Transforaminal Lumbar Interbody Fusion (TLIF)

What is a transforaminal lumbar interbody fusion (TLIF)?
Transforaminal lumbar interbody fusion (TLIF) is a contemporary approach to spinal fusion surgery. It is an operation performed on the lower back to remove an intervertebral disc and join two or more spinal bones (vertebrae) together using screws and a cage.

Specifically, a TLIF involves:

  1. Decompression of the nerves in the lower back
  2. Removal of a facet joint
  3. Removal of the intervertebral disc
  4. Stabilisation of the disc level by inserting screws into the bones above and below (pedicle screws)
  5. Fusing the spine by inserting a cage filled with bone into the disc space (interbody fusion)

A TLIF offers important advantages over the alternative surgical techniques of both a posterior lumbar interbody fusion (PLIF) and posterolateral instrumented fusion. These advantages will be discussed below.

Why might I need a TLIF?
A TLIF is advised for some patients who may have the following conditions:

  1. Disc prolapse causing pressure on the nerve roots, when one or more of the following conditions exist:
    1. There has been previous surgery
    2. There is significant discogenic back pain (back pain arising from the disc)
    3. There is instability of the spine
    4. Surgery to simply remove the disc and take pressure of the nerves would be likely to cause instability
  2. Lumbar canal and/or lateral recess stenosis, when one or more of the following apply:
    1. There is also significant discogenic back pain (back pain arising from the disc)
    2. There is instability of the spine
    3. Surgery to simply take pressure of the nerves would be likely to cause instability
  3. Foraminal stenosis (decompression for this problem may cause instability unless a fusion is performed at the same time)
  4. Discogenic lower back pain
  5. Facet joint pain which has not responded in a sustained fashion to facet joint blocks and radiofrequency denervations
  6. Spondylolisthesis (slip of one vertebra on another)

Surgery is usually recommended when all reasonable conservative measures (pain medications, nerve sheath injections, physical therapies, braces etc.) have failed.

In cases of significant instability or neurological problems, surgery may be the most appropriate first treatment option.

How is the diagnosis made before deciding upon surgery?
Making the diagnosis usually requires taking a history of the problem, as well as a neurological examination. The history (symptoms or complaints obtained from the patient) is the most important aspect of the assessment.

Important questions often include:

  • Has there been an injury?
  • Where is the pain?
  • Is there any numbness?
  • Is there any weakness?
  • Have you had the same or a similar problem in the past?
  • Have you had any weight loss, fevers, or illnesses recently?
  • Have you had cancer in the past?
  • Are there any problems when you urinate or open your bowels?

Investigations are extremely important, and may include the following:

  • CT scan
    • usually an early investigation
    • shows the anatomy of the bone and joints very well
  • MRI scan
    • gives more detailed information about the discs and nerves
  • CT Myelogram
    • usually performed if an MRI cannot be carried out for some reason
  • Standing X-rays and X-rays taken bending forward and backward (flexion-extension X-rays)
    • to assess for potential spondylolisthesis and instability
  • Nerve conduction studies and/or a nerve sheath injection with local anaeasthetic
    • to confirm which nerve (or nerves) is causing the symptoms
  • Facet joint blocks and/or a nuclear medicine scan (lumbar SPECT)
    • if pain arising from the facet joints is suspected
  • Provocative lumbar discogram
    • if pain arising from an intervertebral disc is suspected
  • Nuclear medicine bone scan
    • if cancer of the spine is suspected
  • Bone density scans (DEXA scan)
    • if osteoporosis is suspected

Sometimes a second opinion from another neurosurgeon or a neurologist, pain physician, orthopaedic surgeon or rheumatologist may be sought.

