Transforaminal Lumbar Interbody Fusion (TLIF)

An Overview of Transforaminal Lumbar Interbody Fusion (TLIF)

Transforaminal lumbar interbody fusion (TLIF) is a fusion procedure designed to join one vertebral body to the next. It is used for various problems such as instability, degenerative spondylolysthesis, isthmic spondylolysthesis, discogenic pain, multiple recurrent disc herniations and foramenal collapse.

The TLIF was designed to perform a complete fusion of the front of the vertebra and back of the vertebra (called a 360) through a small incision only in the back of the spine. Before this procedure was developed, there would have to be incisions in the back of the spine and in the belly to achieve this type of fusion success. With the TLIF, the nerves can be decompressed, the disc height reconstructed and the vertebra leveled. If the foramen is collapsed, this method will allow reconstruction of the collapse and freedom to the crushed nerve.

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(Please keep reading below for more information on this treatment.)

It is performed just as it sounds (unlike 99% of descriptions in medicine). The surgery is done through the foramen (transforaminal) in the lumbar spine into the disc space in between the two vertebral bodies (interbody) to create a fusion. An incision is made midline on the spine (normally about 2 ½ inches long). The two vertebrae are exposed and the transverse processes are exposed on the sides of the vertebra. 4 pedicle screws are place into the vertebrae. The vertebra are the distracted through tools that push the screws apart. The microscope is brought into the field.

The facet from the superior and inferior vertebra on one side are removed. These facets are cleaned, ground up and reused as bone graft. For this procedure, we never have to take bone from the pelvis anymore.

One bonus is that taking the facets on one side solves any type of preexisting foramenal stenosis as the facets themselves cause this condition and are removed.

The disc is opened and any debris remaining in the disc is removed. Remember that this procedure is performed for patients with degenerated discs and a normal disc is never seen as there would be no reason for a transforaminal lumbar interbody fusion in the first place. The disc is spread apart with an interdiscal spreader (a mechanical tool to restore the disc height).

Three things are placed in the disc to hold it apart and get it to fuse together. The first is BMP or bone morphogenic protein. This is a synthetic human protein that causes your own stem cells to turn into bone cells. The second is the ground up facet bone previously removed and cleaned. The last is a little plastic cage that holds the vertebra apart. This is essentially a spacer to hold the vertebra distracted while the bone heals.

The incision is irrigated copiously to wash out any aberrant BMP (you would not want bone to form in the canal) and a Valsalva maneuver is performed to make sure there is no dural leak.

At this point, if there is any further canal decompression to perform, it is done now with the microscope still in the field.

The microscope is removed and the distraction of the screws is taken down. Some bone and BMP that was not placed in the disc space is now placed along the sides of the vertebra on the remaining lamina, facets and transverse processes. Rods are then connected to the screws and tightened down and a small amount of morphine is placed in the spinal canal to control pain overnight.

During the entire transforaminal lumbar interbody fusion (TLIF) procedure, the patient is monitored electronically to make sure the nerves and spinal cord are functioning properly. Any blood loss is recycled through a device called a cell saver. The blood is washed and given back during the actual procedure to minimize blood loss. (All Jehovah’s Witnesses have the procedure performed without cell saver).

The incision is closed and the patient is discharged to the recovery room.

For additional information on transforaminal lumbar interbody fusion (TLIF), please contact the Vail, Aspen, Denver and Grand Junction, Colorado area office of spine surgeon and back specialist Dr. Donald Corenman.

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(Click to Enlarge Image) This is a front to back view of a lumbar fusion about 8 months out from surgery. The black arrows point to the living bone that joins the two vertebra together.

(Click to Enlarge Image) This is a side view of the fusion. Note that the arrow points to the bone that has fully filled in the old degenerative disc space.

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

An Overview of Transforaminal Lumbar Interbody Fusion (TLIF)

Are you a candidate for Transforaminal Lumbar Interbody Fusion (TLIF)?

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About the Author: Donald Corenman, MD, DC

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