Transforaminal lumbar interbody fusion

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Biomechanics

Why fuse the anterior lumbar spine? When the anterior column is insufficient, a posterolateral fusion alone may not be the procedure of choice. Classic studies by Rolander [9] have shown that there is motion in the spine despite a solid posterior fusion. Zdeblick [10] has shown that the decrease of motion of the motion segment is through the disc, not the facets, transverse process, or spinous processes. Weatherly [11] reported on five patients who had a solid posterior spinal fusion but had

Transforaminal lumbar interbody fusion

What is a transforaminal lumbar interbody fusion (TLIF) and why do it? TLIF is load sharing. It provides for anterior column support and provides a posterior tension band. It is a unilateral approach to the spine only, and with no exposure or manipulation of the dura there is a lower risk of neurologic injury. It provides the benefits of a 360° fusion by helping to improve the success rate of the fusion. It immobilizes the anterior column more effectively than a posterior or posterolateral

Indications

The ideal indication for a TLIF is a grade I or grade II spondylolisthesis without neurologic deficit or with a deficit on one side only. It also may be used in degenerative disease with positive discography without any intracanal pathologic condition. Contraindications to a TLIF include cases of tight anterior disc space with osteophyte formation in which there is no potential for disc space distraction. If there is extensive epidural scarring or history of prior infection a TLIF may be

Operative procedure

Standard preoperative evaluation and preparation are used. Appropriate studies may include MRI, myelo/CT, discography, and selective nerve root blocks to determine the appropriate pathology and plan for the procedure. Before surgery, one to two units of autologous blood are obtained from the patient. The patient is placed in the prone position, and one of two positioning frames is helpful. An appropriate adjustable frame may be used with the spine in flexion to make the approach to the disc

Complications

Transforaminal lumbar interbody fusion is a major procedure and, as with other such procedures, requires complete understanding of normal pathologic anatomy of the spine and neurologic structures. Complete understanding of spinal biomechanics and fusion technique is mandatory. General complications common to any major spine surgery, such as urinary infections, thrombophlebitis and deep venous thrombosis, pulmonary atelectasis, and abdominal ileus, are not discussed.

The following complications

Case 1: D.R.

D.R. is a 46-year-old white woman with a 4-year history of back and left leg pain that radiates to her toes (Fig. 1). She had previous discectomy at L5-S1 with temporary relief of back and leg pain. She had weakness of dorsiflexion and plantar flexion on the left with decreased sensation in the L5 and S1 dermatomes on the left. Reflexes were intact and symmetrical, and there was tenderness at the lumbosacral junction. Evaluation included electromyograms, a myelo/CT, and a disco/CT evaluation

Summary

Indication and technique of TLIF procedure are described. TLIF provides for anterior column support and posterior tension band. It is a unilateral approach to the spine, and there is no need to expose or manipulate the dura. It provides the benefits of a 360° fusion without performing an anterior approach. It restores the normal anatomy of the motion segment and maintains normal lumbar lordosis. Patients are mobilized quickly and resume activities early.

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    Transforaminal lumbar interbody fusion (TLIF) is a safe and effective technique for addressing degenerative disease of the lumbosacral spine that avoids some of the challenges associated with posterior lumbar interbody fusion, such as narrow exposure to the disc space and thecal sac retraction.1-5

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