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Review
. 2025 Nov 29:25:100830.
doi: 10.1016/j.xnsj.2025.100830. eCollection 2026 Mar.

Extraforaminal lumbar interbody fusion: A systematic review of clinical outcomes, fusion rates, and safety profile

Michael K Coffin  1 , Kyle A McGrath  1 , Rebecca M Garner  1 , Christiana M Cornea  1 , Joseph S Cheng  1 , Justin N Virojanapa  1
Affiliations
Review

Extraforaminal lumbar interbody fusion: A systematic review of clinical outcomes, fusion rates, and safety profile

Michael K Coffin et al. N Am Spine Soc J. .

Abstract

Background: Extraforaminal lumbar interbody fusion (ELIF) accesses the disc through a posterolateral extraforaminal corridor that preserves the posterior ligamentous complex and avoids abdominal exposure. The objective of this systematic review is to synthesize the clinical outcomes, fusion rates, complications, and surgical indications for ELIF.

Methods: PRISMA 2020-conformant review registered in PROSPERO (ID: 1111090). Eligible studies reported clinical or radiographic outcomes of ELIF performed via the posterolateral extraforaminal approach. Extracted variables included indications, operative time, patient-reported outcomes, fusion, and complications. Risk of bias was assessed with the Newcastle-Ottawa Scale (NOS).

Results: Thirteen retrospective studies (n=518) met inclusion. The quality of studies included was generally fair, as graded by Newcastle-Ottawa Scale (NOS). The most common indication was degenerative disc disease. Mean operative time was 168.7 minutes. Fusion by technique: open pooled mean 98%, minimally invasive pooled mean 84%, and endoscopic 100% in a single series. Pooled VAS back improved as follows: open 6.27 to 2.80 (Δ 3.47; mean follow-up 12.8 months), minimally invasive 8.16 to 3.52 (Δ 4.64; 18.8 months), endoscopic 6.49 to 1.66 (Δ 4.83; 13.2 months). Pooled VAS leg improved: open 6.66 to 2.35 (Δ 4.31, 13.3 months), minimally invasive 8.66 to 2.17 (Δ 6.49; 15.5 months), endoscopic 6.60 to 1.50 (Δ 5.10; 14.2 months). Pooled Oswestry disability index (ODI) improved: open 60.17 to 26.25 (Δ 33.92; 9.5 months), minimally invasive 56.02 to 21.46 (Δ 34.56; 18.8 months), endoscopic 34.59 to 12.19 (Δ 22.40; 13.2 months). Transient radiculopathy was reported at 9.5% and dural tear at 0.5%.

Conclusions: As the first systematic review on ELIF, findings indicate it is a safe, effective alternative for lumbar fusion in select patients. Success necessitates favorable extraforaminal anatomy and intraoperative nerve monitoring to minimize complications. Future prospective trials are essential to validate these outcomes and standardize patient selection criteria.

Keywords: Degenerative disc disease; ELIF; Extraforaminal lumbar interbody fusion; Indirect decompression; Kambin’s triangle; Lumbar fusion; Systematic review.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig 1
Fig. 1
Representative postoperative images after mELIF (AP and lateral radiographs; sagittal and axial MRI; CT demonstrating fusion around the cage) (Fig. 4) [17].
Fig 2
Fig. 2
Schematic of the microendoscopy-assisted extraforaminal lumbar interbody fusion (mELIF) approach, illustrating the extraforaminal working corridor and cage trajectory (Fig. 1) [17].
Fig 3
Fig. 3
PRISMA 2020 flow diagram illustrating the study selection process for the systematic review. The initial database search identified 202 records. After removal of duplicates and screening of titles and abstracts, 13 full-text studies met inclusion criteria and were included in the final analysis. Boxes represent stages of screening, arrows indicate study flow, and numbers within boxes correspond to the number of records at each stage. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
See this image and copyright information in PMC

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