Transverse lumbar interbody fusion (TLIF)

Last updated date: 13-Mar-2023

Originally Written in English

Transverse Lumbar Interbody Fusion (TLIF)

Transforaminal interbody lumbar fusion (TILF) is a surgical treatment that includes the permanent joining of portions of the lower back's bones (lumbar area). A TILF is a specialized procedure that makes use of bone graft material, either derived from a bone bank or a body cavity. Segments of the spine's bones and the bone graft eventually fuse to form one solid bone. To relieve pressure (decompress) on the spinal cord and nerves, a treatment is performed to permanently fuse a few of the lower spine's bones. A TLIF operation stabilizes the spine and stops the joints from deteriorating further after being damaged by an accident (including a car accident that caused a herniated disc) or an illness (such as degenerative disc disease).  In general, a spinal fusion stops movement between the vertebrae and, as a result, stops movement-related pain.

 

Spinal Anatomy

Spinal Anatomy

It is helpful to grasp the definitions of specific terms, such as the following, to fully comprehend a spinal fusion operation such as TLIF:

The spine. A spine in an adult consists of 24 vertebrae, or bones. Starting at the base of the skull and running down to the pelvis, the vertebrae are piled on top of one another.

The backbones (vertebrae). The vertebral body, which is the main component of the vertebrae, is just one of several elements that make up a vertebra (plural: vertebrae). The spinal cord and nerve roots are protected by the front of the vertebral body. The 24 vertebrae work as a unit to support the body's upright posture, protect the spinal cord and nerves, and give structure.

The vertebral discs. The discs, which are bony structures located between each vertebra, have an external layer and a gelatinous center that serve as shock absorbers and impact cushions.

Spinal canal. The front portion, known as the vertebral body, the pedicles on either side of the vertebral body, and the lamina in the back form the bone tunnel that surrounds the spinal cord.

Lamina. This is the portion of the spinal canal's top where the spinal cord's back is covered. The portion of the vertebra that joins the transverse process and the spinous process, a bony protrusion off the back's posterior, is known as the lamina. When the goal of back surgery is to relieve the pressure on the spinal nerve roots, the lamina is frequently the site of the procedure.

Facet joints. Each vertebra has a pair of joints that allow for a connection above and below it. One set of joints is on each vertebra's right side, while the other pair is on each vertebra's left side.

 

Lumbar Transforaminal Interbody Fusion

Transforaminal interbody lumbar fusion is a particular kind of surgical surgery that permanently joins or fuses the spine's bones. Bone grafts, either taken from a bone bank or transplanted from the patient's own body, are used to accomplish the fusion.

 

TLIF Indications

TLIF Indications

A TILF technique may be necessary for a variety of reasons including:

  • Herniated discs. In this condition, the spinal disc's outer layer is torn, allowing the inner layer to protrude through the fibers. The material that has herniated compresses the nerves near the disc, resulting in discomfort.
  • Spondylolisthesis. The spinal bone shifts out of its usual position in this disorder, squeezing the nerve and resulting in excruciating back pain.
  • Mild to moderate scoliosis. This is a curvature of the spine caused by out-of-place bones. Scoliosis can develop in adults as a result of aging, arthritis, or a prior back procedure.
  • Degenerative disc disease. This is the shrinkage of the disc that happens with time. Because of the disc's thinning or herniation (protrusion through an abnormal body hole), the bones rub against and press against the nerves (usually resulting in severe back pain).
  • Spinal stenosis. This occurs when the spinal canal narrows and the ligaments around the nerves squeeze them, which can cause pain and numbness in the lower extremities.
  • Broken vertebra. The primary cause of this is a serious impact-producing accident involving a vehicle.
  • Treatment may be required if the spine is infected.
  • Mass can press on the spinal nerves
  • Physiotherapy or other treatment modalities may not be sufficient to treat severe back pain, and TLIF may be required.