What are the alternatives to a TLIF?
A number of alternatives to a TLIF may exist, depending upon your individual circumstances. These include:

  1. Pain medications. A number of medications may be useful for pain. These include the standard opioid and non-opioid analgesic agents, membrane stabilising agents and anticonvulsants, as well as the most recent agent to be released- Pregabalin. Special medical treatments such as Ketamine infusions may be appropriate in some situations.
  2. Nerve sheath injections. Local anaesthetic may be injected, under CT scan guidance, around the compressed nerve. This is also known as a ‘foraminal block’. Patients frequently obtain a significant benefit from this procedure, and surgery can sometimes be delayed or even avoided. Unfortunately, the benefit obtained from this procedure is usually only temporary, and it tends to wear off after several days, weeks, or sometimes months. This procedure is also an excellent diagnostic tool, especially when the MRI scan suggests that multiple nerves are compressed and your neurosurgeon would like to know exactly which nerve is causing your symptoms.
  3. Physical therapies.
  4. Activity modification. Sometimes simply modifying your workplace and recreational activities, to avoid heavy lifting, prolonged sitting, and repetitive bending and twisting, allows the healing process to occur more quickly.
  5. Other surgical approaches. These include:
    • lumbar microdiscectomy
    • lumbar decompression (also known as a laminectomy and rhizolysis)
    • non-instrumented fusion: where bone is laid down without using screws or cages to stabilise the spine
    • posterolateral instrumented fusion: where screws are placed but the disc space is not fused by inserting a cage
    • posterior lumbar interbody fusion (PLIF)
    • anterior lumbar interbody fusion (ALIF)
    • artificial disc replacement (arthroplasty)
    • disc nucleus replacement (nucleoplasty)
    • spinal cord stimulation

You should discuss these alternatives, together with their potential risks and benefits, with your neurosurgeon.

How does TLIF compare with other types of fusion surgery, such as PLIF?
Like all types of spinal fusion surgery, both TLIF and PLIF procedures involve the laying down of bone graft (from the spine or iliac crest) or bone graft substitute (such as tricalcium phosphate and bone morphogenetic proteins) across certain areas of the spine to stimulate bone to grow between the two spinal bones and thereby prevent any significant motion at that segment.

The success rate for posterior or posterolateral fusion (where bone is laid down over the lamina and/or transverse processes after screws have been inserted) in the treatment of discogenic back pain is only around 60%. Possible reasons for this significant failure rate include:

  • Selection of the ‘wrong types’ of patients for this surgery
  • The fact that the actual pain-generator, the disc, is not fused
    • significant movement of the disc persists despite a solid fusion at the back of the spine
    • patients with ongoing back pain after solid posterior fusion often experience significant improvement following a second operation to fuse the disc space itself

In an attempt to improve outcomes following lumbar fusion, fusion of the disc has been performed to directly address the most common source of pain. This is known as an interbody fusion, and was originally done via a PLIF approach. More recently, a TLIF approach had become more popular. The goal of both is to achieve a bony union across the disc space (see picture).

Unlike a simple posterolateral instrumented fusion fusion, a PLIF works by placing bone graft and a cage directly into the disc space itself. This is done by removing a large amount of bone from the back of the spine (a wide laminectomy), and retracting (pulling) the nerves (within their lining known as the theca or dura) to one side.

TLIF, a more modern approach, avoids significant retraction of the dura and nerve roots. By removing one of the facet joints, a different trajectory is adopted to take out the disc and insert bone graft and a cage into the disc space. This exposes the nerves to a lower risk of injury, and also requires less muscle retraction (which may contribute to post-operative and long-term back pain).

[[PASTING TABLES IS NOT SUPPORTED]]

In most cases of lumbar fusion a TLIF can be carried out, however in some patients a PLIF is still an appropriate option.

