Transforaminal lumbar interbody fusion (TLIF) surgery

A transforaminal lumbar interbody fusion (called a TLIF) is essentially like an extended PLIF. It was developed in response to some of the technical problems with a PLIF procedure. The main difference between the two spine fusion procedures is that the TLIF approach to the disc space is expanded by removing one entire facet joint (whereas a PLIF is usually done on both sides by only taking a portion of each of the paired facet joints).

Transforaminal lumbar interbody fusion description

By removing the entire facet joint, visualization into the disc space is improved and more disc material can be removed. It should also provide for less nerve retraction. Because one entire facet is removed it is only done on one side. Removing the facet joints on both sides of the spine would result in too much instability.

With increased visualization and room for dissection a larger implant and/or bone graft can be used. Theoretically, this can allow the spine surgeon to distract the disc space more and realign the spine better (re-establish the normal lumbar lordosis).

Although this has some improvements over a PLIF procedure, the anterior approach in most cases still provides the best visualization, most surface area for healing, and the best reduction of any of the approaches to the disc space. This however must be weighed against the increased morbidity (e.g. unwanted aftereffects, postoperative discomfort) of a second incision.

Probably the biggest determinate in how the disc space is approached is the spine surgeon's comfort level with an anterior approach for the spine fusion surgery. Not all spine surgeons are comfortable with operating around the great vessels (aorta and vena cava) or have access to a skilled vascular surgeon to help them with the approach. Therefore, choosing one of the posterior approaches for the spine fusion surgery is often a more practical solution.

TLIF surgery risks and complications

The principal risk of this type of lower back surgery is that a solid fusion will not be obtained (nonunion) and further surgery to re-fuse the spine may be necessary. Fusion rates for a TLIF should be as high as 90-95%.

Nonunion rates after a spine fusion surgery are higher for patients who have had prior surgery, patients who smoke or are obese, patients who have multiple level fusion surgery, and for patients who have been treated with radiation for cancer. Not all patients who have a nonunion will need to have another spine fusion procedure. As long as the joint is stable, and the patient's symptoms are better, more back surgery is not necessary.

Other than nonunion, the risks of a spinal fusion surgery include infection or bleeding. These complications are fairly uncommon (approximately 1% to 3% occurrence). In addition, there is a risk of achieving a successful fusion, but the patient's pain does not subside.