Awake TLIF Can Be Worth the Investment

Awake TLIF takes minimally invasive endoscopic spine surgery one step further and eliminates general anesthesia in favor of local. Learn about the benefits the technique conveys—and the barriers to its adoption.

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While general endoscopic spinal surgery—the impressive feat of performing surgery through a tube the size of a pencil—has moved into the mainstream, the procedure of awake transforaminal lumbar interbody fusion (TLIF) has been slower to take hold in the U.S.

Surgeon using endoscope during awake endoscopic TLIF surgeryAwake endoscopic TLIF conveys benefits to both patient and surgeon, but has a steep learning curve.

However, the awake TLIF surgery is becoming a more popular thanks to numerous benefits that include shorter recovery time and decreased complications for the patient, as well as fewer incisions and active nerve monitoring feedback for the surgical team. SpineUniverse spoke with Albert E. Telfeian, MD, PhD, Professor of Neurosurgery, Warren Alpert School of Medicine at Brown University, Director of Division of Minimally Invasive Endoscopic Spine Surgery to learn more about this innovative procedure and how surgeons can adopt the technique for their own practice. 

History of the Awake TLIF Procedure 

TLIF surgery is often indicated for conditions such as a pinched nerve, sciatica, herniated discs, or bone growth. Until fairly recently, open surgery was the standard—and for a long time, only—option. Endoscopic spinal surgery, minimally invasive and increasingly common, allows the procedure to be performed with smaller incisions and lower risk of complications. Awake endoscopic surgery takes minimally invasive surgery one step further, using only minimal sedation and local anesthetic to keep the patient fully awake. 

Endoscopic spine surgery in general has been evolving over the past 20 years to the point where it’s a very common procedure performed in Asia, but endoscopic fusion has been slower to gain acceptance. However, it is growing in popularity and is offered in several locations in the US.

For surgeons, the procedure differs little from any other method of lumbar transforaminal interbody fusion, says Dr. Telfeian. “All the TILF really involves is going through the foramen and removing the disc, pinching the nerves and replacing the disc with bone graft and an interbody spacer, then placing the screws,” Dr. Telfeian explains. 

Advantages of Awake TILF

There’s no second-guessing how Dr. Telfeian feels about the benefits of the awake TLIF procedure: “The benefits are huge,” he says. “With endoscopic spine surgery, infections are almost non-existent. Patients have fewer complications and fewer spinal fluid leaks, experience less bleeding and much faster return to life and work—weeks faster than a regular fusion surgery.”

He notes that with a regular fusion surgery, a patient might be in hospital for a few days, but with an endoscopic fusion, they go home the same day. Additionally, there is the clear advantage of fewer incisions, taking a significant surgical procedure down to only two to five small incisions and a surgical area that is about the size of a pea. 

He also points out that the benefits for the patient involve significant time savings: not only do the patients spend less time in the hospital, taking a former several-day stay down to a single outpatient visit, but their recovery time is far less too. 

“The average person travels over 100 miles to Rhode Island Hospital to have endoscopic spine surgery, so it’s so amazing to be able to offer life-changing surgery in a time-compressed manner,” Dr. Telfeian notes. He points to examples of his own patients, who have flown in from places like Hawaii and Alaska to have the procedure, only to fly out the very next day again to return home. “To make spine surgery like a dental procedure, so you're not giving up days, weeks, or months of life—especially for older individuals, who want to enjoy the life that they have—is very satisfying,” he adds.  

Adding to the decreased recovery time is eliminating the necessity for general anesthesia, which again, benefits both the patient and clinician. With just a local anesthetic, patients avoid the potential risks of general anesthesia and are able to provide active nerve monitoring during the surgical procedure because they are awake. Fewer incisions, decreased potential complications for the patient and less recovery time—what’s not to love? 


Adoption and Barriers

While the benefits of the awake TLIF procedure may seem clear, the adoption is not so straightforward. Dr. Telfeian notes that the most significant barrier to offering the surgery is the capital cost, which can be as high as $350,000 for equipment alone. Costs aside, surgeons may also face some hesitation from anesthesiologists who may be unfamiliar with awake procedures.

And speaking of adapting, the learning curve with the TLIF surgery can be pretty steep too. Dr. Telfeian admits that it will take some time to become adept at the procedure and he recommends doctors interested in learning how to offer awake TLF find a mentor in the field who can help train and guide them. He often takes on mentees himself and he also suggests interested parties reach out directly to the companies that make the endoscopic spine equipment.

For instance, companies such as joimax and RIWOspine offer courses and training on endoscopic spine surgery products and techniques. Dr. Telfeian also offers two YouTube videos that may be helpful: Transforaminal Endoscopic Fusion: Where, What, How, Why featuring Dr. Albert Telfeian and Albert Telfeian, M.D., Ph.D., Endoscopic Lumbar Spine Fusion Surgery. 

Awake TLIF surgery has many advantages for the patient and almost as many as the surgery. But, cost and learning curve may be preventing more widespread adoption of this innovative technique. Still, considering the benefits, it may behoove spine surgeons to learn and invest in awake TLIF before more patients start demanding it.

Updated on: 03/08/21
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Transforaminal Lumbar Interbody Fusion (TLIF) Technique
Albert Telfeian, MD, PhD

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