What is TLIF surgery?

Renowned consultant neurosurgeon Mr James Walkden explains TLIF (transforaminal lumbar interbody fusion) surgery, including its benefits, what is involved in the procedure and associated complications.

What is TLIF surgery?

MIS surgery is minimally invasive spinal surgery, where small ports are used through the muscles in the skin to access the skin, rather than doing a traditional open surgery, where the muscle of the bone to the spine would be stripped or removed.

The purpose is to improve post-operative pain and enable faster recovery. There’s also some evidence about lowered fraction rates and improved patient outcomes.

The slight downside is that there’s usually a training curve to learn these techniques and working through smaller operative channels and navigation to make sure they´re in the right place.

What is the difference between TLIF surgery and PLIF surgery?

Both surgeries aim to stabilise the level of the spine which is being operated on. The transforaminal lumbar interbody fusion (TLIF) approach is where you come from the side of the spine at a bleak angle.That gives you very good access to the side of the spine, so if the nerve compression is at the side of the spine, that’s a very good approach and is more minimally invasive.

You need smaller muscle cuts than what you require for a PLIF (posterior lumbar interbody fusion). That’s where you’re coming straightforward onto the spine. The PILF is generally less minimally invasive and a bit more painful to recover from than a TLIF, but in some cases you need access to the midline so if the spinal problem is in the middle, that’s quite hard to access from a TLIF. In that case, we would favour a PLIF approach.

However, essentially, the purpose of both surgeries is to stabilise the level with pedical screws and put an interbody spacer in the disk space to aid fusion. The big decision for surgeons is to decide which direction to come from.

What are the steps involved in the TLIF surgery procedure?

The patient is put under general anaesthesia. The surgeon is heavily dependent on x-rays for a minimally invasive TLIF, so the patient is face down. An x-ray is used to see where the pedicels are. They’re the boney bridges which link the back of the spine to the front of the spine.

Screws are placed under x-ray guidance with little needles so that the muscle cuts needed are quite small, just enough to let a needle down, and then a guidewire is put down the needle. The guidewire can be used (the screw has a hole in it), and the screw can be put in the wire. Then the screw will go into the virtual body.

Once those screws are in place, they can be used as a torrent and then the retractor will clip onto the screws. The hope is that it nicely comes out and there will be a small tunnel to view down exactly onto the facet and the disk space below.

Following this, once the surgeon has a good view, they can remove the facet with bone chissiles.

Afterwards, underneath, the surgeon should be able to see the exertion nerve. Usually, the disk is pressing up and then this disk is removed. The nerve should be free in that space. A spacer is added, which opens the space and therefore it opens the space for the nerve.

Finally, once that is done, the retractors are removed. They are connected with a rod and then secured. After, bone graft is put all around the rods so that the bone will grow around and over the rod, which means there’s a solid fixation. Then the small cuts which were made in the skin are closed and the patient should wake up with improved leg pain.

What are the complications in TLIF surgery?

The main risks of any surgery are bleeding and infection.

Specific to TLIF, putting the screws is probably the riskiest step, so it’s possible that the needles can go in the wrong direction, that’s why they’re put under x-ray guidance. However, that’s quite rare.

In patients with very poor bone quality (osteoporosis), the surgeon needs to be quite careful because the thin little wires can break through the porous bone, coming to a blood vessel or the abdomen. The likelihood of this happening is very rare but that’s the main big risk that surgeons worry about.

There’s also a risk to the nerve that the surgeon is trying to go to. It is usually very compressed, so it’s that nerve that is most at risk of being injured while removing the bone. Again, it’s quite rare because we remove the bone under x-ray guidance.

The nerve that the surgeon tries to access is usually very compressed, so that nerve is most at risk of being injured while removing the bone. Again, it’s quite rare because the bone is removed under x-ray guidance.

The other rare possible injuries after would be wound healing problems or the metal work coming loose over time. Again, that tends to happen in older patients with poorer bone quality. Surgeons can get around that if they know that the person has poorer bone quality beforehand. Cement can be put down the screws, which gives it a stronger purchase but that just adds an extra little bit of risk that the cement stays in place. It’s liquid cement, so there’s always a small chance that it’ll go in a direction that you don’t want it to go, but again, that’s quite rare.

How long does it take to recover from TLIF surgery?

It’s quite dependent on how the person is to begin with. If the patient is fully mobile and has severe leg pain but is otherwise independent, most patients would be able to be discharged within 48 hours.

The back pain recovery normally takes 6-8 weeks on average, but a lot of TLIF patients are probably improved by 4 weeks.

PLIF takes an extra 2-3 weeks, just because the muscle cuts are bigger than in TLIF surgery. Usually, follow-up x-rays are done at about 3 months, 6 months, and a year to ensure that the metalwork is fusing nicely.

Post-operative physiotherapy is encouraged for 3 to 6 months to try and build up muscle. This is particularly important in patients who may have a more advanced disability before the surgery is done, so not only may they have leg pain if they’ve already developed a weakness, that´s obviously going to take much longer to build back up again, probably over 6 months to a year with physiotherapy.

If you would like to book a consultation with Mr Walkden, simply visit his Top Doctors profile today.