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  Transforaminal lumbar interbody fusion (TLIF) first described in 1982
  
  
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  Enables fusion of spinal segment anteriorly and posteriorly through single posterior procedure; eliminates morbidity, complications of anterior fusion
  
  
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  Can access disk space through single unilateral posterior approach, preserving contralateral lamina and spinous process, creating larger surface area for posterolateral fusion
  
  
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  Exposes neural foramen for direct decompression, eliminates need to retract thecal sac, reducing risk of incidental durotomy, neural injury
  
  
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  Intervertebral disk space ideal for obtaining bony fusion due to compressive forces of anterior column and blood supply provided by prepared end plates
  
  
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  In lumbar spine, 80% of mechanical load transmitted through vertebral body, 20% through posterior elements; in posterolateral fusion, fusion bed under tensile forces; in interbody fusion, fusion surface under compression
  
  
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  TLIF combined with posterolateral instrumentation and fusion achieves fusion rates greater than 90% and clinical outcomes comparable to anterior lumbar interbody fusion with posterolateral instrumentation and fusion

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  TLIF ideal for treating lumbar spine deformity, degenerative disk disease; interbody fusion restores disk space height and lordosis, indirectly decompressing neural foramen and improving sagittal balance
  
  
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  Isthmic spondylolisthesis (grades I and II)
  
  
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  Foraminal intervertebral disk herniations and recurrent disk herniations
  
  
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  Degenerative disk disease causing mechanical back pain with or without radiculopathy
  
  
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  Postlaminectomy spondylolisthesis
  
  
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  Postlaminectomy kyphosis
  
  
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  Lumbar coronal or sagittal plane deformities

Contraindications

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  Severe osteopenia
  
  
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  Bleeding disorders
  
  
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  Relatively contraindicated in active local or systemic infection

Preoperative Imaging

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  Preoperative AP and lateral radiographs (Figure 1)
  
  
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  CT/MRI

Procedure

Room Setup/Patient Positioning

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  Prone position on Jackson table
  
  
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  Pad bony prominences; free abdomen of compression to relieve intra-­abdominal pressure
  
  
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  Place neuromonitors on lower extremities in lumbar dermatomal distribution
  
  
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  Anesthesiologist keeps patient in hypotensive state to help reduce blood loss

Special Instruments/Equipment/Implants

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  Pedicle screw system
  
  
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  Structural interbody spacer options: titanium cages, polyetheretherketone cages, structural machined allograft, poly-­L/d-­lactide resorbable spacer
  
  
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  Bone graft materials
  
  
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  C-­arm
  
  
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  Neuromonitoring equipment
  
  
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  Bipolar cautery, straight osteotomes, Kerrison and Leksell rongeurs, straight and curved curets and pituitaries, disk space shavers, disk space dilators, disk space trials, and high-­speed burr