLIF are contested among many
spine experts. The optimum indications for use of this technique are:
1. Grade 1 or 2 spondylolisthesis;
2. Degenerative disc disease with a specific discogenic pain
pattern; and/or
3. Segmental kyphosis.
JUNE 2005
Fig. 8 T2-weighted sagittal MRI scan of L3–L4, L4–L5 degen-
erative disc disease.
Degenerative spondylolisthesis can be effectively man-
aged with the large anterior column surface area as a fusion
surface and posterior instrumentation to correct the slip.
Three parameters are used to measure the amount of slip
objectively: percentage of slippage; slip angle; and sacral
inclination. Degenerative spondylolisthesis usually becomes
noticeable in middle age when the L5–S1 disc degenerates in
addition to the chronic pars defect. The slip is usually less
than 50% (grade 1 or 2). The slip angle is usually 0 degrees
with sacral inclination greater than 30 degrees.
Congenital forms of spondylolistheses usually have a
greater degree of slippage. The endplate of S1 frequently has
a dome-shaped configuration, while the vertebral body of L5
is usually wedge-shaped. This anatomy requires resection of
the endplate of S1 to obtain a reduction. This resection can
be accomplished via a posterior approach to the spine, fol-
lowed by the TLIF technique to provide anterior column sup-
port. By applying compression across the instrumented seg-
ment, further normalization of the sacral inclination can be
attained. The risk of motor deficits is reduced with resection
of the S1 endplate. The shortening that results from the
resection has a protective effect.
5
Contemporary Spine Surgery
Spondylolisthesis is a form of lumbar instability, which
Knuttson defined as more than 3 mm of translation in the
sagittal plane.9 Segmental instability versus physiologic
hypermobility is a difficult diagnosis to make. This cannot be
determined with x-rays alone; it is a clinical decision. The
patient may report a sensation of “giving way” or “slipping
out” with a repeating mechanism of injury. A positive torsion
test may be reproduced on physical examination.10 The test
is performed by having the patient lie face down on the exam-
ining room table. The examiner’s hand is placed firmly over
the upper lumbar vertebrae. The pelvis is gripped anteriorly
with the opposite hand and drawn posteriorly. The test is pos-
itive when pain is reproduced with this rotation.
Degenerative disc disease as the cause of the patient’s
symptoms must be diagnosed methodically. Patients report
nonradicular low back pain primarily in a sitting position. On
physical examination, the rhythm of the patient’s movement
should be observed when he or she leans forward to touch the
toes. If the patient does this in a cogwheel motion or requires
hands on the thighs to return to an upright position, suspi-
cion should arise for degenerative disc disease. Documented
MRI findings in conjunction with concordant pain response
and a negative control on a discogram are essential to estab-
lishing this diagnosis (Fig. 8). Operative intervention should
be offered only after an appropriate trial of conservative man-
agement consisting of activity modification, physical therapy,
and nonsteroidal anti-inflammatory medication.
Segmental kyphosis may be seen above a previously fused
level and is common in patients with osteoporotic compression
fractures. If the adjacent disc space above a compression frac-
ture demonstrates symptomatic instability, osteoporotic pedi-
cles provide a challenge for a posterior instrumented fusion.
TLIF allows improved load sharing by placing anterior column
support into the front of the vertebral body, which decreases
stress to the pedicle screws. In these cases, preservation of the
cortical integrity of the endplate is essential to a successful
outcome. To minimize subsidence, Polikeit et al. determined
that cages should be positioned in the strong peripheral part of
the endplate for support. After cage positioning, bone graft
should be placed posteriorly in the disc space.11
In addition to its benefits in patients with low-grade
spondylolisthesis, degenerative disc disease, and segmental
kyphosis, TLIF is advantageous when ALIF is not possible.
Previous anterior surgery, obesity, or a young man who does
not want to entertain the risk of retrograde ejaculation pre-
clude the use of ALIF. Whitecloud et al. performed a cost
analysis of one-level TLIF versus circumferential fusions in 80
patients. The authors demonstrated that the anterior–posterior
group required an average 56 minutes more of operative time
compared with the TLIF group, plus an additional 38 minutes
was required to turn the patient from an anterior to a posteri-
or position. Use of the surgical intensive care unit was lower
in the TLIF group, with an average length of stay of 3.3 days
versus 6.1 days for the anterior-posterior fusion group. TLIF
was associated with an average savings of $15,000 per admis-
sion compared with circumferential fusion.12
Contemporary Spine Surgery
The major contraindication to TLIF is a history of previous
wide posterior decompression. The risk of catastrophic neuro-
logic injury is significantly increased secondary to epidural scar-
ring. The technique may be used successfully in a patient who
has undergone previous hemilaminotomy for microdiscectomy.
Preoperative planning requires that the location of the previous
surgery be determined with MRI so that the TLIF may be per-
formed from the contralateral side. If the patient has recurrent
foraminal stenosis, a foraminotomy may be performed at the site
of previous surgery. The tissue plane between the dura and the
scar tissue can be determined by patiently working from normal
tissue to abnormal scar tissue toward the foramen.
SUMMARY
TLIF provides the surgeon with the ability to restore
intervertebral body height, reduce spondylolisthesis, neutral-
ize degenerative instability, and enhance lordosis by main-
taining anterior column height with posterior spinal fixation.
By preserving the contralateral facet and interlaminar sur-
face, a greater surface area is provided for a higher likelihood
of fusion. TLIF also provides a revision option for the future
if further surgery is required.
REFERENCES
1. Blume HG, Rojas CH. Unilateral lumbar interbody fusion (posterior
approach) utilizing dowel graft. J Neurol Orthop Surg 2:171–5, 1981
6
VOLUME 6 ■ NUMBER 6
2. Cloward RB. The treatment of ruptured lumbar intervertebral discs by
vertebral body fusion. I. Indications, operative technique, after care. J
Neurosurg 10:154–68, 1953
3. Lin PM. A technical modification of Cloward’s posterior lumbar inter-
body fusion. Neurosurgery 1:118–24, 1977
4. Turner PL. Neurologic complications of posterior lumbar interbody
fusion. Presented at the Annual Meeting of the Spine Society of
Australia, Melbourne, Australia, May 14, 1994.
5. Ray CD. Threaded titanium cages for lumbar interbody fusion. Spine
22:667–80, 1997
6. Harms J, Jeszenszky D, Stolze D, et al. True spondylolisthesis reduc-
tion and more segmental fusion in spondylolisthesis. In: Textbook of
Spinal Surgery, 2nd ed. Philadelphia: Lippincott-Raven, 1997, pp
1337–47
7. Humphreys SC, Hodges SD, Patwardhan AG, et al. Comparison of pos-
terior and transforaminal approaches to lumbar interbody fusion. Spine
26:567–71, 2001
8. Harris BM, Hilibrand AS, Savas PE, et al. Transforaminal lumbar inter-
body fusion ñ the effect of various instrumentation techniques on the
flexibility of the lumbar spine. Spine 29:E65–70, 2004
9. Knutsonn F. The instability associated with disc degeneration in the
lumbar spine. Acta Radiol 25:593–609, 1944
10. Farfan HF. The use of mechanical etiology to determine the efficacy of
active intervention in single joint lumbar intervertebral joint problems:
surgery and chemonucleolysis compared—a prospective study. Spine
10:350–58, 1985
11. Polikeit A, Ferguson SJ, Nolte LP, Orr TE. The importance of the end-
plate for interbody cages in the lumbar spine. Eur Spine J 12:556–61,
2003
12. Whitecloud TS, 3rd, Roesch WW, Ricciardi JE. Transforaminal inter-
body fusion versus anterior-posterior interbody fusion of the lumbar
spine: a financial analysis. J Spinal Disord 14:100–3, 2001
JUNE 2005 Contemporary Spine Surgery

