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Transforaminal Lumbar Interbody Fusion: Indications and Techniques
Lumbar fusion is an accepted treatment for spinal deformity, degenerative instability, and iatrogenic instability following decompressive procedures. Lumbar interbody fusion yields certain advantages over posterolateral fusion alone, particularly because of higher rates of fusion. Segmental motion still exists with posterolateral fusion alone, but this motion is significantly reduced with fusion techniques through the intervertebral disc space. , Biomechanically, the disc contributes significantly to anterior column stability, and the stabilizing influence of a posterolateral fusion depends on an intact anterior column. Transforaminal lumbar interbody fusion (TLIF) reestablishes anterior column support while allowing for posterior fixation, thereby imparting improved fusion rates because of circumferential support. Furthermore, as an interbody technique, TLIF helps restore disc and foraminal height and promotes lumbar lordosis. TLIF obviates the morbidity from the retroperitoneal dissection and subsequent posterior fixation required from anterior lumbar interbody fusion (ALIF). And unlike posterior lumbar interbody fusion (PLIF), TLIF requires minimal to no retraction on the thecal sac and nerve roots while still providing 360 degrees of support. In addition, because TLIF utilizes a more lateral trajectory, it can be performed in the setting of previous surgery with identifiable landmarks and a cleaner plane of dissection.
Indications
The indications for lumbar fusion are described elsewhere. In general, however, we utilize TLIF for degenerative disc disease, low-grade spondylolisthesis, synovial cysts (when fusion is required), multiply recurrent disc herniations, and foraminal stenosis associated with deformity. TLIF is ideal for grade I or II spondylolisthesis with unilateral symptoms. TLIF is contraindicated with complete disc desiccation or the presence of extensive osteophytes, because this limits disc distraction. Extensive scarring from prior posterior surgery serves as a relative contraindication.
Surgical Technique
In general, TLIF utilizes an imagined quadrangular space between the transverse processes of the vertebral bodies adjacent to the affected disc space and the traversing nerve root medially ( Fig. 154.1 ). Both open and minimally invasive techniques are utilized. The open technique is described stepwise, followed by modifications for the minimally invasive procedure.
Positioning
A Foley catheter, sequential compression devices, and stockings are placed on the patient. Depending on the surgeon’s experience, autologous blood and a cell saver can be available. The patient is placed in prone position on a radiolucent frame. Use of a Jackson table allows decompression of the abdomen to decrease epidural bleeding. Positioning of the patient is performed to facilitate encouragement of lordosis. Fluoroscopy or plain films are used to localize the affected level.
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