Evolution of the Transforaminal Lumbar Interbody Fusion (TLIF): From Open to Percutaneous to Patient-Specific

Abstract

The transforaminal lumbar interbody fusion (TLIF) has seen significant evolution since its early inception, reflecting advancements in surgical techniques, patient safety, and outcomes. Originally described as an improvement over the posterior lumbar interbody fusion (PLIF), the TLIF began as an open surgical procedure, that notably reduced the need for the extensive neural retractation that hindered the PLIF. In line with the broader practice of surgery, trending toward minimally invasive access, the TLIF was followed by the development of the minimally invasive TLIF (MIS-TLIF), a technique that further decreased tissue trauma and postoperative complications. Subsequent advancements, including Trans-Kambin's Triangle TLIF (percLIF) and transfacet LIF, have continued to refine surgical access, minimize surgical footprint, and reduce the risk of injury to the patient. The latest evolution, as we will describe it, the patient-specific TLIF, is a culmination of the aforementioned adaptations and incorporates advanced imaging and segmentation technologies into perioperative planning, allowing surgeons to tailor approaches based on individual patient anatomy and pathology. These developments signify a shift towards more precise methods in spine surgery. The ongoing evolution of the TLIF technique illustrates the dynamic nature of surgery and emphasizes the need for continued adaptation and refinement.

Keywords: Kambin’s Triangle; MIS; PLIF; TLIF; neurosegmentation; transfacet.

Figure 1

Representative images demonstrating statistically significant postoperative reductions in multifidus (encircled at the bottom of each panel) lean muscle mass in MIS-TLIF versus conventional open TLIF (CO-TLIF). Reproduced in its original form from Global Spine Journal, Volume 14, Dave et al. [13], Does Conventional Open TLIF cause more Muscle Injury when Compared to Minimally Invasive TLIF?—A Prospective Single Center Analysis, 93–100, Creative Commons Copyright 4.0 (2024), Sage Journals.

Figure 2

Animated depiction of various access trajectories at the level of the skin (A) and target vertebral level (B). Wide midline incision (A) representing the exposure for the PLIF and open TLIF. More laterally, paramedian is a representation of the skin incision for the MIS-TLIF and the transfacet LIF; most laterally is the representative incision for the Trans-Kambin’s Triangle TLIF at approximately 8 cm from midline. The green circle highlights (A,B) the point of access osteotomy for the TLIF and blue encircles the facet joint, which represents the transfacet corridor. Finally, the red dashed triangle is a depiction of where Kambin’s Triangle would lie from a lateral viewpoint—dashes indicate that the triangle is not viewable from this posterior angle. Figure created using BioRender.com.

Figure 3

(A) Preoperative standing X-ray demonstrating the L4-5 grade 1 spondylolisthesis, with (B) flexion films demonstrating dynamic instability. (C) Sagittal and (D) axial T2-weighted MRI slices revealing the advanced central and bilateral recess stenosis at the L4-5 level. (E) Intraoperative fluoroscopic image following cage placement with a guidewire within the disc space. (F) Postoperative lateral and (G) AP X-rays supporting a satisfactory appearance of the construct. LL: Lumbar lordosis. PI: Pelvic incidence.

Figure 4

(A) Preoperative standing lateral X-ray demonstrating the L4-5 grade 1 spondylolisthesis. (B) Sagittal and (C) axial T2-weighted MRI showing the mild central and severe lateral recess stenosis, respectively, with the latter image depicting the bilateral facet joint effusion. (D) Axial slice of the CT SPECT scan showing the isolated increase in radiotracer uptake at both L4-5 facet joints. (E) Intraoperative view of a right-sided transfacet approach with the joint line (dashed line), inferior articular process (IAP), and superior articular process (SAP) illustrated. (F) The same approach after completing the required facetectomy and discectomy to allow adequate room for cage trials; bony boundaries protecting the neural structures (L shape). (G) Postoperative lateral X-ray with adequate reduction in the slip and improved lordosis.

Figure 5

(A,B) Preoperative T2-SPACE-weighted 1 mm slice MRI showing L4-5 grade 1 spondylolisthesis on both sagittal and axial views. (C,D) Preoperative extension and flexion radiographs further depicting the instability of the pathologic L4-5 facet joints. (E) BrainLab’s planning software highlighting the left trans-Kambin corridor (outlined in blue) and (F) the right trans-Kambin corridor (outlined in green), with the maximum permissible cannula measurement overlaying each area and 3D reconstrued images below. (G) Postoperative radiograph confirming appropriate hardware placement and correction of their spondylolisthesis.

Figure 6

(A,B) Preoperative T2-SPACE-weighted 1 mm slice MRI showing L4-5 grade 1 spondylolisthesis on both sagittal and axial views. (C,D) Preoperative extension and flexion radiographs, further depicting the instability of the pathologic L4-5 facet joints. (E) BrainLab’s planning software highlighting the left trans-Kambin corridor (outlined in green) and (F) the left trans-facet corridor (outlined in red) with the maximum permissible cannula measurement overlaying each area. (G) 3D reconstructed image based on the segmented objects displaying the overlapping left TF-LIF (green) and percLIF (red) approaches. (H) Postoperative radiographs confirming appropriate hardware placement and correction of their grade 1 spondylolisthesis.

Figure 7

Lateral flexion plain film (A) demonstrating the L4-5 spondylolisthesis and disc height loss. Sagittal (B) and axial (C) T2-weighted MRI depicting the L4-5 facet cyst (yellow arrow) and lateral recess stenosis. Preoperative 3D rendering (D) of the patient’s spine and proposed custom L4-5 interbody (Carlsmed aprevo, Carlsbad, CA, USA). Postoperative lateral (E) lumbar plain film with overlying custom cage rendering (F). Postoperative AP (G) plain film with overlying custom cage rendering (H).