TLIF: A Minimally Invasive Spine Surgery

What is transforaminal lumbar interbody fusion (TLIF)?

Transforaminal lumbar interbody fusion (TLIF) is a surgical procedure to treat affected vertebrae in the lumbar spine, which is the lower back area including five spine joints called the L1-L5 vertebrae. TLIF surgery can also include the L5-S1 area, which is the lowest vertebrae in the low back and the top vertebrae (S1) in the sacrum. The  L4-L5 vertebrae and the L5-S1 areas are the most common types of areas treated during TLIF surgery due to high rates of spinal stenosis in these vertebrae.

TLIF fuses two or more vertebrae in the spine together to relieve pressure on the nerves or spinal cord (decompress), improve instability, and reduce pain caused by conditions including degenerative disc disease, spondylolisthesis, recurring disc herniation, or spinal stenosis. TLIF surgery frequently requires the complete removal of the lamina (bony structure surrounding the vertebrae that protects the spine), known as a laminectomy, and a unilateral foraminotomy (performed on one side). These procedures allow the surgeon to access the vertebrae to fuse and create more space in the spinal column to decompress pressure on the nerves or spinal cord causing issues, respectively.

How is TLIF surgery performed?

For TLIF surgery, the patient is positioned laying on their stomach, or face down, so the surgeon can reach the spine through the posterior position (back). The surgeon accesses the damaged vertebral disc in the spine through the foramina, which are the natural openings in the vertebrae where nerve roots exit the spine to reach other areas of the body. As part of the procedure, the foramina are expanded to decompress areas of the nerves causing pain. The damaged disc is removed. A bone graft, which may come from another area of the patient’s body or a bone bank, is then inserted into the opening fuse the vertebrae together. The bone that is being removed during the decompression is also collected and used as autograft, meaning placed in another location of the spine to promote healing. The bone graft will eventually fuse the two vertebrae together. Screws and rods are attached to area of the spine being repaired to provide stability and promote healing.

Traditionally, TLIF surgery was performed as an open procedure that requires a large incision (3-6 inches) along the midline of the back to access the targeted area of the spine. Today, TLIF surgery is most often performed as minimally invasive spine surgery. Minimally invasive TLIF surgery requires 2-3 incisions that are less than 1 inch in length (and often as small as 3 centimeters, depending on the technology used) over the vertebrae being addressed.

During TLIF surgery, a spine neurosurgeon can fuse 2 or more vertebrae in the lumbar region. Each fusion involving one set of vertebrae is referred to as a level, so two adjacent levels would mean that 3 vertebrae are being joined.

How is minimally invasive TLIF different from traditional spinal fusion surgery?

During minimally invasive (MIS) TLIF, the surgeon creates 2-3 small incisions near the vertebrae being repaired. Each incision is less than 1 inch long and can be as small as 3 centimeters, depending on the size of the surgical instruments being used and the number of levels of the lumbar spine being fused together. One incision is used to insert the surgical tools being used for the procedure, and another incision is often made to insert a camera and/or obtain bone graft for the fusion. The sutures used to close the incisions often absorb on their own.

During open TLIF surgery, a much larger incision of up to 6 inches is required along the midline of the back to access the vertebrae being targeted. While dissolving sutures can be using with open TLIF procedures, staples and non-dissolving sutures may also be used depending on the patient and size of the incision. Open TLIF surgery is more common with multi-level fusions.

Minimally invasive (MIS) TLIF surgery has been shown to reduce tissue damage and shorten patients’ recovery time, both of which can lead to better post-surgical outcomes. MIS TLIF surgery was found to take longer than open TLIF surgery, according to a study published in World Neurosurgery. However, MIS-TILF offers the following benefits compared to open TLIF surgery:

• Shorter hospital stay
• Less blood loss during the procedure
• Improved long-term functional outcomes.

At Parker Advent Health Hospital, Neurosurgery One spine surgeons use the new TELIGEN™ System to perform minimally invasive TLIF surgery. This technology reduces the surgical time, compared to standard MIS-TLIF procedures, and surgeons have enhanced visualization of the spine with the technology.

Who is a candidate for TLIF?

TLIF surgery is only considered when conservative, non-surgical treatments including medication, physical therapy, injections, or interventional pain management have failed to provide adequate relief and stabilization. People who may be good candidates for TLIF surgery include those who have:

• Spinal conditions, such as degenerative disc disease, spondylolisthesis, recurring disc herniation, spinal stenosis, and scoliosis, that cause spinal instability or pain.
• Tumors, infections, or fractures of the spine that have caused instability or weakness.
• Previously failed spinal fusion surgery.