What are the potential benefits of a TLIF?
The goals of a TLIF may include:

  • Reduction of leg pain, numbness, tingling and weakness
  • Reduction of back pain
  • Stabilisation of an unstable spine
  • Medication reduction
  • Prevention of deterioration
  • Improved lower back and leg function
  • Improved work and recreational capacity
  • Improved quality of life

Generally, the symptom that improves the most reliably after surgery is leg pain. Back pain also often improves, but occasionally can be worse. The next symptom to improve is usually weakness. Your strength may not return completely back to normal, however. Improvement in strength generally occurs over weeks and months. Numbness or pins and needles may or may not improve with surgery, due to the fact that the nerve fibres transmitting sensation are thinner and more vulnerable to pressure (they are more easily permanently damaged than the other nerve fibres). Numbness can take up to 12 months to improve, if it does so.

The chance of obtaining a significant benefit from surgery depends upon a wide variety of factors. Your neurosurgeon will give you an indication of the likelihood of success in your specific case.

What are the possible outcomes if treatment is not undertaken?
If your condition is not treated appropriately (and sometimes even if it is), the possible outcomes may include:

  • Ongoing pain
  • Paralysis, weakness, and/or numbness
  • Impaired bowel and/or bladder control
  • Erectile dysfunction
  • Problems with walking and balance

What are the specific risks of a TLIF?
Generally, surgery is fairly safe and major complications are uncommon. The chance of a minor complication is around 4 or 5%, and the risk of a major complication is 2 or 3%. Over 90% of patients should come through their surgery without complications.

The specific risks of a TLIF include (but are not limited to):

  • Fail to benefit symptoms or to prevent deterioration
  • Worsening of pain/weakness/numbness
  • Infection
  • Blood clot in wound requiring urgent surgery to relieve pressure
  • Cerebrospinal fluid (CSF) leak: this risk is much higher in revision (re-operation) surgery
  • Surgery at incorrect level (this is rare, as X-rays are used during surgery to confirm the level)
  • Blood transfusion
  • Injury to bowel or abdominal blood vessels when the disc is being removed
  • Screw and/or cage breakage, movement, or malposition, sometimes requiring further surgery
  • Recurrent nerve compression
  • Nerve damage (weakness, numbness, pain) occurs in less than 1%
  • Paraplegia (paralysed legs)
  • Incontinence (loss of bowel/bladder control)
  • Impotence (loss of erections)
  • Chronic pain (may require further surgery)
  • Failure to fuse (pseudoarthrosis)
  • Adjacent segment disease (deterioration of the disc above or below)
  • Blindness (extremely rare)

What are the risks of anaesthesia and the general risks of surgery?
Having a general anesthetic is generally fairly safe, and the risk of a major catastrophe is extremely low. All types of surgery carry certain risks, many of which are included in the list below:

  • Significant scarring (‘keloid’)
  • Wound breakdown
  • Drug allergies
  • DVT (‘economy class syndrome’)
  • Pulmonary embolism (blood clot in lungs)
  • Chest and urinary tract infections
  • Pressure injuries to nerves in arms and legs
  • Eye or teeth injuries
  • Myocardial infarction (‘heart attack’)
  • Stroke
  • Loss of life
  • Other rare complications

What are the implications of surgery?
Most patients are admitted on the same day as their surgery; however some patients are admitted the day before.

Patients admitted the day before surgery include those who:

  • reside in country regions, interstate, or overseas
  • have complex medical conditions or who take warfarin
  • require further investigations before their surgery
  • are first on the operating list for the day

You will be given instructions about when to stop eating and drinking before your admission.

Several X-rays of your back will be taken during surgery to make sure that the correct spinal level is being fused, and also to optimise the positioning of the screws and cage. It is critical that you inform us if you are pregnant or think you could possibly be pregnant, as X-rays may be harmful to the unborn child.

You will wake up with a catheter (tube) in your bladder, and a drip in your arm. These will be removed around 24 hours after surgery. It is important that you get up and walk around either on the evening of your surgery or the next day. You will need to wear stockings to prevent blood clots after your surgery.

A CT scan will be performed the day after surgery to check the position of the screws and cage. You will be fitted with a custom-made lumbar brace which you will need to wear whenever you are walking or sitting for 3 months after surgery.

