Understanding the Different Approaches to Lumbar Fusion: PLIF, TLIF, ALIF, and XLIF

John K. Hong, M.D. | 7/21/2025

lumbar spinal fusion with instrumentation

Lumbar spinal fusion is a surgical procedure used to treat various conditions such as degenerative disc disease, spondylolisthesis, spinal instability, and spinal deformities. The goal of fusion is to stabilize the spine by joining two or more vertebrae, thereby eliminating painful motion. While the ultimate goal is the same, there are several different approaches to performing lumbar fusion, each with its own advantages and limitations.

In this article, we’ll explore the most common techniques: PLIF, TLIF, ALIF, and XLIF.

1. PLIF – Posterior Lumbar Interbody Fusion

Approach: Through the back (posterior), with access to the disc space after moving the spinal nerves aside.

Pros:

• Direct access to the spine and neural elements

• Allows for decompression of nerve roots and placement of interbody and posterior instrumentation

• Familiar approach for many surgeons

Cons:

• Increased risk of nerve root irritation or injury

• More muscle dissection and retraction, leading to longer recovery

• Limited view of the disc space compared to anterior approaches

  
  

2. TLIF – Transforaminal Lumbar Interbody Fusion

Approach: Through the back, but enters the disc space from one side (transforaminal), minimizing nerve retraction.

Pros:

• Less nerve retraction compared to PLIF

• Can be done minimally invasively

• Reduced risk of dural tears or nerve injury

• Often less blood loss and quicker recovery than PLIF

Cons:

• Limited access to the disc space

• Technically more demanding than PLIF

• May provide less correction for deformity or sagittal balance than anterior approaches

  
  

3. ALIF – Anterior Lumbar Interbody Fusion

Approach: Through the abdomen (anterior), accessing the front of the spine.

Pros:

• Direct access to the disc with excellent visualization

• Large grafts can be placed, promoting solid fusion

• Spares posterior muscles and nerves

• Better restoration of disc height and spinal alignment

Cons:

• Requires access through the abdomen, often with a vascular surgeon

• Risk of vascular injury (e.g., to the aorta or iliac vessels)

• May cause retrograde ejaculation in males (due to sympathetic plexus injury)

• Limited access to spinal canal—cannot decompress nerves directly

  
  

4. XLIF – Extreme Lateral Interbody Fusion (also known as LLIF)

Approach: Through the patient's side (lateral), passing through the psoas muscle to reach the spine.

Pros:

• Minimally invasive with less muscle disruption

• Shorter hospital stays and faster recovery

• Large graft placement for solid fusion

• Indirect decompression of spinal nerves by restoring disc height

Cons:

• Risk of injury to the lumbar plexus (especially at L4-5)

• Not suitable for L5-S1 level due to the position of the iliac crest

• Requires neuromonitoring due to nerve proximity

  
  

Choosing the Right Approach

The ideal surgical approach depends on:

• The spinal levels involved

• The patient’s anatomy and medical history

• Surgeon experience and preference

• The primary goal—decompression, alignment, or stabilization

  
  

At Parkview Pain and Regenerative Institute, we work closely with spine surgeons and patients to determine the most appropriate and least invasive treatment option. While many patients can benefit from non-surgical or regenerative therapies, we are here to guide you when surgery becomes necessary.