Transforaminal Lumbar Interbody Fusion (TLIF): Everything You Need to Know

Spine Surgery News


“TLIF” stands for “Transforaminal Lumbar Interbody Fusion”. It is a surgical procedure used to treat spinal instability or other conditions that cause pain or nerve compression in the lower back. In a TLIF procedure, a surgeon removes the damaged or diseased disc from between two vertebrae in the lower back and replaces it with a bone graft or synthetic material. The surgeon then places screws and rods into the vertebrae to stabilize the spine and promote fusion of the bone graft with the adjacent vertebrae. The goal of a TLIF is to help alleviate pain and improve spinal stability. TLIF surgery is performed under general anesthesia and may require a hospital stay of several days and have a recovery time of several weeks to months. 

First of all, what is a fusion surgery?

Spinal fusion surgery is a procedure that involves joining two or more vertebrae together in the spine. This is typically done to alleviate pain caused by conditions such as spondylolisthesis, scoliosis, or spinal fractures. During the surgery, the surgeon will use bone grafts and/or metal hardware (such as screws and rods) to hold the vertebrae in place while they fuse together during the healing process. The goal of the surgery is to stabilize the spine and reduce pain and nerve compression.

What are the different types of spinal fusion, and how is TLIF different?

There are several different types of spinal fusion surgeries for the back, each with their own unique approach and techniques. 

Some of the most common types of spinal fusion surgeries include:

  • Transforaminal Lumbar Interbody Fusion (TLIF): In this procedure, the surgeon accesses the spine from the side (through the neural foramen)
  • Posterior Lumbar Interbody Fusion (PLIF): In this procedure, the surgeon accesses the spine from the back of the body
  • Anterior Lumbar Interbody Fusion (ALIF): In this procedure, the surgeon accesses the spine from the front of the body
  • Lateral Lumbar Interbody Fusion (LLIF): In this procedure, the surgeon accesses the spine from the side

A TLIF (Transforaminal Lumbar Interbody Fusion) is named based on the specific techniques and anatomical structures involved in the procedure. 

Let’s break down the word “transforaminal”. “Trans” means across or through, and “foraminal” refers to the neural foramen. The neural foramen is a small opening on the side of the spinal column through which nerves exit the spinal canal and branch out to the rest of the body. In TLIF, the surgical approach is transforaminal because the surgeon accesses the disc space through this neural foramen, working from the back and reaching the disc space through a unilateral approach.

Which conditions can be treated with a TLIF?

Spinal fusion surgery is typically indicated for conditions that cause pain or instability in the spine. Some common indications for the surgery include:

  • Degenerative disc disease: This is a condition in which the discs between the vertebrae begin to wear down, leading to pain and instability in the spine.
  • Spinal fractures: Fractures in the vertebrae can cause instability and pain in the spine.
  • Spondylolisthesis: This is a condition in which one vertebra slips forward over another, which can lead to instability, nerve compression and pain.
  • Scoliosis: This is a condition in which the spine is curved to one side. This can lead to uneven pressure on the vertebrae and cause pain. A fusion surgery is often used to correct the deformity from scoliosis. 
  • Tumors: Spinal tumors can cause pain and instability, especially if they erode through vertebrae. 
  • Instability from Surgery: A fusion surgery is sometimes needed to stabilize the spine after a decompression surgery such as a laminectomy

What are the advantages of TLIF over other types of fusion surgery?

There are many factors that may influence your surgeon’s decision regarding the type of fusion surgery to pursue. Here are a couple of reasons why TLIF may be considered:

  • Reduced risk of nerve injury: The transforaminal approach in a TLIF offers the advantage of minimizing nerve root movement, which theoretically reduces the risk of nerve injury.
  • Enhanced spinal stability: By placing the graft both anteriorly and posteriorly on the spine, the surface area available for fusion is expanded. This larger graft area not only enhances the likelihood of successful graft healing but also contributes to improved stability of the spine.

It’s important to note that the choice of fusion surgery is highly individualized and depends on various factors, including the patient’s specific condition and spinal anatomy. Additionally, the surgeon’s expertise and experience with a particular fusion surgery may also play a role in determining which procedure is used. 

