![]() Initial descriptions of ALIF and PLIF have been challenged by the evolving alternate approaches, such as the transforaminal, lateral and more recently oblique techniques. The growth of new techniques attempts to shorten operative times and achieve faster recovery with reduced operative complications ( 4). Patient expectations and increasing demands for shorter hospital stay and early return to work has led to more innovative surgical techniques to reduce iatrogenic injury and postoperative morbidity. The five primary interbody fusion approaches are shown here schematically: anterior (ALIF), lateral or extreme lateral interbody fusion (LLIF or XLIF), oblique lumbar interbody fusion/anterior to psoas (OLIF/ATP), transforaminal (TLIF or MI-TLIF), and posterior (PLIF) (B) surgical approaches to the lumbar spine for interbody fusion techniques: anatomy of the psoas and anterior vasculature determines approach at various levels. (A) Surgical approaches to the lumbar spine for interbody fusion techniques. Interbody fusion is preferable to postero-lateral ‘on-lay’ fusion techniques due to lower rates of postoperative complications and pseudoarthrosis ( 2). These operations can also be performed using mini-open or minimally invasive (MIS) approaches ( 2, 3). There is no clear definitive evidence for one approach being superior to another in terms of fusion or clinical outcomes. At this time LIF is performed using five main approaches posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF or MI-TLIF), oblique lumbar interbody fusion/anterior to psoas (OLIF/ATP), anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion (LLIF) ( Figure 1A,B). LIF involves placement of an implant (cage, spacer or structural graft) within the intervertebral space after discectomy and endplate preparation. Lumbar interbody fusion (LIF) is an established treatment for a range of spinal disorders including degenerative pathologies, trauma, infection and neoplasia ( 1). Thirdly, this article provides a description of each approach, and illustrates the potential benefits and disadvantages of each technique with reference to indication and spine level performed. Secondly, we propose a set of recommendations and guidelines for the indications for interbody fusion options. The present study aims firstly to comprehensively review the available literature and evidence for different lumbar interbody fusion (LIF) techniques. In addition, lateral and OLIF techniques have potential risks to the lumbar plexus and psoas muscle. Anterior approaches avoid the spinal canal, cauda equina and nerve roots, however have issues with approach related abdominal and vascular complications. ![]() ![]() Minimally invasive (MIS) posterior approaches have evolved in an attempt to reduce approach related complications. In general, traditional posterior approaches are frequently used with acceptable fusion rates and low complication rates, however they are limited by thecal sac and nerve root retraction, along with iatrogenic injury to the paraspinal musculature and disruption of the posterior tension band. The indications may include: discogenic/facetogenic low back pain, neurogenic claudication, radiculopathy due to foraminal stenosis, lumbar degenerative spinal deformity including symptomatic spondylolisthesis and degenerative scoliosis. The surgical options for interbody fusion of the lumbar spine include: posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), minimally invasive transforaminal lumbar interbody fusion (MI-TLIF), oblique lumbar interbody fusion/anterior to psoas (OLIF/ATP), lateral lumbar interbody fusion (LLIF) and anterior lumbar interbody fusion (ALIF). Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct deformity. Lumbar spondylosis may result in mechanical back pain, radicular and claudicant symptoms, reduced mobility and poor quality of life. Degenerative disc and facet joint disease of the lumbar spine is common in the ageing population, and is one of the most frequent causes of disability. ![]()
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