You will be in hospital for between 3 and 5 days after your surgery (on average). This is usually followed by a 5-7 day period of inpatient rehabilitation, but not all patients need this.

You will be given instructions about any physical restrictions that will apply following surgery, and these are summarised later in this section.

There is significant variability between patients in terms of the outcome from surgery, as well as the time taken to recover. You will be given instructions about physical restrictions, as well as your return to work and resumption of recreational activities. You should not drive a motor vehicle or operate heavy machinery until instructed to do so by your neurosurgeon.

You should not sign or witness legal documents until reviewed by your GP post-operatively, as the anaesthetic can sometimes temporarily muddle your thinking.

An important issue relating to spinal fusion is that by fusing level of the spine, slightly increased stress is placed upon the levels directly above and below the fusion. This increases the risk of degeneration at these levels and, therefore, the possibility that you may need further surgery in the future. You should discuss this issue further with your neurosurgeon.

Fusion of the lumbar spine results in a degree of loss of movement in the lower back, mainly in terms of bending forwards and backwards. For a one level fusion, this loss of movement is usually barely noticeable (if at all). There is usually a small but definite loss of movement following a two level fusion. Three or four level fusions are only occasionally carried out, due to less satisfactory postoperative outcomes.

It is critical that you stop smoking for at least 12 months after surgery (but preferably forever!). Smoking impairs the fusion process and leads to worse outcomes after spinal surgery.

How does revision lumbar spine surgery differ from ‘virgin’ surgery?
The risk of complications from lumbar spine revision surgery (surgery after a previous spinal surgical procedure) is significantly higher than in first-time procedures. This is due to a number of factors, particularly scar tissue formation around the nerves and the distortion of the usual anatomical structures. Spinal fluid (CSF) leakage from a hole in the lining over the nerve roots is a significant risk, but is usually managed successfully without serious long-term consequences.

It is also more difficult to relieve pain and restore function in revision surgery, as the nerves may have been damaged by longstanding compression and previous interventions.

It is important be aware that the possibility of experiencing long-term back pain is increased with revision surgery.

What do I need to tell the spine surgeon before surgery?
It is important that you tell your surgeon if you:

  • Have blood clotting or bleeding problems
  • Have ever had blood clots in your legs (DVT or deep venous thrombosis) or lungs (pulmonary emboli)
  • Are taking aspirin, warfarin, or anything else (even some herbal supplements) that might thin your blood
  • Have high blood pressure
  • Have any allergies
  • Have any other health problems

What do I need to do before surgery?
Before your surgery it is imperative that you stop smoking, and you should not smoke for at least 12 months after. Smoking impairs the fusion process and leads to worse outcomes following spinal surgery.

If you are fairly overweight, it is advisable that you engage in a sensible weight loss program before you surgery.

In order to prevent unwanted bleeding during or after surgery, it is critical that you stop taking aspirin, and any other antiplatelet (blood-thinning) medications or substances including herbal remedies at least 2 weeks before your surgery.

If you normally take warfarin, you will usually be admitted to hospital 3 or 4 days before your surgery. Your warfarin will be ceased at that time (it takes a few days to wear off) and you may be commenced on shorter-acting anti-clotting agents for a few days. These can then be stopped a day or so before surgery.

Ideally, you should take a Zinc tablet a day, commencing one month before surgery, and continuing for 3 months after. This should help wound healing.

Will I need further investigations?
Most patients will have had X-rays of their back, as well as a CT scan and MRI. Sometimes standing and ‘dynamic’ X-rays of the lumbar spine are performed, with X-rays taken leaning forwards and backwards; this is to determine the presence and site of any instability.

In some patients there is uncertainty either about the diagnosis or exactly which disc or discs in the back are responsible for their symptoms: in those patients, a provocative lumbar discogram, nerve conduction studies and/or a nerve block may shed light on the diagnostic issues.

