Transforaminal lumbar interbody fusion (TLIF) is a spinal fusion procedure performed as an alternative to posterior lumbar interbody fusion (PLIF) when posterior decompression of the spinal canal is not required 1.
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Indications
See: lumbar interbody overview (overview).
Contraindications
- extensive epidural fibrosis
- arachnoiditis
- infection
- conjoined nerve roots
- osteoporosis 2
Procedure
This procedure can be performed with an open (OTLIF) or minimally invasive (MITLIF) approach for surgery at the L1-to-S1 levels.
Open approach
Via a paramedian incision and after dissection the posterior elements are exposed and pedicle screws are placed. Traditionally, a unilateral laminectomy and facetectomy are usually performed although there can be variation depending on clinical indication and the laminectomy/facetectomy may be unilateral or bilateral, and/or complete or partial. Rods are then placed to distract the disc space and a discectomy and endplate preparation is performed followed by insertion of the interbody cage and graft 1-3.
Minimally invasive approach
Using intraoperative fluoroscopy, pedicle screws are placed percutaneously above and below the surgical level. Via a paramedian incision, access to the surgical is gained via a tubular retractor after serial dilatation and decompression, discectomy, endplate preparation and interbody cage and graft insertion are similar to the open approach 4.
Complications
Compared to PLIF, TLIF has reduced rates of nerve root injury, dural tears and epidural fibrosis due to reduced thecal sac retraction 2,3. TLIF-specific complications include:
- increased lumbar plexus injury (typically transient) from psoas retraction 3,4
- postoperative contralateral radiculopathy 3
There may be higher rates of pedicle screw misplacement and cage migration in MITLIF compared to OTLIF 4.
Outcomes
Compared to OLIF, MITLIF has less intra-operative blood loss, less postoperative pain and a shorter rehabilitation period 4.
History and etymology
The TLIF technique was first described by Harms and Rolinger in 1982 3, and the minimally invasive approach described by Foley et al in the early 2000s 4.