JAAOS - 2026-03-15 - Journal Article; Systematic Review; Meta-Analysis; Comparative Study
Transforaminal Versus Lateral Lumbar Interbody Fusion: A Comprehensive Systematic Review and Meta-analysis of Radiographic, Perioperative, and Patient-Reported Outcomes.
Perez-Albela A, Daher M, Peacock T, Singh M, Sadh P, Sheth S, Daniels AH, Basques BA
Topics
Key Takeaway
In 6,047 patients across 27 studies, LLIF reduced blood loss by 88.3 mL and surgical time by 14.3 minutes while achieving superior disk height restoration (+2.21 mm at late follow-up) and lower subsidence risk (OR 0.40), but TLIF provided greater immediate canal decompression (+49.8 mm²) and marginally better late leg pain scores.
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Summary
This systematic review and meta-analysis compared TLIF versus LLIF across perioperative, radiographic, and patient-reported outcomes using 27 studies from 2000–2025 with random-effects pooling. LLIF demonstrated superior perioperative efficiency (−88.3 mL EBL, −14.3 min OR time, −0.35 day LOS) and better radiographic correction (disk height, foraminal height, segmental lordosis) sustained at 1–2 years, with lower subsidence risk (OR 0.40). TLIF provided greater immediate canal decompression (+49.8 mm²) and marginally superior late leg pain relief, while most PROs were statistically equivalent between approaches.
Key Limitation
The 2:1 TLIF-to-LLIF enrollment imbalance across included studies, combined with the predominantly retrospective design of contributing studies, introduces systematic selection bias that likely confounds the PRO comparisons.
Original Abstract
BACKGROUND
Transforaminal lumbar interbody fusion (TLIF) and lateral approaches such as lateral lumbar interbody fusion (LLIF) are widely used to treat degenerative lumbar disk disease. Although both restore disk height and achieve fusion, comparative advantages in radiographic, perioperative, and patient-reported outcomes (PROs) remain debated.
PURPOSE
To perform an updated meta-analysis comparing TLIF and LLIF with respect to perioperative outcomes, radiographic parameters, complication rates, and PROs.
STUDY DESIGN
Systematic review and meta-analysis.
METHODS
A comprehensive search of PubMed, Cochrane, and Google Scholar (2000 to 2025) was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies directly comparing TLIF and LLIF were included. Random-effects models were used for pooled analyses. Radiographic outcomes were grouped into immediate and 1- to 2-year follow-up. PROs were stratified by early (≤6 months) and late (>6 months) follow-up.
RESULTS
Twenty-seven studies (6,047 patients) met inclusion criteria: 4,098 underwent TLIF and 1,949 underwent LLIF. LLIF was associated with shorter surgical time (-14.3 minute; P = 0.04), lower estimated blood loss (-88.3 mL; P < 0.0001), and reduced length of stay (-0.35 days; P = 0.01). LLIF showed greater immediate improvements in mean disk height (+1.68 mm; P = 0.006), foraminal height (+1.80 mm; P < 0.0001), and segmental lordosis (+2.16°; P = 0.03), with lower subsidence risk (odds ratio: 0.40; P = 0.004). TLIF achieved greater immediate canal decompression (+49.8 mm 2 ; P < 0.0001). At late follow-up, LLIF maintained superior disk height (+2.21 mm), foraminal height (+2.33 mm), and segmental lordosis (+3.01°). LLIF was also associated with improved late leg pain scores (Δ -0.23; P = 0.02).
CONCLUSION
LLIF and TLIF each offer distinct advantages. LLIF was associated with lower subsidence risk, reduced blood loss, shorter surgical time, decreased length of stay, and improved radiographic correction. Most PROs were comparable, but TLIF demonstrated improved late leg pain relief.
LEVEL OF EVIDENCE
III.