What happens during the surgery?

A TLIF surgery typically takes several hours to complete and is performed under general anesthesia. Here is a general overview of what can be expected during the surgery:

  1. Incision: The surgeon will make an incision in your lower back, specifically targeting the affected vertebrae. The length of the incision may vary based on the number of levels being treated.
  2. Access to the Spine: The surgeon will carefully move the muscles and soft tissues aside to expose the spine. This is done using specialized retractors to provide a clear view of the surgical area.
  3. Removal of Bone and Ligaments: Using surgical tools, the surgeon will remove a small portion of the bone and ligamentum flavum (a ligament that runs along the spinal canal) to access the spinal canal and nerve roots.
  4. Nerve Decompression: With a clear view of the nerve roots, the surgeon will gently retract and protect them to relieve any compression or impingement caused by herniated discs, bone spurs, or other factors. This step aims to alleviate nerve-related symptoms.
  5. Discectomy: The surgeon will remove the damaged or diseased intervertebral disc(s) between the affected vertebrae. This involves carefully removing the disc material to create space for the bone graft or implant.
  6. Bone Graft or Implant Placement: A bone graft or synthetic implant will be inserted into the empty disc space. The graft material serves as a bridge between the adjacent vertebrae and promotes fusion. The surgeon may also use additional substances, such as growth factors or bone morphogenetic proteins, to enhance fusion.
  7. Instrumentation and Stabilization: To provide stability and support fusion, the surgeon may use screws, rods, or other instrumentation. These implants are placed into the vertebrae and connected to hold them in the correct alignment during the healing process.
  8. Closure: Once the surgeon is satisfied with the placement of the graft, instrumentation, and overall surgical site, the incision will be closed using sutures or staples. Sterile dressings may be applied to protect the wound.

After the surgery, you will be taken to the recovery area to wake up from anesthesia. You may require a hospital stay for a few days for monitoring and pain management. Physical therapy and rehabilitation are typically recommended to aid in your recovery, restore strength, and improve mobility.

What is the recovery time following a TLIF?

In most cases, you can expect to spend 1 to 3 days in the hospital following a fusion surgery.  The duration of your stay will depend on your level of pain control and your ability to move around.

It is common for patients to begin standing and walking the day after surgery. Your surgeon may give you a back brace to help you feel more comfortable and to protect the surgical fusion.

During the first several weeks after the surgery, you should be able to perform basic exercises like walking but should avoid activities such as bending, twisting, or lifting heavy objects during this time.

Most patients who undergo a fusion procedure should expect to gradually resume their normal activities over a period of several months.

What are the risks of a TLIF?

As with any complex operation, there are several risks associated with spinal fusion surgery. Some of these risks include:

  • Infection: Although surgery is performed in sterile conditions, there is always a small risk of infection at the surgical site. 
  • Nerve damage: Nerves in and around the spinal cord can be damaged during the surgery.
  • Damage to other surrounding tissues: Other tissues as well as blood vessels and organs can be damaged during the procedure.
  • Non-union: The vertebrae may not fuse together properly, which may require additional surgery.
  • Adjacent segment disease: Adjacent segment disease can occur when the segments of the spine above or below the fused area become damaged or degenerate.
  • Hardware complications: There is a risk that the hardware used to fuse the vertebrae together may become loose or cause irritation.

Is a TLIF right for me?

It’s important to consult with a qualified spine surgeon to determine if an TLIF is the right option for you. 

There are many factors to be considered, including the specific condition being treated, your overall health, and your goals and expectations.

It’s also important to note that spinal fusion surgery is not always the best option for everyone. Some patients may be better served by other treatments, such as physical therapy, medications, or minimally invasive procedures.

About the Author

Dave Harrison, MD

Dr. Harrison is a board certified Emergency Physician with a part time appointment at San Francisco General Medical Center and is an Assistant Clinical Professor-Volunteer at the UCSF School of Medicine. Dr. Harrison attended medical school at Tufts University and completed his Emergency Medicine residency at the University of Southern California. Dr. Harrison manages the editorial process for