If you have not had an MRI for over 12 months before your surgery, or if your symptoms have changed significantly since your most recent MRI, then this investigation will need to be repeated to make sure that there are no surprises at the time of surgery!

Who will perform my surgery? Who else will be involved?
Surgery will be carried out by your spine surgeon. A surgical assistant will be present and an experienced consultant anaesthetist will be responsible for your general anaesthetic.

How is a TLIF performed?
A general anaesthetic will be administered to put you to sleep. A breathing tube (‘endotracheal tube’) will be inserted and intravenous antibiotics and steroids injected (to prevent infection and post-operative nausea). Calf compression devices will be used throughout surgery to minimise the risk of developing blood clots in your legs. A catheter will be inserted into your bladder to prevent bladder distension during surgery and to monitor urine output. You will be placed face-down on the operating table on a special spinal frame.

Your skin will be cleaned with antiseptic solution and some local anaesthetic will be injected.

The skin incision is usually about 6-10cm in the middle of you lower back. It is vertical.

The plane between your back muscles on each side of the spine is then followed down, and screws are inserted into the pedicles at the appropriate levels.

The facet joint on one side is removed using a high-speed drill, and the nerve roots are identified and decompressed (this is known as a ‘rhizolysis’).

A microdiscectomy is performed (see picture). This is done by first cutting the outer annulus fibrosis (fibrous ring around the disc) and removing the nucleus pulposus (the soft inner core of the disc). Disc removal is performed using a combination of special instruments.

The boundaries of the disc space (the vertebral end-plates) are then carefully prepared to facilitate fusion. Some bone from the facet joint is mixed with tricalcium phosphate and bone morphogenetic proteins, and this is packed into the empty disc space.

An interbody cage (made of carbon fibre, PEEK, or trabecular metal) is filled with bone and inserted into the disc space.

A small piece of fat is laid over the nerve roots to minimise scarring.

Further bone is laid down over the laminae, as well as the opposite facet joint and transverse processes (posterior and posterolateral fusion).

The screws are then connected by rods and, if a significant slip (spondylolisthesis) is present, this may be partially reduced.

During the procedure,several X-rays are performed to check that the operation is being carried out at the correct disc level, and that the screws and cages are in a satisfactory position. At the end of the procedure, the surgical field is checked for excessive bleeding or any other problems, and a final check is made to ensure that the nerves are no longer under pressure.

The wound is closed with dissolving sutures or with staples.

What happens immediately after surgery?
It is usual to feel some pain after surgery, especially at the incision site. Pain medications are usually given to help control the pain. While tingling sensations or numbness is common, and should lessen over time, they should be reported to your neurosurgeon.

Most patients are up and moving around within several hours of surgery. This is encouraged in order to keep circulation normal and avoid blood clot formation in the legs.

You will be able to drink after 4 hours, and should be able to eat a small amount later in the day.

A CT scan will be performed the next day to check the position of the screws and cage.

You will be discharged home when you are comfortable, usually after a short period of inpatient rehabilitation.

What happens after discharge?
You will need to wear a special brace for 3 months after surgery whilst you are sitting, standing or walking. You will need to take it easy for 8 weeks, but should walk for at least an hour every day. You should avoid sitting for more than 15-20 minutes continuously during this time.

At 6-8 weeks it is likely that you will be able to return to work on “light duties” and to drive a motor vehicle on short trips. This, and the step-wise progression in your physical activities, will be determined on an individual basis.

Bear in mind that the amount of time it takes to return to normal activities is different for every patient. Discomfort should decrease a little each day. Increases in energy and activity are signs that your post-operative recovery is progressing well. Maintaining a positive attitude, a healthy and well-balanced diet, and ensuring plenty of rest are excellent ways to speed up your recovery.

Signs of infection such as swelling, redness or discharge from the incision, and fever should be brought to the surgeon’s attention immediately.

You will be reviewed after 6-8 weeks by your neurosurgeon. Until then, you should not lift objects weighing more than 2kg, and should not engage in bending or twisting movements.