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7
Contemporary Spine Surgery VOLUME 6 ■ NUMBER 6

CME Quiz
To earn CME credit, you must read the CME article and com-
plete the quiz and evaluation assessment survey on the enclosed
form, answering at least 70% of the quiz questions correctly.
Select the best answer and use a blue or black pen to com-
pletely fill in the corresponding box on the enclosed answer
form. Please indicate any name and address changes directly on
the answer form. If your name and address do not appear on the
answer form, please print that information in the blank space at
the top left of the page. Make a photocopy of the completed
answer form for your own files and mail the original answer form
to Lippincott Williams & Wilkins, Continuing Education
Department, P.O. Box 1543, Hagerstown, MD 21741-9914 by May
31, 2006. For more information, call (800) 787-8981.
Wolters Kluwer Health is accredited by the Accreditation Council
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cation for physicians.
Wolters Kluwer Health designates this educational activity for a
maximum of 1.5 category 1 credits toward the AMA Physician’s
Recognition Award. Each physician should claim only those credits
that he/she actually spent in the activity.

1. The most common reported complication
after posterior lumbar interbody fusion is
A. Dural tear
B. Nerve root injury with paresthesia
C. Permanent foot drop
D. Postoperative anemia
2. Who is credited with developing the trans-
foraminal lumbar interbody fusion (TLIF)
technique?
A. Cloward
B. Lin
C. Harms
D. Simmons
3. Which one of the following is a contraindi-
cation to TLIF?
A. Mechanical back pain
B. Herniated nucleus pulposus
C. Previous posterior decompression
D. Segmental kyphosis
4. All of the following are considered indi-
cations for TLIF except
A. segmental kyphosis
B. radiculopathy with symptomatic degen-
erative disc disease
C. lumbar stenosis with symptomatic
degenerative disc disease
D. previous disc arthroplasty
5. All of the following are considered rela-
tive advantages of TLIF over circumfer-
ential fusion except
A. shorter operative time
B. decreased blood loss
C. higher fusion rate
D. lower risk of retrograde ejaculation
6. All of the following are objective parame-
ters to evaluate spondylolisthesis except
A. percentage of slippage
B. lumbar inclination
C. slip angle
D. sacral inclination
7. The cages(s) in the TLIF technique should
be positioned
A. into the anterior portion of the disc
space
B. only cental in the disc space
C. only posterior in the disc space
8. Segmental flexibility of the lumbar spine
at one level can be most closely approxi-
mated with
A. unilateral pedicle screw
B. bilateral facet screws
C. contralateral facet screw
D. bilateral pedicle screws
9. Structures that can be preserved during
TLIF performed on the patientís left
side include the
A. right-sided facet joint
B. left-sided facet joint
C. interspinous ligament
D. A and C
10. The access portal for interbody cage
insertion during a TLIF is
A. caudal to the traversing nerve root at
the operative level
B. medial to the axilla of the traversing
nerve root at the operative level
C. caudal to the exiting nerve root at
the operative level
D. directly posterior to the disc space by
retracting the thecal sac and travers-
ing nerve root

Attention CME Participants

Effective immediately, please fill in the answer boxes on your answer form completely using a blue or black pen. DO NOT
use a check or X mark in the boxes. Thank you.