====== Transforaminal lumbar interbody fusion (TLIF) ======

{{ ::transforaminal_lumbar_interbody_fusion.png?400|}}

[[Pedicle screw]]s and [[rod]]s are attached to the back of the vertebra and an [[interbody fusion]] spacer is inserted into the [[disc space]] from one side of the spine.

Bone graft is placed into the interbody space and alongside the back of the vertebra to be fused. [[Bone graft]] is obtained from the patient's pelvis, although [[bone graft substitute]]s are also sometimes used. As the bone graft heals, it fuses the vertebra above and below and forms one long bone.

A variation on a [[PLIF]] where the [[graft]] is placed from one side (via the [[neural foramen]]) after complete removal of the [[facet joint]] on that side.
Requires much less [[nerve root]] retraction than PLIF, and is often advantageous for re-operations with primarily unilateral pathology were going through the [[foramen]] avoids the [[scar tissue]].

Since its initial description by Harms and Rolinger in [[1982]],
(( Harms J, Rolinger H. [A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition and anterior fusion (author's transl)]. Z Orthop Ihre Grenzgeb 1982; 120:343–347.))
[[transforaminal lumbar interbody fusion]] (TLIF) has been used with high rates of success in patients who present with [[instability]] or [[deformity]]
((Cole CD, McCall TD, Schmidt MH, et al. Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches. Curr Rev Musculoskelet Med 2009; 2:118–126.)).

The TLIF procedure described by [[Jürgen Harms]] was a new modification and minimized complications of [[lumbar fusion]]s and reduced the invasiveness of the procedure.

Nowadays a wide variety of implants and implantation techniques are available, making [[interbody fusion]]s in [[PLIF]] and [[TLIF]] techniques safe and successful procedures
((Rickert M, Rauschmann M, Fleege C, Behrbalk E, Harms J. [Interbody fusion
procedures. Development from a historical perspective]. Orthopade. 2015
Feb;44(2):104-13. doi: 10.1007/s00132-015-3076-1. German. PubMed PMID: 25626703.)).


===== Types =====

==== Minimally invasive transforaminal lumbar interbody fusion ====

[[Minimally invasive transforaminal lumbar interbody fusion]] (MIS-TLIF) 

==== Open transforaminal lumbar interbody fusion ====

[[Open transforaminal lumbar interbody fusion]] (Open-TLIF).

Transforaminal lumbar interbody fusion (TLIF) with bilateral [[facetectomy]] (BF) versus unilateral facetectomy (UF).
===No differences===
MIS-TLIF is a safe and viable option for lumbar fusion in morbidly obese patients, and when compared to open-TLIF, resulted in similar improvement in pain and functional disability. Post-operative complications rates between both cohorts were also not significantly divergent
((Adogwa O, Carr K, Thompson P, Hoang K, Darlington T, Perez E, Fatemi P,
Gottfried O, Cheng J, Isaacs RE. A Prospective, Multi-Institutional Comparative
Effectiveness Study of Lumbar Spine Surgery in Morbidly Obese Patients: Does
Minimally Invasive TLIF Result in Superior Outcomes. World Neurosurg. 2014 Dec
19. pii: S1878-8750(14)01405-3. doi: 10.1016/j.wneu.2014.12.034. [Epub ahead of
print] Review. PubMed PMID: 25535070.
)).

===Differences===
MI-TLIF is associated with reduced blood loss, decreased length of stay, decreased complication rates, and increased radiation exposure. The rates of fusion and operative time are similar between MI-TLIF and O-TLIF. Differences in long-term outcomes in MI-TLIF vs O-TLIF are inconclusive and require more research, particularly in the form of large, multi-institutional prospective randomized controlled trials
((Khan NR, Clark AJ, Lee SL, Venable GT, Rossi NB, Foley KT. Surgical Outcomes
for Minimally Invasive vs Open Transforaminal Lumbar Interbody Fusion: An Updated
Systematic Review and Meta-analysis. Neurosurgery. 2015 Jul 24. [Epub ahead of
print] PubMed PMID: 26214320.
)).

