Anterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion

  • Tristan B. FriedEmail author
  • Tyler M. Kreitz
  • I. David Kaye
Living reference work entry


The use of interbodies as a method for lumbar fusion has been increasing over the past decades. Increased surface area and enhanced biomechanical forces for achieving fusion have made the technique more appealing than traditional posterolateral lumbar fusion. While many interbody techniques are actually less invasive than traditional open procedures, there are unique complication profiles with different approaches. The benefits of interbody fusion must be considered with the potential morbidity of these approaches. This chapter focuses on the techniques of both lumbar transforaminal and anterior interbody fusion along with potential complications with special attention toward graft/interbody selection and pearls and pitfalls of the respective technique.


Anterior lumbar interbody fusion Transforaminal lumbar interbody fusion Technique Complications Graft 


  1. Anderson DG, Sayadipour A, Shelby K, Albert TJ, Vaccaro AR, Weinstein MS (2011) Anterior interbody arthrodesis with percutaneous posterior pedicle fixation for degenerative conditions of the lumbar spine. Eur Spine J 20(8):1323–1330. Scholar
  2. Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA (1996) Complications of iliac crest bone graft harvesting. Clin Orthop Relat Res 329:300–309CrossRefGoogle Scholar
  3. Behrbalk E, Uri O, Parks RM, Musson R, Soh RCC, Boszczyk BM (2013) Fusion and subsidence rate of stand alone anterior lumbar interbody fusion using PEEK cage with recombinant human bone morphogenetic protein-2. Eur Spine J 22(12):2869–2875. Scholar
  4. Benglis D, Wang MY, Levi AD (2008) A comprehensive review of the safety profile of bone morphogenetic protein in spine surgery. Neurosurgery 62(5 Suppl 2):ONS423–ONS431. (Discussion ONS431). Scholar
  5. Boden SD (2002) Overview of the biology of lumbar spine fusion and principles for selecting a bone graft substitute. Spine 27(16 Suppl 1):S26–S31. Scholar
  6. Boden SD, Zdeblick TA, Sandhu HS, Heim SE (2000) The use of rhBMP-2 in interbody fusion cages. Definitive evidence of osteoinduction in humans: a preliminary report. Spine 25(3):376–381CrossRefGoogle Scholar
  7. Briggs H, Milligan PR (1944) Chip fusion of the low back following exploration of the spinal canal. J Bone Joint Surg Am 26(1):125–130. Scholar
  8. Burkus JK, Gornet MF, Dickman CA, Zdeblick TA (2002) Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages. J Spinal Disord Tech 15(5):337–349CrossRefGoogle Scholar
  9. Burkus JK, Gornet MF, Schuler TC, Kleeman TJ, Zdeblick TA (2009) Six-year outcomes of anterior lumbar interbody arthrodesis with use of interbody fusion cages and recombinant human bone morphogenetic protein-2. J Bone Joint Surg Am 91(5):1181–1189. Scholar
  10. Capener N (1932) Spondylolisthesis. Br J Surg 19:374–386CrossRefGoogle Scholar
  11. Chen Z, Ba G, Shen T, Fu Q (2012) Recombinant human bone morphogenetic protein-2 versus autogenous iliac crest bone graft for lumbar fusion: a meta-analysis of ten randomized controlled trials. Arch Orthop Trauma Surg 132(12):1725–1740. Scholar
  12. Cloward RB (1953) The treatment of ruptured lumbar intervertebral discs by vertebral body fusion. I. Indications, operative technique, after care. J Neurosurg 10(2):154–168. Scholar
  13. Coe JD (2004) Instrumented transforaminal lumbar interbody fusion with bioabsorbable polymer implants and iliac crest autograft. Neurosurg Focus 16(3):11. Scholar
  14. Cole CD, McCall TD, Schmidt MH, Dailey AT (2009) Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches. Curr Rev Musculoskelet Med 2(2):118–126. Scholar
  15. Collis JS (1985) Total disc replacement: a modified posterior lumbar interbody fusion. Report of 750 cases. Clin Orthop Relat Res 193:64–67. Scholar
  16. Craig Humphreys S, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA (2001) Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine 26(5):567–571. Scholar
  17. Fernyhough JC, Schimandle JJ, Weigel MC, Edwards CC, Levine AM (1992) Chronic donor site pain complicating bone graft harvesting from the posterior iliac crest for spinal fusion. Spine 17(12):1474–1480. Scholar