 

TLIF Preparation

TLIF Preparation

Before a TLIF, your doctor will perform a preoperative assessment and collect information about your medical history to check for any bleeding issues, history of anesthetic reactions, allergies, current medications, and vitamins or supplements you may be taking. Your healthcare practitioner may run the following tests among others:

  • Blood tests
  • Chest X-ray
  • Electrocardiogram (ECG)

Before a TLIF operation, preoperative recommendations may include:

  • Several medications, including nonsteroidal anti-inflammatory drugs like ibuprofen, naproxen, aspirin, and clopidogrel, should be stopped one to two weeks before surgery, or as directed by your doctor.
  • Use of blood thinners like warfarin should be stopped one to two weeks before surgery, or as directed by your doctor.
  • Stop using tobacco, including cigarettes, chewing tobacco, snuff or dip, nicotine gum or patches, or e-cigarettes. Nicotine has been associated with slowing bone tissue formation, which is necessary for fusion to succeed. It has been observed that fusion fails in 40% of smokers as opposed to only 8% of nonsmokers.
  • To prevent bleeding issues, stop drinking alcohol at least one to two weeks before surgery, depending on your surgeon's advice.
  • All nicotine replacement therapies and medications, whether they contain or do not contain nicotine, such as Chantix (varenicline) and Wellbutrin (bupropion), are substances that prevent bone fusion.

 

The Surgery Day

The preoperative instructions may include the following on the morning of surgery:

  • Use antibacterial soap when you take a shower.
  • Take any essential drugs (allowed by a surgeon) with a tiny bit of water.
  • All hardware from body piercings, hair, etc. should be removed.
  • Take off all jewelry, including a wedding band, and leave it at home.
  • Taking off nail polish
  • Arrive early at the hospital or outpatient clinic two hours before the surgery if it will be done there and one hour before it if it will be done elsewhere.

Before surgery, the anesthesiologist will typically discuss with the patient the benefits and risks of the anesthetic. To give the anesthesia and any other medications needed during or after the operation, the nurse will insert an IV line into the patient's arm.

Depending on how many levels of the spine are affected, the treatment itself often takes one to two hours. Arriving early will give you time to complete any preoperative workups, such as labs, that need to be completed on the day of surgery, one hour before outpatient procedures, and two hours before hospital procedures.

A TLIF is typically done as an outpatient surgery or as an inpatient hospital operation. Wear loose-fitting, freshly washed clothing and closed-back, flat shoes (not sandals, slippers, or flip-flops). On the morning of the procedure, refrain from eating or drinking anything, including water. Bring a list of your current medications, including prescriptions, OTCs, and herbal or natural supplements, together with dose instructions and the typical times of day you take them. Bring a list of any food or medication allergies.

 

TLIF Procedure

TLIF Procedure

Although the incision is done towards the back of the spine, the surgeon is still able to reach and fuse the vertebral bodies, which are the bones in the front of the spine. The interbody fusion part of the procedure's name is the outcome of fusion between these bodies.

To gain access to the front of the spine, the surgeon must remove bone and disc material. The foramina, also known as the exit points for the nerve roots, have gotten bigger. The transforaminal part of the procedure's name derives from this. TLIF surgery differs from other kinds of spinal fusion operations in that it involves the removal of bone and disc material and the widening of the foramina. The basic steps of a TLIF process are as follows:

