TLIF

Objective

The ultimate goal of a fusion is the elimination of pathologic motion segment

and its accompanying symptoms.

Achieved by formation of osseous bridge across the previously mobile level.

Three basic requirements for a successful fusion are

Immobilization

Fusion bed

Bone Graft

Transforaminal lumbar interbody fusion (TLIF) reestablishes anterior column

support while allowing for posterior fixation, thereby improved fusion rates

because of circumferential support.

Indications

Degenerative Disc disease

Low Grade spondylolisthesis

Multiply recurrent disc herniation and foraminal stenosis associated with

deformity.

TLIF is ideal for grade 1 and 2 spondylolisthesis with unilateral symptoms.

Contraindications

Complete disc dessication

Presence of extensive osteophytes – limits disc distraction

Extensive scarring from prior posterior surgery serves as a relative

contraindication.

The pathology

Technique - Incision

Bone Removal

Remove the entire facet joint on one side in order to allow access to the

degenerated disc.

Removing the facet joint and disc relieves pressure on the compressed spinal

nerve, allowing it to return to the proper position.

Unilateral facetectomy

Total discectomy and end plate preparation

Total disc resection using special curettes and angled pituitary forceps under

image intensifier.

Marginal resection of dorsal edges of endplates.

Disc removal

Damaged portion is removed.

Graft placement A single bone graft is placed in the disc space from the lateral (side) aspect

through the area exposed when the facet joint was removed.

The bone graft will provide stability to the spine when it fuses with the

vertebrae above and below it.

In variations of this procedure, spacers, cages packed with graft material, or

ground bone graft material may also be packed into the disc space to aid with

the fusion.

Rectangular or Bean shaped cages can be placed.

Three methods of TLIF Technique

Bone graft final positioning Central alignment of graft allows

Realignment of vertebral bodies

This also lifts pressure form pinched nerve roots

Preparing for fusion

To prepare for additional fusion along the transverse processes, which will

further stabilize the vertebrae, a motorized instrument is used to remove the

top (cortical) layer of the transverse processes.

Placement of pedicle screws

The construct is compressed to establish optimal bone-cage interface and

reestablish lumbar lordosis.

Rod Placement

Rods are placed into screws to immobilize the painful vertebral segment.

The rod screw system is tightened and crosslinked.

Fusion

Bone forms along the rods and bone laterally and this creates the final fusion

construct.

Bone Graft

Bone grafting can be done with pieces of a patient’s own bone (autograft),

processed bone from a bone bank (allograft), or a bone graft substitute

(demineralized bone, ceramic extender, or bone morphogenetic protein).

Closure

The incisions are closed and dressed to complete the procedure. Adding the

instrumentation with bone graft fusion increases the strength of the spine

directly after surgery, and may decrease the need for a post-operative brace.

Final outcome

Complications

Most frequent is blood loss requiring transfusion.

Lumbar wound infection.

Postoperative radiculitis.

Cage subsidence or extrusion and pseudo arthrosis.

TLIF advantages over other fusion techniques

No morbidity from retroperitoneal dissection as in ALIF.

Unlike PLIF, TLIF requires minimal to no retraction on thecal sac and nerve

roots while still providing 360 degrees of support.

Because TLIF uses a more lateral trajectory, it can be performed in a setting

of previous surgery with identifiable landmarks and cleaner plane of

dissection.

Thank you.