Trans-foraminal versus posterior lumbar interbody fusion: comparison of surgical morbidity

Background: Posterior lumbar interbody fusion (PLIF) and trans-foraminal lumbar interbody fusion (TLIF) are both accepted surgical approaches for spinal fusion in spondylolisthesis and degenerative disc disease. The unilateral approach of TLIF may minimize the risk of iatrogenic durotomy and nerve root injury; however, there is no definitive evidence to support either approach. We review our experience with TLIF versus PLIF to compare operative complications. Methods: We retrospectively reviewed 119 consecutive cases of PLIF or TLIF performed for degenerative disc disease or spondylolithesis at a single institution over 5 years and examined the incidences of operative complications and outcomes. Results: PLIF was performed in 76 (63%) patients and TLIF in 43 (37%). Patients were 48 +/- 13 years old and presented with mechanical back pain [109 (92%)], radicular pain [95 (80%)], and radicular motor weakness [10 (8%)]. Patients undergoing PLIF and TLIF had similar baseline demographic, clinical, and radiographic characteristics. PLIF was associated with a higher incidence of post-operative iatrogenic nerve root dysfunction [6 (7.8%) versus 1 (2%)] and durotomy [13 (17%) versus 4 (9%)]; however, these differences did not reach statistical significance. All cases of nerve root injury were transient and resolved by the third month post-operatively. Estimated operative blood loss, length of hospitalization, and other peri-operative indices were similar between cohorts. By 12 months, evidence of pseudoarthrosis was present in 2 (2.6%) and 2 (4.6%) patients with PLIF or TLIF, respectively. There was a similar incidence of improvement in radicular pain (88% versus 79%) and low back pain (74% versus 80%) between TLIF and PLIF. Conclusion: In our experience with surgical management of degenerative disc disease and spondylolesthesis, PLIF versus TLIF was associated with a trend toward a higher incidence of nerve root injury and durotomy. However, iatrogenic nerve root dysfunction was transient in all cases and 12-month pseudoarthrosis rates were similar between cohorts. Similar to previous clinical studies, the incidence of neurological complications and durotomy increases when an interbody fusion is performed through a posterior approach compared to non-interbody fusion techniques. However, the fusion rates with the interbody technique are also enhanced. TLIF and PLIF should only be considered when the goals of surgery cannot be addressed with decompression and traditional posterolateral fusion.