The transforaminal lumbar interbody fusion (TLIF) is a relatively new procedure. It is a modification of the PLIF procedure but offers the advantage of access to the spinal canal and disc unilaterally through the foramen, thereby minimizing retraction on the nerve roots and dural sac. This approach reduces the risk of neurologic injury and spares the posterior tension band. Additionally, the TLIF achieves a single-stage circumferential fusion through a posterior approach alone and as such may be considered a minimally invasive alternative to a combined anterior/posterior approach or instrumented PLIF.

First developed in 1982 (38), the TLIF has been performed in patients with mechanical back pain and radiculopathy with or without spondylolisthesis and especially in patients who have had previous surgery (39,40). The patient is placed in the prone position and a midline incision is made and transverse processes exposed after subperiosteal dissection of the paraspinous muscles. If the patient has a radiculopathy, the laminectomy and inferior facetectomy are performed on the side of the radicular pain; otherwise, the side of bony decompression is chosen arbitrarily. The contralateral interspinous ligament and liga-mentum flavum are left intact. The nerve root is identified and protected. Thereafter, pedicle screws are placed in standard fashion; however, some authors perform this step before unilateral bony exposure (40). A discectomy is then performed from the side of the laminectomy, the endplates are prepared for graft placement by removing the posterior lip of the endplate and exposing bleeding cancellous bone, and the interspace is distracted for maximum disc height. Can-cellous bone is packed anterolaterally and two cages are placed, the first con-tralaterally and the second on the ipsilateral side. All interbody material is placed through the unilateral approach. Disc space distraction is released and the rod-screw system tightened, after which cancellous bone graft is laid over the decorticated transverse processes to complete the circumferential fusion (39-41).

Initial results in small retrospective case series have been encouraging, with fusion rates and patient satisfaction between 85-90% and 75-85%, respectively (39-42). Complications included transient L5 injury and cerebrospinal fluid (CSF) leak. Although surgically demanding, the TLIF is a viable alternative to conventional approaches to circumferential fusion in degenerative lumbar spine disease, offering maximal stability through minimal posterior column disruption. Furthermore, it is an attractive choice in patients with scarring from prior operations.

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