Transforaminal lumbar interbody fusion (TLIF) was developed by Harms in the 1990s as a refinement of posterior lumbar interbody fusion (PLIF), addressing some of PLIF's limitations including bilateral nerve root retraction and high risk of nerve injury. TLIF utilizes a posterior approach with unilateral total facetectomy (complete removal of the facet joint on one side), exposing the disc space through the enlarged foramen without crossing the thecal sac, allowing interbody cage placement and grafting under direct visualization with minimal neural retraction.
Indications include single-level or selected multi-level degenerative disc disease with mechanical back pain, low-grade spondylolisthesis (Meyerding grade I-II), recurrent disc herniation requiring fusion, foraminal/lateral recess stenosis, post-laminectomy syndrome, and selected cases of revision spinal surgery. Compared to PLIF, TLIF provides better access to lateral pathology, reduces dural tear and nerve injury risk, and allows for unilateral approach with preserved contralateral structures. Compared to ALIF (anterior approach), TLIF avoids vascular and visceral risks, ureter injury, retrograde ejaculation in males, and provides simultaneous posterior decompression and stabilization.
Surgical technique includes posterior midline or paramedian incision, exposure of pedicles bilaterally, pedicle screw placement, unilateral facetectomy and partial laminectomy on the symptomatic side, decompression of nerve roots, complete discectomy through the foramen, endplate preparation, insertion of interbody cage filled with autograft (iliac crest or local bone) or allograft/synthetic substitutes (BMP-2 use is debated), pedicle screw rod fixation with posterior compression, and posterolateral fusion bed preparation. Modern variants include minimally invasive (MIS-TLIF) using tubular retractors and percutaneous pedicle screws — reducing blood loss, length of stay, and postoperative pain. Outcomes show 85-95% fusion rates and 70-85% good clinical outcomes at 2 years. Complications include cage subsidence, nerve injury (especially exiting root), dural tear, infection, adjacent segment disease (10-15% at 5-10 years), and pseudarthrosis.