  18. Foley KT, Holly LT, Schwender JD (2003) Minimally invasive lumbar fusion. Spine 28(15 Suppl):S26–S35. Scholar
  19. Galbusera F, Schmidt H, Wilke H-J (2012) Lumbar interbody fusion: a parametric investigation of a novel cage design with and without posterior instrumentation. Eur Spine J 21(3):455–462. Scholar
  20. Gibson S, McLeod I, Wardlaw D, Urbaniak S (2002) Allograft versus autograft in instrumented posterolateral lumbar spinal fusion: a randomized control trial. Spine 27(15):1599–1603. Scholar
  21. Gray RJ, Rampersaud YR (2010) Comparison of the incidence of radiculitis and radiographic adverse event following minimally invasive lumbar transforaminal interbody fusions (TLIF) with and without the use of bone morphogenetic protein (BMP). Spine J 10(9):S8–S9. Scholar
  22. Hackenberg L, Halm H, Bullmann V, Vieth V, Schneider M, Liljenqvist U (2005) Transforaminal lumbar interbody fusion: a safe technique with satisfactory three to five year results. Eur Spine J 14(6):551–558. Scholar
  23. Harms J, Rolinger H (1982) A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion. Z Orthop Ihre Grenzgeb 120(3):343–347. Scholar
  24. Helgeson MD, Lehman RA, Patzkowski JC, Dmitriev AE, Rosner MK, Mack AW (2011) Adjacent vertebral body osteolysis with bone morphogenetic protein use in transforaminal lumbar interbody fusion. Spine J 11(6):507–510. Scholar
  25. Holly LT, Schwender JD, Rouben DP, Foley KT (2006) Minimally invasive transforaminal lumbar interbody fusion: indications, technique, and complications. Neurosurg Focus 20(3):E6. Scholar
  26. Kaiser MG, Eck JC, Groff MW et al (2014) Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 1: introduction and methodology. J Neurosurg Spine 21(1):2–6. Scholar
  27. Khan TR, Pearce KR, McAnany SJ, Peters CM, Gupta MC, Zebala LP (2018) Comparison of transforaminal lumbar interbody fusion outcomes in patients receiving rhBMP-2 versus autograft. Spine J 18(3):439–446CrossRefGoogle Scholar
  28. Kurz LT, Garfin SR, Booth RE (1989) Harvesting autogenous iliac bone grafts: a review of complications and techniques. Spine 14(12):1324–1331. Scholar
  29. Lai PL, Chen LH, Niu CC, Fu TS, Chen WJ (2004) Relation between laminectomy and development of adjacent segment instability after lumbar fusion with pedicle fixation. Spine 29(22):2527–2532. Scholar
  30. Lin PM (1985) Posterior lumbar interbody fusion technique: complications and pitfalls. Clin Orthop Relat Res 193:90–102. Scholar
  31. Lowe TG, Coe JD (2002) Resorbable polymer implants in unilateral transforaminal lumbar interbody fusion. J Neurosurg 97(4 Suppl):464–467. Scholar
  32. McAfee PC, DeVine JG, Chaput CD et al (2005) The indications for interbody fusion cages in the treatment of spondylolisthesis. Spine 30(Suppl):S60–S65. Scholar
  33. Michielsen J, Sys J, Rigaux A, Bertrand C (2013) The effect of recombinant human bone morphogenetic protein-2 in single-level posterior lumbar interbody arthrodesis. J Bone Joint Surg Am 95(10):873–880CrossRefGoogle Scholar
  34. Min JH, Jang JS, Jung BJ et al (2008) The clinical characteristics and risk factors for the adjacent segment degeneration in instrumented lumbar fusion. J Spinal Disord Tech 21(5):305–309. Scholar
  35. Mobbs RJ, Loganathan A, Yeung V, Rao PJ (2013a) Indications for anterior lumbar interbody fusion. Orthop Surg 5(3):153–163. Scholar
  36. Mobbs RJ, Chung M, Rao PJ (2013b) Bone graft substitutes for anterior lumbar interbody fusion. Orthop Surg 5(2):77–85. Scholar
  37. Mobbs RJ, Phan K, Malham G, Seex K, Rao PJ (2015) Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF. J Spine Surg 1(1):2–18. Scholar
  38. Mummaneni PV, Pan J, Haid RW, Rodts GE (2004a) Contribution of recombinant human bone morphogenetic protein-2 to the rapid creation of interbody fusion when used in transforaminal lumbar interbody fusion: a preliminary report. J Neurosurg Spine 1(1):19–23. Scholar
  39. Mummaneni PV, Haid RW, Rodts GE (2004b) Lumbar interbody fusion: state-of-the-art technical advances. J Neurosurg Spine 1(1):24–30. Scholar
