You may be contemplating the advantages and disadvantages of PLIF vs. TLIF if you are suffering from lower back pain or instability and fusion surgery has been recommended. PLIF vs. TLIF is a common question when patients fail to find relief with conservative treatments for spinal stenosis, degenerative disc disease, spondylolisthesis, recurrent disc herniation, or spondylolisthesis.
PLIF stands for posterior lumbar interbody fusion. TLIF is the acronym for transforaminal lumbar interbody fusion. Both are procedures that fuse vertebrae together in the lower (lumbar) spine. While PLIF was developed in the 1940s, TLIF arose as a modification of PLIF in the 1980s, reducing the amount of trauma to the nerves.
Truth be told, I have not performed a PLIF surgery in nearly a decade as I have found — and studies validate – that TLIF can provide similar results as PLIF with less blood loss and shorter surgical times. But, smart patients who are researching all of their options often ask about PLIF vs TLIF (along with ALIF vs TLIF), so I wanted to take time to help explain the differences as well as the pros and cons.
What are PLIF and TLIF?
Posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) are surgical procedures used to treat pain or weakness in the lumbar spine area (L1-L5 vertebrae). PLIF and TLIF surgeries can also be performed on the L5-S1 area of the spine. The L4-L5 and L5-S1 areas of the spine are the most common vertebrae treated with PLIF and TLIF given the high incidence of spinal stenosis in these vertebrae.
PLIF and TLIF are performed with the patient lying on their stomach. The surgeon accesses the spine through the posterior (or back). Using different techniques, as outlined in the next section, the surgeon removes the disc and inserts a cage or spacer to create disc height and promote fusion between vertebrae.
PLIF vs. TLIF
The main differences of PLIF vs. TLIF are:
- PLIF involves a wide laminectomy (removal of the lamina that is causing pressure on the nerve) and a bilateral partial facetectomy (removal of a portion of the facet joints in a set of vertebrae), followed by placement of two cages in the disc space (one on each side). What this means is that the back of the spine is opened up more extensively in PLIF than in TLIF and requires moving the nerve root to access and remove the disc.
- TLIF requires a midline incision and then a unilateral full facetectomy, meaning the facet joints are completely removed from one side of the vertebrae, followed by placement of one cage in the disc space. Because the disc space is accessed from one side, there is less movement of the nerve roots, compared to PLIF.
- In both procedures, once the damaged disc is removed, a cage or spacer is put in place to restore the height and promote fusion between the vertebrae.
Biomechanically, I do not believe there is any difference with partial removal of the facet joints, like in PLIF, compared to the full removal of the facet joint in TLIF as we put screws in place to create stability. However, if your surgeon is recommending PLIF, it is important to understand why that procedure may be better for your condition.
Both PLIF and TLIF have been shown to have similar fusion rates, while TLIF has shorter operative times, less blood loss, and a lower risk of damage to the nerve root, compared to PLIF.
PLIF has existed for more than 80 years. TLIF evolved as a modified version of PLIF in the 1980s as a way to minimize trauma to the nerves by only requiring an incision on one side of the spine.
Are there minimally invasive PLIF and TLIF surgeries?
Yes, absolutely, both minimally invasive PLIF and TLIF are available. With minimally invasive procedures, surgeons use smaller incisions, which can lead to less blood loss and shorter recovery times. However, we have found that surgical times with minimally invasive TLIF often can be longer than traditional surgery as a result of the smaller incision reducing our visibility.
Innovations like the TELIGEN™ System for minimally invasive TLIF surgery , which I use at AdventHealth Parker, provide better visualization for surgeons and have helped us reduce surgical times. At Neurosurgery One, my colleagues and I are routinely assessing new technologies and their impact on outcomes for patients.
If my surgeon is recommending PLIF, should I be concerned?
No, PLIF can be a very effective procedure for many patients. While I have found the benefits of TLIF to be similar to PLIF without the downsides of a larger, more invasive incision in the back, your surgeon may have valid reasons for recommending PLIF. There may be a structural issue or your condition may benefit most from the PLIF procedure. Your surgeon may also be more experienced or comfortable with the PLIF procedure.
Ask your surgeon to explain why they are recommending PLIF. If you are uncomfortable with the answer, I encourage you to seek a second opinion. Oftentimes, a second opinion will support the recommendation and help you feel more confident about moving forward.
I have found that younger surgeons are rarely trained on PLIF now, given the advantages of TLIF. TLIF evolved from PLIF and is essentially an improvement on the traditional posterior lumbar interbody fusion. I always recommend that patients ask their surgeons how many times they have performed the procedure they are recommending. This is a good practice for any type of surgery you may undergo, not just spine surgery.
TLIF vs. ALIF
TLIF is often compared to another fusion surgery called anterior lumbar interbody fusion (ALIF). Both surgeries may be recommended for patients who suffer from degenerative disc disease, spondylolisthesis, or spinal instability and who have not found relief with conservative treatment.
Unlike TLIF in which the surgeon accesses the spine through the posterior (back), during ALIF, the surgeon accesses the vertebral body through the abdomen in the front (anterior) of the patient. One advantage to this approach, as compared to the posterior approach, is avoiding damage to the back muscles. Another advantage is that a larger spacer can be placed between the vertebrae, offering increased stability, fusion rates, and decompression benefits. ALIF has also been shown to provide better visualization of the L4/L5 and L5/S1 fusion levels, less blood loss, and shorter operating times for patients with spondylolisthesis, and less tissue, nerve, and spine bone damage, compared to other lumbar interbody fusion procedures.
What questions should I be asking before considering ALIF, PLIF, or TLIF surgery?
I encourage all patients and their families to ask as many questions as possible that will make them feel informed about the back surgery and more comfortable with their surgeon. While the questions you ask should pertain to the condition you are seeking treatment for, in general, below are a few universal questions:
- What surgery are you recommending and why?
- Are there alternatives to this surgery and why did you rule those out?
- How many times have you performed the surgery you are recommending?
- How should I prepare for surgery?
- What outcomes can I expect after surgery?
- What does recovery entail?
- Will you or a member of your team be available for questions that may arise before and after surgery?
I also encourage all patients to seek out a second opinion. This can provide peace of mind or give you options you may have not considered.
Dr. Wissam Asfahani, a spine surgeon and neurosurgeon in Parker, Colorado, is board certified by the American Board of Neurological Surgery. Dr. Asfahani is the medical director of neurosurgery at AdventHealth Parker hospital. He specializes in all facets of neurosurgery including, but not limited to, degenerative and traumatic disorders of the spine and brain, as well as brain and spinal cord tumors, and traumatic brain injuries.
