June 20, 2024

TLIF (Transforaminal Lumbar Interbody Fusion) surgery is performed to stabilize the spinal vertebrae or disc. It is also performed to act as a shock absorber in the vertebral column

Load shaing of vertebrae

The goal of fusion is to eliminate pathological motion segment and its accompanying symptoms which is achieved by the formation of the osseous bridge across the previous mobile level

3 Basic requirements for a successful fusion are:

  1. Immobilization
  2. Fusion bed
  3. Bone graft

TLIF Surgery

  • It helps to reestablish anterior column support and allows posterior fixation.
  • Improve fusion rate (due to circumferential support)

Indications of TLIF

  • Degenerative disc disease
  • Low-grade spondylolisthesis (TLIF is ideal for Grade 1 and 2 with unilateral symptoms)
  • Multiple recurrent disc herniation and foraminal stenosis associated with deformity

Contraindications of TLIF

  • Complete disc dessication
  • Presence of extensive osteophytes, limits disc distraction
  • Excessive scarring from prior posterior surgery serves as a relative contraindication

The goal in case of spondylolisthesis following surgery are

  • Solid fusion
  • Ensure saggital balance
  • Prevent further slip
  • Reduce pain

Preparation and approach for TLIF

Wiltse paraspinal approach in prone

Wiltse paraspinal approach in TLIF
Wiltse paraspinal approach

Skin and subcutaneous tissue infiltrated with 1:500000 epinephrine to achieve hemostasis

Linear incision 2.5 cm lateral to the midline

Dissection of TLIF

  • The intramuscular plane is developed
  • As the plane is developed: One palpates medially the facet while continuing to dissect laterally to them all the way to the transverse process
  • Self-retaining retractors are used: Allowing visualization of part articulation medially and transversely process laterally
  • A pedicle screw is inserted on L5 and S1 with/without breaching the proximal facet
  • Interbody fusion is performed by a transforaminal approach
  • Facet is removed
    • The superior facet of S1
    • Inferior facet of L5
  • Care not to injure nerve
  • The disc is removed by incising the annulus and using a series of Kerrison rongeur
  • End plates are cleared for all traces of cartilaginous materials
  • Grafting is done by( Should rest between both endplates):
    • Cancellous bone
    • Structural bone graft
    • A cage
  • Contoured Rod Insertion (to respect lordosis) with pedicle screw
  • Fusion
  • Closure and dressed to complete the procedure

Complications following TLIF

  • Most frequent is blood loss requiring transfusion
  • Lumber wound infection
  • Postoperative radiculosis
  • Cage subsidence or extrusion and pseudoarthrosis

Advantages of TLIF

  1. Minimal retraction of the neural elements during graft placement (as entire facet and pars are removed)
  2. Allow reduction of slip
    • Maintain the reduction and decompression of compressed roots
  3. Use of disc spacer; anteriorly increase the height of lateral recess (indirect decompression) and also helps in the correction of kyphotic deformity
  4. TLIF can be performed on the entire lumbar spine
  5. Preserve interspinous ligaments and contralateral laminar surface for bone grafting
  6. Previous intercanal surgery will not pose difficulty in TLIF

The posterior approach of the spine

Summary of posterior approach of spine
Posterior approach of spine

Other approaches to Spine are discussed here.