Candidates for TLIF surgery must also be evaluated for their:

• Overall health: Patient’s overall health and medical history, including age, body mass index (BMI), and any existing medical conditions, are carefully considered when determining their surgical options.
• Bone health: Weak bones can hinder fusion results and surgical outcomes. At Neurosurgery One’s Spine Fracture and Bone Health Clinic, we work closely with patients with osteoporosis and weak bones to improve bone health. Patients can strengthen their bones in as little as 6-12 weeks, which can make them better candidates for surgery and avoid failed fusion surgery.
• Smoking habits: Smoking can hinder the healing process and fusion success rates. Candidates who smoke may be required to quit before the surgery.

Before recommending the procedure, your Neurosurgery One neurosurgeon will discuss your goals and expectations of surgery as well as thoroughly review your symptoms, condition, and responsiveness to conservative treatments.

What are the benefits of TLIF?

TLIF offers several benefits for patients who have been carefully assessed and recommended for the surgery. Like other minimally invasive lumber spine fusion surgeries, such as lateral lumbar interbody fusion (LLIF), posterior lumbar interbody fusion (PLIF), and anterior lumbar interbody fusion (ALIF), minimally invasive TLIF reduces pain associated with the surgery and provides quicker recovery times compared to traditional open fusion surgeries. Because surgeons access the vertebrae through a unilateral approach during TLIF surgery, compared to a bilateral approach with PLIF, TLIF has been found to have less blood loss, complication rates, surgical time than PLIF.

Because TLIF surgery preserves the natural structure of the spine and can alleviate symptoms caused by nerve compression or spinal instability, the spinal fusion surgery has been found to lead to improved quality of life for many patients.

Additional benefits include:

• Fusion rates for both open TLIF and MIS-TLIF are greater than 90%
• Up to 86% of patients said their expectations of surgery were met with TLIF surgery
• 7% of patients were satisfied with the result of TLIF surgery 2 years post-operation
• Numerous studies, including this research published in The Spine Journal, show patients experience up to a 70% pain reduction after TLIF surgery

The success and benefits of TLIF surgery depend on various factors, including a patient’s overall health, the severity of their spinal condition, and their adherence to postoperative care instructions. You should always openly and honestly discuss the potential outcomes and expectations with your Neurosurgery One Denver spine surgeon.

What is the recovery process like after TLIF surgery?

Recovery after TLIF surgery varies from person to person and depends on the surgical approach used (minimally invasive vs. open. Open TLIF patients stay in the hospital for 3-5 days, with MIS-TLIF patients typically returning home within 1-3 days of surgery. Neurosurgery One uses a unique pain management and recovery process known as Enhanced Recovery After Surgery (ERAS). ERAS has been shown to improve recovery and reduce surgical complications, opioid use, and hospital stay length.

Many minimally invasive TLIF surgical patients can eliminate pain medication and return to driving and work within two weeks. A 2019 study found that MIS-TLIF patients were much less likely to use opioids while in the hospital and during recovery than those who underwent open TLIF.

During recovery, physical therapy, rest, and pain management are important to healing and returning to full function. Patients are usually advised to avoid heavy lifting, bending, or twisting for several weeks to allow for proper healing. Most patients can expect the surgery recovery process to take 6-12 weeks. It can take up to a year for the vertebrae to fully fuse together.

What are the potential risks and complications of TLIF surgery?

As with any surgical procedure, TLIF carries some risks. However, with advancements in surgical techniques and careful patient selection, the overall risks associated with the procedure are relatively low. Risks include:

• Infection: There is a less than 2-4% risk of infection nationally and less than 1% in Denver at Neurosurgery One. Infections are often related to comorbidities, such as obesity and diabetes, number of levels fused (more levels have a higher rate of infection), and length of surgery (longer surgery increases the likelihood of infection). At Neurosurgery One, we minimize risk of infection by ensuring patients are prepared through our Spine Fracture and Bone Health Clinic and pre-operation education as well as by using proper sterilization techniques and preventive techniques.
• Bleeding: Although rare, excessive bleeding may occur during or after the surgery.
• Nerve Damage: The proximity of nerves to the surgical site poses a slight risk of nerve injury. However, experienced surgeons take great care to protect the nerves during the procedure.
• Blood Clots: Prolonged immobilization after surgery can increase the risk of blood clots forming in the legs.
• Pseudoarthrosis: Known as failure of fusion, this may happen if the graft does not take, or fuse properly. This is common in smokers and patients with poor bone quality or osteoporosis. If pseudoarthrosis happens, the screws may loosen, causing pain and requiring spinal fusion revision surgery.
• Anesthesia Complications: The use of anesthesia carries its own set of risks, including allergic reactions, respiratory problems, or adverse reactions to medications. Anesthesiologists closely monitor patients during the procedure to minimize these risks.