Transforaminal Lumbar Interbody Fusion (TLIF)
Transforaminal Lumbar Interbody Fusion (TLIF) is a newer fusion technique for the relief of persistent lumbar region, or lower back, pain. TLIF is performed from the side of the back rather than the midline. Transforaminal refers to crossing the foramen, which is the opening within each of the spinal bones that allows nerve roots to pass through. This approach is chosen because it offers the advantages of placing two grafts at once with a very low risk of nerve damage. Interbody fusion refers to the removal of an interverterbal disc, which is replaced with a bone spacer, and the adjacent vertebrae are fused together.
TLIF can be used to treat nerve compression, disc space collapse, spondylothesis and other painful lower back conditions. After obtaining images of the spine with MRI and CT scans, a physician can determine just what type of implant would be best suited to correct the problem.
This surgery is very similar to posterior lumbar interbody fusion (PLIF). They vary in that during TLIF, it is standard to remove the pars interarticularis of the vertebrae. The pars interarticularis is the portion of the bone between the lamina and the pedicle. Removing it in addition to the lamina creates a larger space in which to place the bone graft without putting pressure on the nerve roots. Since the site is only being accessed by one area, complications are generally fewer and recovery is faster and easier than with other fusion procedures.
The TLIF Procedure
The TLIF procedure is performed under general anesthesia with the patient lying face down on an operating table. The treatment site is cleansed with an antiseptic and the surgeon makes a three- to six-inch incision in the side of the back near the affected area. Tools are used to separate and retract the muscles. An imaging device will ensure that the precise vertebrae are targeted. Next, the lamina and pars interarticularis are removed to provide a better view of the nerve roots. The injured disc, bone spurs or any other nearby debris are then taken out. This restores room for the nerves that have been compressed, relieving pain and symptoms in the lower back and legs.
To fill the space that has been created, a bone graft or bone morphogenetic proteins are then attached in the open disc area along with any necessary instrumentation to promote stability in the spine. Often, two spacers containing the graft material will be placed, with one positioned on each side of the interbody space. The surgeon carefully inserts the spacers, avoiding the spinal cord and nerves present nearby. In addition, metal plates, rods and screws are attached as needed to hold the spinal bones in place while fusion is occurring.
Bone morphogenetic protein (BMP) is an FDA-approved treatment used in conjunction with spinal fusion surgery to stimulate bone growth within the treated area and achieve optimal results without the need for a bone graft. However, bone grafts taken from another part of the patient's own body or obtained from donor bone are also highly successful.
Once complete, imaging is used again to confirm the placement of the spacers and instrumentation. The surgeon can then close up the incision with sutures or surgical staples. The TLIF surgery may vary in length, generally lasting between three and six hours, depending on the extent of the damage in the spine.
Recovery from a TLIF Procedure
After undergoing a TLIF procedure, patients will typically remain in the hospital for three to five days. A physical therapy regimen should be started soon after, as it is beneficial for regaining strength and full mobility. Certain activities may be restricted, including lifting objects, twisting the midsection and bending at the waist. Many patients can return to work two to three weeks following the procedure if their employment does not require strenuous exertion. After three months, patients may be cleared to resume some sports and more rigorous activities, but this will depend on the number of vertebrae fused during the surgery as well as each patient's individual healing process.
Risks of a TLIF Procedure
While TLIF is considered a safe procedure, it is still a form of spinal surgery and it therefore carries some risks. While uncommon, the complications it is associated with include infection, bleeding, nerve damage, blood clots, hardware failure and graft failure.