Lumbar – Minimally Invasive Approach (TLIF)

A transforaminal lumbar interbody fusion(TLIF) is performed to remove a portionof a disc that is the source of back or legpain and fuse the spi  ne.  Like the PLIF(posterior lumbar interbody fusion)procedure, bone graft is used to fuse thespinal vertebrae after the disc isremoved. 

However, the TLIF procedureplaces a single bone graft between thevertebrae from the side, rather than twobone grafts from the rear as in the PLIFprocedure.  In patients with spinalinstability, instrumentation is used tohelp stabilize the spine during the bonegraft fusion. 

Using a technique knownas minimally invasive surgery, thisprocedure can be done with a muchsmaller incision than traditional openspinal surgeries and decreases damageto the low back muscles

Introduction

A transforaminal lumbar interbody fusion (TLIF) is performed toremove a portion of a disc that is the source of back or leg painand fuse the spine. Like the PLIF (posterior lumbar interbodyfusion) procedure, bone graft is used to fuse the spinal vertebraeafter the disc is removed. However, the TLIF procedure places asingle bone graft between the vertebrae from the side, rather thantwo bone grafts from the rear as in the PLIF procedure. In patientswith spinal instability, instrumentation is used to help stabilize thespine during the bone graft fusion. Using a technique known asminimally invasive surgery, this procedure can be done with amuch smaller incision than traditional open spinal surgeries anddecreases damage to the low back muscles

Accessing the Spine

A short incision, approximately 2.5 cm. (1 in.), is made to the sideof the middle of the lower back. A device that projects live X-rayimages onto a screen, called a fluoroscope is typically used topinpoint the exact position on the spine where the surgery will beperformed. Next, a thin wire or needle is inserted through tissuesand muscle to the level of the spine. Special dilators are guideddown the wire to separate muscle fibers and provide access to theunderlying spine without cutting through the muscles. After theinitial dilator is docked on the back of the spine, larger dilators areadded, gradually increasing the diameter to allow enough room forthe surgical procedure

Retractor and Instrument Set Up

A retractor device that can expand the surgical field and hold backthe muscle is placed over the dilators. The dilators are removedand a lighting component is attached to illuminate the surgicalfield. A hex screwdriver is used to open the retractor blades,holding the soft tissue out of the way. The surgical exposure isnow complete. An endoscope or microscope is then added to theedge of the retractor to provide close-up imagery on a screen tohelp guide the procedure.

Accessing the Disc

Through the opening in the retractor, the surgeon is now able toremove the entire facet joint in order to allow access to the disc.Removing bone here allows the surgeon to access the disc

Excision

A grasping instrument is used to remove most of the intervertebraldisc. Removing the facet joints and disc relieves pressure on thespinal nerves.

Graft Placement

A single bone graft is placed in the disc space from the lateral
(side) aspect through the area exposed where 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.

Instrumentation

Next, the vertebrae are prepared for instrumentation. A sharp awl
is used to make holes in the pedicles for insertion of pedicle
screws. A guide wire is positioned in the holes and screws are
placed over the guide wire and screwed into the pedicle. After the
screws have been placed, the guide wire is removed. Next, a rod
is positioned between the screws and fastened in place. The rod
and screw instrumentation provides stability to the spine and
prevents the vertebrae from moving while the bone graft fusion
takes place.

Summary

The Minimally Invasive Surgery (MIS) approach to the TLIF
procedure can be safely performed with little trauma to the
surrounding low back muscles. MIS procedures may result in less
postoperative pain, shorter hospitalizations, and quicker patient
recovery than traditional open surgical methods.
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