Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis, a systematic review and meta-analysis.

BACKGROUND CONTEXT: Transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) are both frequently used as surgical treatment for lumbar spondylolisthesis. Due to the unilateral transforaminal route to the intervertebral space used in TLIF, opposed to the bilateral route used in PLIF, TLIF could be associated with fewer complications, shorter duration of surgery, and less blood loss, while effectiveness of both techniques on back and/or leg pain is equal. PURPOSE: To compare the effectiveness of both TLIF and PLIF in reducing disability, and to compare the intra- and postoperative complications of both techniques in patients with lumbar spondylolisthesis. STUDY DESIGN/SETTING: A systematic literature review and meta-analysis was carried out. METHODS: We conducted a Medline (using Pubmed), Embase (using Ovid), Cochrane Library, Current Controlled Trials, ClinicalTrials.gov and NHS Centre for Review and Dissemination search for studies reporting TLIF, PLIF, lumbar spondylolisthesis and disability, pain, complications, duration of surgery and estimated blood loss. A meta-analysis was performed to compute pooled estimates of differences between TLIF and PLIF. Forest plots were constructed for each analysis group. RESULTS: 192 studies were identified, nine studies were included (one randomized controlled trial and eight case series), including 990 patients (450 TLIF and 540 PLIF). Pooled mean difference in postoperative ODI scores between TLIF and PLIF was -3.46 (95% CI -4.72, -2.20, p = <0.001). Pooled mean difference in postoperative VAS scores was -0.05 (95% CI -0.18, 0.09, p = 0.480). The overall complication rate for TLIF was 8.7% (range 0-25%), for PLIF 17.0% (range 4.7-28.8%), pooled odds ratio was 0.47 (95% CI 0.28, 0.81, p = 0.006). The average duration of surgery was 169 minutes for TLIF and 190 minutes for PLIF (mean difference -20.1, 95% CI -33.5, -6.6, p = 0.003). Estimated blood loss was 350 ml for TLIF and 418 ml for PLIF (mean difference -43.9 ml, 95% CI -71.2, -16.6, p = 0.002). CONCLUSIONS: TLIF has advantages over PLIF in complication rate, blood loss and operation duration. Clinical outcome is similar, with a slightly lower postoperative ODI score for TLIF.