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Lumbar canal stenosis is one of the most common causes of back pain, radiculopathy, and neurogenic claudication in adults. When conservative treatment fails, surgical decompression with interbody fusion becomes the definitive solution.
But one of the most confusing aspects for residents and young surgeons is choosing the right surgical approach — anterior, lateral, or posterior.
Here, in this blog, Dr. Jitesh Manghwani simplifies the entire concept of interbody fusion approaches in lumbar canal stenosis, making it easy to understand and clinically relevant.
Key Landmark That Decides Your Surgical Approach:
When planning interbody fusion, everything starts with one crucial bony landmark:
👉 The Transverse Process
Your surgical approach is defined based on your relation to the transverse process:
- Anterior to the transverse process → Anterior surgery
- Posterior to the transverse process → Posterior surgery
This simple anatomical concept decides whether your procedure is classified as anterior, lateral, or posterior fusion.
Anterior and Lateral Interbody Fusion Options
When approaching anterior to the transverse process, the available options are:
1. ALIF – Anterior Lumbar Interbody Fusion
- Approach: Directly from the front
- Route: Bang on anterior to the spine
- Advantages: Good disc height restoration and lordosis
- Risks: Injury to IVC, ureter, major vessels
2. OLIF – Oblique Lumbar Interbody Fusion
- Approach: Anterior to the psoas
- Route: Oblique corridor between vessels and psoas
- Advantages: Less muscle disruption than XLIF
- Limitations: Difficult at L5–S1
3. ELIF / XLIF – Extreme Lateral Interbody Fusion
- Approach: Through the psoas muscle
- Route: Trans-psoas corridor
- Risks:
- Lumbar plexus injury
- Psoas muscle injury
- Not suitable for L5–S1 due to plexus location
Because of these risks, lateral approaches are used selectively.
Posterior Interbody Fusion Options
When approaching posterior to the transverse process, the options include:
1. PLIF – Posterior Lumbar Interbody Fusion
- Approach: Direct midline posterior
- Requires significant dural retraction
2. TLIF – Transforaminal Lumbar Interbody Fusion
- Approach: Through the neural foramen
- Less dural retraction than PLIF
- Safer and more commonly preferred
3. MIS-TLIF – Minimally Invasive TLIF
- Most commonly performed today
- Uses guide wires and percutaneous screws
- Less blood loss
- Faster recovery
- Minimal muscle damage
Why MIS-TLIF Is the Most Popular Procedure Today?
According to Dr. Manghwani, MIS-TLIF has become one of the most frequently performed surgeries for lumbar canal stenosis because:
- Minimal tissue trauma
- Smaller incision
- Faster rehabilitation
- Less blood loss
- Excellent decompression
- Allows bilateral decompression via table bending
- Reliable fusion rates
Basic Steps of MIS-TLIF:
- Placement of guide wires
- Pedicle screw positioning
- Interbody decompression
- Cage insertion
- Rod fixation
- Over-the-top decompression for contralateral side
Comparing ELIF and TLIF
| Parameter | ELIF (XLIF) | TLIF |
| Dural injury | Lower | Higher |
| Blood vessel injury | Higher | Lower |
| Disc height restoration | Better | Moderate |
| Foraminal decompression | Better | Moderate |
| Lordosis correction | Better | Limited |
| Neurological injury | Risk to plexus | Root-related risk |
| Clinical outcome | Similar | Similar |
Although radiological correction is superior with anterior/lateral approaches, clinical outcomes are comparable.
Why TLIF Is Preferred Over PLIF?
- PLIF requires significant dural retraction
- TLIF needs less dural handling
- Lower risk of dural tears
- Easier access through foramen
- Safer for neural structures
That’s why TLIF is preferred over PLIF in most centers.
Level-Wise Recommendation for Interbody Fusion
| Level | Recommended Approach |
| Thoracolumbar junction | Posterior fusion |
| Lower lumbar spine | TLIF / MIS-TLIF |
| L2–L3 | ELIF not recommended |
| L5–S1 | ELIF contraindicated |
| Dorsolumbar region | OLIF is a fair option |
| All lumbar levels | TLIF is reliable |
Important Instruments for TLIF
For exams and practical training, residents must be familiar with:
- TLIF cage
- Disc shavers
- Endplate curettes
- Trial spacers
- Pedicle screw system
- Rod inserters
- Guide wires
These instruments are frequently asked in theory and practical orthopedic and spine exams.
Final Thoughts
Interbody fusion in lumbar canal stenosis is not about choosing a fashionable technique — it’s about choosing the right approach for the right patient at the right level.
While anterior and lateral approaches provide better radiological correction, MIS-TLIF remains the gold standard because of its safety, reproducibility, and excellent functional outcomes.
Understanding the anatomy, landmarks, indications, and risks is what separates a good surgeon from a great one.
