What is a TLIF Surgery?
A transforaminal lumbar interbody fusion surgery, also known as a TLIF procedure, is a type of lumbar spinal fusion procedure that is performed through an incision in the lower back alone. It can be performed for a variety of reasons, but the most common cause is for a spondylolisthesis or slippage of the spine that is causing back and leg pain from nerve compression.
Other reasons for surgery include degenerative disc disease with primarily leg pain symptoms, scoliosis, or fractures causing spinal instability.
The surgery itself involves removing pressure on the affected nerves and then stabilizing the spine using spinal instrumentation (screws, rods, and a titanium cage) and placing bone graft around the spine and in the disc space to allow the bones to heal together.
While in other spinal fusion procedures a cage in the disc space can be placed from the front through an incision in the abdomen or through the side, in a TLIF surgery the cage is placed without any additional incisions through the same incision in the back used to decompress the nerves and place the screws.
Transforaminal lumbar interbody fusion surgery is performed under general anesthesia. The patient is positioned on their stomach for the operation. Needles are placed on the skin throughout the body to monitor spinal cord and nerve function during the surgery.
An incision is made in the lower back over the affected levels of the spine.
After the spine is exposed, pedicle screws are placed into the vertebrae (bones) of the spine that are being fused together. Next the nerves are decompressed using a high speed burr and special cutting instruments to remove bone, ligament, and disc that may be narrowing the space available for the nerves that is causing leg pain, numbness and weakness.
Once this is done, the facet joint on one side is completely removed which allows safe access to the disc space without having to manipulate the nerves excessively. Then the disc is completely removed and in its place a titanium cage filled with bone graft is placed into the empty disc space. Then more bone graft is placed on the back of the spine and rods are placed to secure the screws together.
Final x-rays are obtained to make sure the screws and cage are in good position and the incision is then closed.
What to Expect After TLIF Surgery?
If transforaminal lumbar interbody fusion surgery is performed for sciatica or radiculopathy (severe leg pain from nerve compression), patients typically wake up from anesthesia with decreased leg pain immediately after surgery. Leg pain symptoms usually continue to improve over the next several weeks during the early recovery. After TLIF surgery it is normal to have some back pain from the surgical procedure itself but this surgical pain resolves over the course of 4-6 weeks.
Weakness and numbness in the legs if present prior to surgery can take longer to recover, often weeks to months. Sometimes these symptoms may never completely recover, especially if they had been long-standing prior to surgery.
Recovery Time for Transforaminal Lumbar Interbody Fusion Surgery
Transforaminal lumbar interbody fusion recovery time varies depending on how extensive the spinal fusion procedure performed was (single level vs multi-level).
Usually most patients can go home after 2 days in the hospital. Walking is encouraged immediately after surgery and it is recommended to gradually increase your walking in the first 6 weeks of recovery until you are able to walk up to 20-30 minutes briskly at a time.
Brisk walking encourages blood flow to the spine and helps the muscles heal faster and encourages healing of the spinal fusion. For the first 3 months after surgery heavy lifting, bending, or twisting should be limited to decrease stress on the spinal instrumentation and to allow the initial phases of the spinal fusion to occur.
After 3 months, patients can gradually return to their usual activities while focusing heavily on improving their core strength through isometric core exercises (e.g. planks). Sports that require repetitive bending or twisitng (such as golf) should usually be avoided until 6 months after surgery.
Post-operative appointments are recommended at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years to monitor transforminal lumbar interbody fusion recovery.
TLIF Spinal Fusion Surgery Risks
All spinal operations carry some risks and these should be considered carefully along with the potential benefits of surgery which are to relieve symptoms of spinal instability and nerve compression in the lower back.
The most common risks after transforaminal lumbar interbody fusion surgery are:
Back pain while recovering from the operation itself which usually resolves over 4-6 weeks
Risk of persistent leg symptoms such as pain, numbness, or weakness. This is particularly true if the symptoms have been long-standing prior to surgery, or in patients that are elderly, smoke cigarettes, or are overweight as the nerves have a limited healing potential
Risk of pseudarthrosis, which means that the bones did not successfully heal or fuse together. This occurs more commonly in patients that have osteoporosis, smoke cigarettes, have diabetes, are overweight, or have other medical conditions that may limit their healing potential. To decrease this risk a bone growth factor called bone morphogenetic protein (rhBMP-2) is occasionally also used during surgery to increase the chances of a successful spinal fusion.
Some rare risks that are specific to transforaminal lumbar interbody fusion surgery are:
Risk of nerve injury or new nerve pain. This is quite rare but can sometimes occur because the nerves have to be gently moved to the side to allow access to the disc space to remove the disc and place the bone graft and cage. If new nerve pain occurs it is usually transient and will resolve in several days to weeks.
Risk of a malpositioned screw or cage that may need repeat surgery to reposition the instrumentation
Risk of infection
Persistent back pain, leg pain, numbness, and weakness. Even if the surgery is successful and the spinal fusion heals successfully, sometimes patients will not fully recover due to reasons not fully understood
Risk of a medical complication around the time of surgery such as a pneumonia, urinary tract infection, stroke, heart attack, or blood clot (DVT or pulmonary embolism)