Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF)

Also known as mini-open TLIF, a transforaminal lumbar interbody fusion is a minimally invasive surgical technique that is performed in patients with refractory mechanical low back and radicular pain associated with spondylolisthesis, degenerative disc disease, and recurrent disc herniation. The TLIF approach may also have potential in patients with low back pain caused by post-laminectomy instability, spinal trauma, or for treating pseudoarthrosis. This procedure is contraindicated in patients who have a conjoined nerve root within the foramen, a very rare occurrence, but one that may present during surgery.

The procedure is performed from the back (posterior) with the patient on his or her stomach. The major difference in the TLIF approach is that the operation is performed unilaterally, and the bone graft is inserted into the disc space through the side.

Using x-ray guidance, a 2- to 4-cm incision is made approximately 4 to 5 cm lateral to the midline. The muscles are gradually dilated and a tubular retractor is inserted to allow access to the affected area of the lumbar spine. The lamina is removed to allow visualization of the nerve roots, and the facet joints may be trimmed or removed to allow more room for the nerve roots.

The disc material is removed from the spine and replaced with a bone graft and structural support from a cage made of bone, titanium, carbon-fiber, or a polymer, followed by rod and screw placement. Surgeons may position small screws on the other side of the spine through a percutaneous technique to provide additional stability. The tubular retractor is removed, allowing the dilated muscles to come back together, and the incision is closed. This procedure typically takes about 2 ½ hours to perform.

Outcome
A comparison study of 20 patients who underwent endoscopic-assisted MIS TLIF with a group of patients who underwent the open PLIF procedure for single-level degenerative disease yielded the following results:

In the TLIF group, there was less intraoperative blood loss, a shorter hospital stay, and narcotic use after surgery significantly decreased.

In a larger study of 49 patients (45 with both low back pain and radicular pain in the legs), and the remaining four with low back pain, there were very promising results. Eleven of the patients had previous surgeries at the same levels of the spine.

After surgery, all 45 patients with both back and leg pain reported improvement in their symptoms. The four patients with low back pain also reported a decrease in pain. Eighteen months after surgery, all the patients had solid, successful fusions. The patients appeared to have less pain after surgery than with the open TLIF procedure, with narcotic pain relief medications discontinued 2 to 4 weeks after surgery.

American Association of Neurological Surgeons
Neurosurgerytoday.org
Minimally Invasive Spine Surgery, January 2009

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