Transforaminal Lumbar Interbody Fusion (TLIF): Spine Surgeon Explains

Can a TLIF spine surgery resolve your severe low back and leg pain? Learn from Timothy’s experience.

If you’ve tried a myriad of non-surgical treatments for your chronic low back and leg pain with no success, you may be a candidate for spine surgery. One approach your doctor may consider is called a transforaminal lumbar interbody fusion—or TLIF.

To help you learn more about TLIF, SpineUniverse asked Howard Eisenbrock, DO, a neurosurgeon affiliated with Hackensack Meridian Health Bayshore Medical Center in Holmdel, NJ, and Hackensack Meridian Health Riverview Medical Center in Red Bank, NJ, how he would treat a patient using this approach.

Patient Background
Timothy is a 55-year-old software engineer with chronic low back pain and periodic sciatica that is caused by a bulging disc. In the past year, to avoid surgery, he’s tried anti-inflammatory medications and 2 spinal injections, which didn’t provide adequate pain relief. He feels that something has changed in his low back and is fearful because his leg pain now travels into his foot.

SpineUniverse: How common is Timothy’s spine problem? Is his presentation typical to other patients you see in your practice?
Dr. Eisenbrock: His problem is common in the general population. In fact, the second most common reason for doctor’s visits is back pain. His presentation is also common. Timothy is following the typical pattern: You begin with conservative therapy under the guidance of a physician. If your symptoms don’t respond, or if they progress, then you would be referred for a surgical evaluation.

SpineUniverse: How do you start to diagnose the cause of his symptoms?
Dr. Eisenbrock
: I start with the basics. I would perform a thorough medical history and physical exam. I would also order imaging scans. The standard imaging test for the symptoms Timothy is describing is magnetic resonance imaging (MRI), but if Timothy can’t have an MRI (if he has metal implants, for example), I’d order a computed axial tomography (CAT) scan.

SpineUniverse: Since Timothy has already tried non-surgical treatment, is surgery the logical next step? How do you tell a patient they need spine surgery?
Dr. Eisenbrock
: Yes, if Timothy is still experiencing severe pain after trying non-surgical treatment, then the conversation can turn to surgery. When I tell my patients they need surgery, I always make sure they understand what their problem is by showing them the films from their imaging scans, explaining what is abnormal, and connecting that back to their symptoms. I also use models, so they conceptualize their own anatomy. Spine surgery is a big deal, and patients deserve to know what they’re going to go through. When I meet with patients about having spine surgery, I never leave the conversation without answering all their questions.

SpineUniverse: We understand TLIF procedure is an option for some patients with a damaged disc. Please explain what a TLIF is and how it’s performed.
Dr. Eisenbrock
: A TLIF can restore disc height, which helps decompress surrounding nerve roots. But the procedure can address more than a damaged disc—it’s also a good option for patients with spondylolisthesis or spinal instability.

The TLIF is performed posteriorly, or from the back, which allows the surgeon to directly access the compressed nerves while avoiding injury to bodily structures at the front of your body (such as your bowel).

After the damaged disc is removed, interbody devices, such as cages, are placed into the disc space to restore and maintain space between the 2 vertebrae to prevent nerve compression. These devices are made out of many materials—most nowadays are synthetic grafts made from surgical plastic or titanium. The devices are filled with bone graft or bone graft substitute to facilitate the fusion of the 2 vertebrae into a single bone. I typically use a locally harvested bone for the bone graft, or an autograft, which means it was taken from the patient’s own body. If bone from the patient isn’t available, I use cadaver-derived products and synthetic bone extenders.

SpineUniverse: Is TLIF an open or minimally invasive procedure? Would Timothy’s procedure be single-level TLIF?
Dr. Eisenbrock
: Timothy’s procedure would be a single-level TLIF. The TLIF approach can be performed both open (or traditionally) or minimally invasively. I’ve been classically trained to perform open TLIFs, so that is my preference. It largely comes down to patient selection—some people are better served with an open approach, while others can be successfully treated with a minimally invasive technique. I’d recommend patients talk to their doctor about the best approach for them.

SpineUniverse: Can a TLIF be performed on an outpatient basis?
Dr. Eisenbrock
: TLIFs may be performed in an outpatient setting, but I don’t recommend it. Patients who have their procedure performed in a hospital report better pain control and higher patient satisfaction. After inpatient surgery, patients spend 2 to 3 days in the hospital, which can alleviate a lot of stress on yourself and your family in terms of taking care of yourself those first few days after surgery.

SpineUniverse: Will Timothy need to wear a post-op lumbar brace?
Dr. Eisenbrock
: I don’t recommend a brace for every patient, but I think patients greatly appreciate them. Bracing is a good reminder that your muscles are sore, and it provides some added support. The need for bracing is not so much a stability issue as much as it’s a reminder that you should take it easy, because you just had a major operation.

SpineUniverse: How long is Timothy’s recovery?
Dr. Eisenbrock
: The typical recovery from a single-level TLIF is 4-6 weeks. Because Timothy has a desk job, he may be back to work 4 weeks after surgery. The best advice I have is to follow your post-operative instructions and don’t rush your recovery—you’re healing from a major operation, so take it slow and give your body time to heal.


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