Transforaminal Lumbar Intersomatic Fusion – TLIF

The goals of spinal surgery in the lumbar spine typically involve decompression of the neural elements. However, in many cases these techniques are associated with iatrogenic instability, worsening of pre-existing deformity, instability or potential development of further neurological compromise in the future.

Unilateral Technique

TLIF is a unilateral technique that allows the surgeon to access the intervertebral disc space to augment a posterior intertransverse fusion. The TLIF technique is superior to the posterior spinal fusion technique alone because the surgeon is not only able to re-establish the height of the intervertebral space, reduce spondylolisthesis and degenerative instability, and increase lordosis while maintaining spinal height through posterior fixation. This technique also allows the surgeon to increase fusion potential by obtaining a circumferential fusion surface and to treat anterior spine pathology directly, which cannot be repaired via an isolated intertransverse fusion technique. Comparing the TLIF technique with the ALIF (Anterior Lumbar Intervertebral Intervertebral Fusion) technique, it can be seen that a posterior decompression allows direct neural decompression in addition to the intervertebral technique. Exposure of the posterior fusion also allows the advantages relative to pedicle fixation to maximize and enhance stability, contribute to deformity correction, and facilitate fixation stiffness.

Risks

There are certainly risks associated with the posterior technique, which is originally neural. They are certainly easier to manage and more routine in nature than the potentially catastrophic vascular risks that are inherent to the ALIF technique. Although these aforementioned advantages are considerable, there are limitations to the posterior intersomatic technique. This is especially evident in cases with significant kyphosis, where TLIF is less capable of achieving maximum lordosis than an anterior exposure and fusion.

In summary, the rationale for TLIF is to obtain spinal support through a single posterior approach, while performing decompressive surgery and posterior fusion with instrumentation. There is also the added biological advantage of intersomatic fusion by compression through a structural fusion box that will enhance the success of the arthrodesis. There are different advantages of the TLIF approach.

Advantages of TLIF

The first and most obvious is the unilateral nature. This results in less destruction of the posterior elements and less destabilization of the spine, which will improve the stability of the fusion. Although the PLIF technique in the past offered the possibility of performing an isolated anterior and posterior procedure, the unilateral technique allows much less perineural retraction, scarring and preserves the bony surfaces for posterior fusion. This can be assured by the fact that the contralateral joint remains intact with respect to its bony anatomy. TLIF allows, as part of the dissection, much more lateral access to the neuroforamina to decompress the exiting and descending nerve without neural manipulation. This avoids nerve root retraction injuries often seen with the PLIF technique and bilateral fusions. Much more lateral access to the disc space can be made through the safety zone.

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