The results of fusion surgery are not as good in patients who smoke or are very overweight. It is therefore important that you give up smoking permanently before your surgery and try to lose as much weight as possible.

You should continue wearing your TED stockings for a couple of weeks after surgery.

What are my discharge instructions following TLIF?

Diet:
Maintain normal healthy diet, high in fibre to avoid constipation

Medications:
You may be prescribed analgesia (pain medications), muscle relaxants, and stool softeners. Be aware that some pain medications can cause constipation. Please take only the analgesia that has been prescribed for you.

Activity:

Allowances:

  • Frequent short walks (at least 1-2 hours per day)
  • Travelling by car is allowed for short distances. If you are making longer trips, break the trip up into 20 minute segments, getting out of the car for a few minutes to go for a short walk.
  • Walking up and down stairs

Restrictions (aimed at protecting your back and allowing healing to occur)

  • No sitting for longer than 20 minutes at a time or as directed by your neurosurgeon
  • Do not bend from the waist (you should bend at the knees)
  • No twisting
  • No stretching or reaching for items above your head
  • Sleep with a pillow between your knees when lying on your side
  • Do not lift anything heavier than 2kg for the first 6 weeks post-operatively. Light housework only – no hanging washing out on the line, carrying baskets of clothing, no vacuuming, lawn mowing.
  • No driving for at least 6-8 weeks after surgery
  • No vigorous exercising/playing sports until you are cleared by neurosurgeon to commence these.
  • Strict bed rest IS NOT required or recommended.

Smoking:
Smoking impairs wound healing and damages the discs in your back. Stopping smoking may improve outcomes.

Wound Care:

  • You will have either dissolvable sutures or staples.
  • Have GP check your wound 4 days after discharge. A new dressing will be applied and this is to remain on for a further 4 days then is to be removed. Staples will usually be removed 7-8 days after surgery.
  • Keep wound dry for 12 days after surgery.
  • Shower if the dressing is intact. If the wound becomes moist, it will need to be dried and a new dressing applied.
  • Report any redness, discharge, persistent oozing or drainage from the wound.
  • Avoid swimming, spas or baths until your wound has completely healed, or until you are cleared to commence these.
  • Keep taking your Zinc tablets daily for 3 months after surgery (this helps wound healing).
  • You should gently rub Vitamin E cream into your wound commencing 3 weeks after surgery and continuing for 6-12 months (this may reduce scarring).

What do I need to tell my surgeon about after the operation?
You should notify your neurosurgeon and should also see your GP if you experience any of the following after discharge from hospital:

  • Increasing leg pain, weakness or numbness
  • Worsening back pain
  • Problems passing urine or controlling your bladder or bowels
  • Problems with your walking or balance
  • Fever
  • Swelling, redness, increased temperature or suspected infection of the wound
  • Leakage of fluid from the wound
  • Pain or swelling in your calf muscles (ie. below your knees)
  • Chest pain or shortness of breath
  • Any other concerns

What are the results of surgery?
Overall, over 70% of patients will obtain a significant benefit from surgery, and this is usually maintained in the long term.

It is important to note that few patients become completely free of symptoms- the goals are pain and medication reduction, as well as prevention of deterioration.

What are the costs of surgery?
Private patients undergoing surgery will generally have some out-of-pocket expenses.

A quotation for surgery will be issued, however this is an estimate only. The final amount charged may vary with the eventual procedure undertaken, operative findings, technical issues etc.

Separate accounts will be rendered by the anaesthetist and sometimes the assistant, and hospital bed excess charges may apply.

You should fully understand the costs involved with surgery before going ahead, and should discuss any queries with your surgeon.

What is the consent process?
You will be asked to sign a consent form before surgery. This form confirms that you understand all of the treatment options, as well as the risks and potential benefits of surgery. If you are unsure, you should ask for further information and only sign the form when you are completely satisfied.