  • The patient will be put into a prone (downward-facing) posture by the anesthesiologist, with pillows supporting either side of the body. Cleaning and preparation for surgery are done on the back's incision region.
  • The surgeon will split the back muscles with a specific tool after the patient has fallen asleep to establish a path to the spine.
  • To open the spinal canal and reveal the sac that shields the nerves, a portion of the lamina and facet joint are removed. To release the nerve, the surgeon removes a ligament and bone spurs.
  • The disc nucleus, a jelly-like substance found in the inner core of the disc, is removed after the surgeon carefully retracts the nerve. The bone graft cage, which is the hardware used to stabilize the vertebra throughout the fusion process, is held in place by a portion of the disc that is still there.
  • The bone graft material is prepared for the fusion while the fusion bed is prepared using bone shavers, and specialized tools for removing bone tissue. An X-ray is taken after inserting a trial spacer (often the interbody cage type) into the empty disc space to check that it is properly positioned to sufficiently decompress the nerves. Additionally serving as a means of support for the vertebral bodies is the spacer. Bone-growing proteins are found in a unique paste known as bone morphogenic protein (BMP). The spacer cage is filled with a unique paste.
  • Both above and below the disc space, two sets of screws are inserted into the bone, and a rod is inserted to link the screws.
  • The top vertebra is corrected using a wedged bone graft, and the remaining vertebrae are brought back into alignment with screws. During the process of fusion, the hardware gives the vertebrae stability. Once the bones have fused, the spinal column is permanently stabilized. The incision has finally closed.

 

TLIF Recovery

TLIF Recovery

Patients stay in the hospital for an average of two to four days following a typical TLIF spinal fusion procedure. In the time following surgery, patients may:

  • Keep an eye out for any infection-related symptoms, such as fever.
  • Experiencing pain at the site of the incision, which is typically treated with oral pain relievers.
  • The day after surgery, have a computed tomography (CT) scan done.
  • To enhance mobility and prevent blood clots, start physiotherapy as soon as possible after surgery.
  • Use a spinal brace for three months following surgery to accelerate recovery.

Patients are discharged with instructions to reduce activities. The most important precautions during recovery are to avoid moving heavy objects, bending or twisting the back, and sitting continuously for extended periods. Light walking is recommended. The surgeon must be informed of any numbness or tingling in the leg.

Patients can typically return to work in 4 to 6 weeks, or longer if their job requires greater physical work. Following surgery, a follow-up appointment with the surgeon is often planned for a date a few weeks later.

 

TLIF Risks

TLIF Risks

Even though TLIF surgery complications are uncommon, there is no way to be certain that spinal fusion will occur. There is no certainty that the operation will lead to bone fusion and a significant reduction in pain. The advantages and hazards must be examined, just like with any other surgical operation, before a person is considered a candidate. A TLIF operation could result in several problems, which may include:

Failure of the vertebrae to fuse. If the fusion doesn't occur or the fused area doesn't heal adequately, this may necessitate the need for another surgical treatment. Smoking, drinking alcohol, being overweight, having diabetes, malnutrition, and osteoporosis are some common factors.

Broken hardware. This could happen if the metal screws used to stabilize the spine during the treatment break before the bones have fully fused. Another surgical treatment might be necessary for this situation to repair or replace the damaged hardware.

Bone graft migration. It is an uncommon occurrence for a bone graft to shift into the space between the vertebrae. It typically happens when hardware, such as plates, screws, or other hardware, is not utilized to temporarily fuse the region before the bones fuse entirely. It may be necessary to do another operation to address the issue of bone graft migration.

Transitional syndrome (adjacent segment disease). The strain on the discs right above and below the fusion site is under additional stress as a result of this. This may eventually lead to the nearby discs degenerating, which frequently brings on excruciating back pain.

Nerve damage. Damage to the nerves or the spinal cord could arise during any type of spinal surgery, which could induce numbness or even paralysis in the lower extremities.

Long-lasting or chronic pain. The most typical reason for persistent pain following TLIF is a herniated disc that has damaged the nerves. Permanent nerve injury prevents the nerve from reacting to surgical decompression and limits pain relief.

In some cases, additional treatments or a procedure called spinal cord stimulation, in which electrical impulses are sent to the spine's nerves to block the pain, may be able to relieve discomfort. Remember that these risks should be discussed with the surgeon before your treatment to make sure that all questions are answered.

 

Conclusion

For a variety of spinal problems, including degenerative pathologies, trauma, infection, and neoplasia, interbody fusion is still a viable therapeutic option. For interbody fusion, there are several methods available, including TLIF, Mini TLIF, OLIF, and others. Comparative research proving that one technique is better than another in terms of fusion or clinical results is limited.