  40. Mura PP, Costaglioli M, Piredda M, Caboni S, Casula S (2011) TLIF for symptomatic disc degeneration: a retrospective study of 100 patients. Eur Spine J 20(Suppl. 1):57–60. Scholar
  41. Newman MH, Grinstead GL (1992) Anterior lumbar interbody fusion for internal disc disruption. Spine 17(7):831–833CrossRefGoogle Scholar
  42. Ozgen S, Naderi S, Ozek MM, Pamir MN (1999) Findings and outcome of revision lumbar disc surgery. J Spinal Disord 12(4):287–292CrossRefGoogle Scholar
  43. Resnick DK, Choudhri TF, Dailey AT et al (2005) Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: lumbar fusion for disc herniation and radiculopathy. J Neurosurg Spine 2(6):673–678. Scholar
  44. Richter M, Weidenfeld M, Uckmann FP (2015) Anterior lumbar interbody fusion. Indications, technique, advantages and disadvantages. Orthopade 44(2):154–161. Scholar
  45. Rish BL (1989) A critique of posterior lumbar interbody fusion: 12 years’ experience with 250 patients. Surg Neurol 31(4):281–289. Scholar
  46. Rompe JD, Eysel P, Hopf C (1995) Clinical efficacy of pedicle instrumentation and posterolateral fusion in the symptomatic degenerative lumbar spine. Eur Spine J 4(4):231–237. Scholar
  47. Sakeb N, Ahsan K (2013) Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability. Indian J Orthop 47(3):255–263. Scholar
  48. Sarwat AM, O’Brien JP, Renton P, Sutcliffe JC (2001) The use of allograft (and avoidance of autograft) in anterior lumbar interbody fusion: a critical analysis. Eur Spine J 10(3):237–241CrossRefGoogle Scholar
  49. Sasso RC, Kitchel SH, Dawson EG (2004) A prospective, randomized controlled clinical trial of anterior lumbar interbody fusion using a titanium cylindrical threaded fusion device. Spine 29(2):113–22-122. Scholar
  50. Sonmez E, Coven I, Sahinturk F, Yilmaz C, Caner H (2013) Unilateral percutaneous pedicle screw instrumentation with minimally invasive TLIF for the treatment of recurrent lumbar disk disease: 2 years follow-up. Turk Neurosurg 23(3):372–378. Scholar
  51. Spruit M, Falk RG, Beckmann L, Steffen T, Castelein RM (2005) The in vitro stabilising effect of polyetheretherketone cages versus a titanium cage of similar design for anterior lumbar interbody fusion. Eur Spine J 14(8):752–758. Scholar
  52. Stevenson S (1999) Biology of bone grafts. Orthop Clin North Am 30(4):543–552CrossRefGoogle Scholar
  53. Strube P, Hoff E, Hartwig T, Perka CF, Gross C, Putzier M (2012) Stand-alone anterior versus anteroposterior lumbar interbody single-level fusion after a mean follow-up of 41 months. J Spinal Disord Tech 25(7):362–369. Scholar
  54. Weiner BK, Fraser RD (1998) Spine update lumbar interbody cages. Spine 23(5):634–640. Scholar
  55. Wong DA, Kumar A, Jatana S, Ghiselli G, Wong K (2008) Neurologic impairment from ectopic bone in the lumbar canal: a potential complication of off-label PLIF/TLIF use of bone morphogenetic protein-2 (BMP-2). Spine J 8(6):1011–1018. Scholar
  56. Xiao YX, Chen QX, Li FC (2009) Unilateral transforaminal lumbar interbody fusion: a review of the technique, indications and graft materials. J Int Med Res 37(3):908–917. Scholar
  57. Yan DL, Pei FX, Li J, Soo CL (2008) Comparative study of PILF and TLIF treatment in adult degenerative spondylolisthesis. Eur Spine J 17(10):1311–1316. Scholar
  58. Younger EM, Chapman MW (1989) Morbidity at bone graft donor sites. J Orthop Trauma 3(3):192–195. Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Tristan B. Fried
    • 1
    Email author
  • Tyler M. Kreitz
    • 2
  • I. David Kaye
    • 3
  1. 1.Sidney Kimmel Medical College, Thomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Thomas Jefferson University HospitalPhiladelphiaUSA
  3. 3.Rothman Institute, Thomas Jefferson University HospitalPhiladelphiaUSA

Section editors and affiliations

  • Don K. Moore
    • 1
  • William C. Welch
    • 2
    • 3
  1. 1.Department of Orthopaedic SurgeryUniversity of Missouri Health CareColumbiaUSA
  2. 2.Dept. of Neurosurgery, Pennsylvania HospitalUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.Department of NeurosurgeryPerelman School of Medicine, University of PennsylvaniaPhiladelphiaUSA

Personalised recommendations