Transforaminal Lumbar Interbody Fusion (TLIF)

TLIF of Transforaminal Lumbar Interbody Fusion is a traditional open-surgical procedure aimed to remove pressure to the spinal nerves and provide stabilization of the spine bones (vertebrae) when there is abnormal motion between them.

TLIF is one of the most common procedures used to decompress and stabilize the spine.

Indications

Formally speaking, TLIF is indicated in cases of spinal stenosis with instability. This means, if there is pressure on the spinal nerves and if there is an abnormal amount of movement between the spine bones (degenerative or isthmic spondylolisthesis, Figure 1).

Figure 1. Degenerative spondylolisthesis L4-5, degenerative disc disease L5-S1.

How is TLIF performed?

After an incision is made and the spine is exposed in the wound, the bones and ligaments that compress the nerves from the back are then removed, and spinal nerves are exposed to ensure there is no pressure on them.

Next, the disc is removed and a spacer and bone graft are placed between the bones to secure them in the corrected position and then fused together, eliminating abnormal movement.

Then, the screws are placed in the bones and connected with rods, securing the correct position of the bones (Figure 2).

Figure 2. Same patient: spondylolisthesis L4-5 is reduced, bones are secured together.

Are there alternatives to TLIF?

The main goal is to help your symptoms with the least-invasive interventions. Before considering surgery, the following should be tried:

• Activity modifications
• Physical therapy
• Over-the-counter medications
• Injections

When it comes to surgery, there are other, less-invasive options that can be used instead of TLIF:

• LLIF – lateral lumbar interbody fusion
• ALIF – anterior lumbar interbody fusion
• Laminectomy and posterior instrumented fusion

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What are the benefits of TLIF when compared to other procedures?

Even though TLIF is more traumatic than the above surgeries, it is considered to be the most thorough procedure. It allows your surgeon to directly look at the nerves and ensure there is no pressure on them. TLIF also provides higher rates of fusion, which may determine the outcome of surgery.

You need to discuss with your surgeon if the less-invasive surgeries are available in your case.

What is recovery like after TLIF?

There are three parts to recovery:

1. Immediately after the surgery:
   1. Pain persists for 3-5 days while inflammation is subsiding
   2. Skin sutures or staples are removed two weeks after surgery
2. Three months after the surgery (approximate time for bones to heal):
   1. During this period, physical limitations are recommended, including limited range of motion and limited amount of lifting
   2. Remember NO BLT (Bending, Lifting, Twisting)
3. One year after surgery:
   1. You are allowed to be more physically active, but some lifting limitations continue. Most people continue to notice some improvement for the whole year after surgery

How long will I stay in the hospital?

Physical therapy will visit you either on the same day or the day after the surgery. They will teach you how to get out of bed safely and how to use assisting devices (a cane or a walker).

You will stay in the hospital approximately one or two nights, depending on your progress with physical therapy and the amount of pain you are experiencing.

How much range of motion will I loose?

You may notice temporary stiffness in the back that is primarily related to muscle tightness. Range of motion in one spine segment is limited to about 5-10 degrees. Therefore, you will hardly notice any loss of motion. Most range of motion, in fact, is coming from the hip joints, not the spine itself.

How much pain will I have?

You can expect to have pain in the surgical area for three to five days after the procedure. Most people grade their pain around 3-5 / 10. Opioid pain medications and Tylenol are used by most people for up to two weeks.

What are the risks of TLIF?

As with any surgical intervention, there are risks that need to be considered before deciding to have surgery. Below are the most common risks you should know about:

1. Infection – about 3% of patients. This may be higher in patients with diabetes or other chronic diseases
2. Injury to the nerves – less than 1%
3. Dural tear and CSF leak
4. Collection of hematoma in the wound with pressure on the nerves
5. Failure to improve
6. Breakdown of instrumentation
7. Nonunion (failure of bones to fuse together)
8. Adjacent disc disease – in about 20% of patients in 10 years post-surgery
9. Need for more procedures in case of complications
10. Risks of anesthesia.

Who should not have TLIF?

Together with general medical contraindications to spine surgery, people with weak bone (osteoporosis) should avoid fusion procedures with instrumentation.

What imaging studies will I need prior to TLIF?

To determine if you need a TLIF, you will need to have a set of imaging including MRI, CT and x-rays, including long scoliosis x-ray and flection-extension x-ray views. To determine if your bones can support instrumentation, a bone density scan (DEXA) will be obtained.

What should I know in preparation to surgery?

Our office will communicate with you on how to prepare for the surgery. Certain medications should be discontinued, including blood thinners and drugs affecting wound healing and immunity.

If there are abnormalities on the preoperative labs and studies, they may need to be corrected by your primary care provider or other specialists before we proceed with surgery.