Patients treated with MIS TLIF have less need for post-operative blood transfusion, decreased post-operative back pain, and shorter hospital admission time than those treated by open TLIF techniques
((Wang J, Zhou Y, Zheng Z, et al. Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J. 2010;19:1780–4.))
((Schizas C, Tzinieris N, Tsiridis E, et al. Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience. Int Orthop. 2009;33:1683–8.))
((Karikari I. O, Isaacs R. E. Minimally invasive transforaminal lumbar interbody fusion: a review of techniques and outcomes. Spine. 2010;35(26S):S294.)).

Several studies have shown MIS TLIF to have significant improvement in 2-year VAS and ODI scores as well as a shorter time to ambulation compared to open TLIF
((Villavicencio AT, Burneikiene S, Roeca CM, et al. Minimally invasive versus open transforaminal lumbar interbody fusion. Surg Neurol Int. 2010;1:12.))
((Shunwu F, Xing Z, Fengdong Z, et al. Minimally invasive transforaminal lumbar interbody fusion for the treatment of degenerative lumbar diseases. Spine. 2010;35:1615–20.))
((Peng CW, Yue WM, Poh SY, et al. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine. 2009;34:1385–9.))
((Park P, Foley KT. Minimally invasive transforaminal lumbar interbody fusion with reduction of spondylolisthesis: technique and outcomes after a minimum of 2 years’ follow-up. Neurosurg Focus. 2008;25:E16.))
((Adogwa O, Parker S. L, Bydon A, Cheng J, McGirt M. J. Comparative effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion: 2-year assessment of narcotic use, return to work, disability, and quality of life. Journal of Spinal Disorders & Techniques. 2011;24(8):479)).

Patients who underwent MiTLIF were exposed to 2.4-fold more radiation than those who underwent OTLIF. Although the theoretical cancer risk associated with radiation exposure may be tolerable, stochastic effects should not be disregarded
((Kim CH, Lee CH, Kim KP. How High Are Radiation-related Risks in Minimally
Invasive Transforaminal Lumbar Interbody Fusion Compared With Traditional Open
Surgery?: A Meta-analysis and Dose Estimates of Ionizing Radiation. J Spinal
Disord Tech. 2015 Nov 12. [Epub ahead of print] PubMed PMID: 26566253.
)).

===== Cages =====

see [[TLIF cage]]


====Cost effectiveness====
TLIF and [[LLIF]] produced equivalent 2-year patient outcomes at an equivalent cost-effectiveness profile
((Gandhoke GS, Shin HM, Chang YF, Tempel Z, Gerszten PC, Okonkwo DO, Kanter AS. 
A Cost-Effectiveness Comparison Between Open Transforaminal and Minimally
Invasive Lateral Lumbar Interbody Fusions Using the Incremental
Cost-Effectiveness Ratio at 2-Year Follow-up. Neurosurgery. 2016
Apr;78(4):585-95. doi: 10.1227/NEU.0000000000001196. PubMed PMID: 26726969.))

===== Outcome =====
Stand alone TLIF may be associated with progressive [[lumbar spondylolisthesis]] at that level and are usually supplemented with pedicle screw/rod.

Age was not associated with [[complication]]s nor predictive of [[functional outcome]]s in patients who underwent multilevel [[TLIF]]. Age alone, therefore, may not be an appropriate surrogate for risk. Furthermore, baseline preoperative independent ambulation was associated with better clinical outcomes and should be considered during preoperative surgical counseling. Level of Evidence: 3
((Claus CF, Tong D, Lytle E, Bahoura M, Garmo L, Li C, Park P, Carr DA, Easton R, Abdulhak M, Chang V, Houseman C, Bono P, Richards B, Soo TM. Age as a Predictor for Complications and Patient-reported Outcomes in Multilevel Transforaminal Lumbar Interbody Fusions: Analyses From the Michigan Spine Surgery Improvement Collaborative (MSSIC). Spine (Phila Pa 1976). 2021 Mar 15;46(6):356-365. doi: 10.1097/BRS.0000000000003792. PMID: 33620179.)).

===== TLIF Prolonged Length of Stay Calculator =====
https://spine.shinyapps.io/TLIF_LOS/
===== Case series =====

[[Transforaminal lumbar interbody fusion case series]].