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153© Springer Nature Switzerland AG 2020
J. R. O’Brien et al. (eds.), The Resident’s Guide to Spine Surgery,
https://doi.org/10.1007/978-3-030-20847-9_18
Chapter 18
Minimally Invasive Transforaminal
Lumbar Interbody Fusion
DavidVincent andJ.AlexThomas
Introduction
Lumbar fusion is an effective treatment for low back pain secondary to degenerative
lumbar pathology [1]. The posterior lumbar interbody fusion (PLIF), described by
Cloward in the 1952, has long been considered the most popular technique of
achieving lumbar fusion. Indeed, these methods of interbody fusion, now typically
supplemented with posterior instrumentation, are still routinely performed today.
Unfortunately, both of these techniques are known to have high complication rates:
ALIF with its visceral, vascular, and male reproductive complications and PLIF
with its complications associated with bilateral neural retraction [2].
Unilateral PLIF, rst described by Blume and then popularized by Harms as the
TLIF, reduced the risks of PLIF associated with excessive retraction of the neural
elements. Compared to PLIF, TLIF allows for lateralized access to the disc space and
foramen with less exposure and retraction of the neural elements all with preserva-
tion of the contralateral structural anatomy. Despite these potential advantages of
TLIF over PLIF, open TLIF, like other open spinal procedures performed via midline
incisions, is still quite destructive. The midline incisions and prolonged retraction
time seen with open TLIF are associated with signicant iatrogenic injury to sup-
porting anatomical structures and thus may result in poor clinical outcomes [3–8].
The MIS-TLIF was introduced by Foley etal. in 2003 as a way to mitigate the
collateral damage to supporting anatomical structures seen in open TLIF [9].
Despite an initial steep learning curve, experience with MIS-TLIF grew rapidly, and
the procedure has become widely accepted [10–13]. Like other minimally invasive,
muscle-sparing techniques, MIS-TLIF is associated with less blood loss, decreased
D. Vincent (*)
The Jordan Young Institute, Virginia Beach, VA, USA
J. A. Thomas
Atlantic Neurosurgical and Spine Specialists, Wilmington, NC, USA
154
risk of infection, faster return to ambulation, and shorter hospitalization [14–16].
Also, especially important in the era of value-based care, MIS-TLIF has been shown
to be more cost-effective when compared to open TLIF [17, 18]. Certainly, circum-
ferential fusions have improved clinical outcomes and are more cost-effective when
compared to posterolateral fusions only. [19, 20]
Today, technologies such as image guidance, surgical robotics, expandable inter-
body spacers, and advanced spacer materials have only increased the ease and effec-
tiveness of MIS-TLIF.Here we discuss indications, technical nuances, and outcomes
of MIS-TLIF.
Indications
MIS-TLIF has the same indications as its open analog, namely, spondylolisthesis/
instability, unilateral foraminal stenosis, recurrent disc herniation, focal kyphotic
deformity, and discogenic pain [21]. Due to the signicant reduction in wound/inci-
sion size, it is arguably a superior choice for obese and healing-challenged patients
(i.e., diabetes mellitus, rheumatologic disease, etc.) [22–24].
Surgical Management
Positioning
This procedure is typically performed under general endotracheal anesthesia and,
due to the brevity of the procedure, a Foley catheter is seldom necessary for one and
two level cases. Preoperative antibiotics are given and serial compression devices
placed. Neural monitoring is commonly used and signicantly improves the safety
and predictability of the procedure.
After induction the patient is placed in the prone position on the operating table
(we prefer an open Jackson table) with the hips extended and the knees slightly
exed in order to maximize lordosis.
Radiation Reduction
MIS-TLIF is a uoroscopy-intensive procedure. There are numerous studies in the
literature documenting the health risks of excessive radiation exposure to the patient
as well as the treatment team [25]. ALARA (As Low As Reasonably Achievable) is
the practice of adopting methodologies to lower the radiation exposure in medical
procedures as much as possible. With most modern C arms, there are some simple
D. Vincent and J. A. Thomas
155
actions can dramatically lower the radiation exposure for both the patient and the
team. Simple measures such as turning off auto-contrast, activating low-dose mode,
and going to pulse mode (decreasing the number of pulses down to the lowest num-
ber where the image is still diagnostic and usable) can achieve 90–95% dose reduc-
tion. New technologies such as LessRay® can further help reduce the radiation
exposure and improve image quality. Procedurally, standing on the image intensier
side of the table and using predominately AP ouro (and more sparing use of lateral
imaging) further help to lower exposure for the team.
Pedicle Screw Placement
The skin is then prepped widely as the paramedian incisions are at times farther
from the midline than is initially expected, particularly in obese and wide girth
patients. The C-arm is then brought in, and using AP imaging the boundaries of the
pedicles are marked. The bilateral, paramedian incisions are then marked out
between 3 and 5cm lateral to the midline. This is variable and is largely dependent
on patient girth, with larger patients requiring more lateral incisions to achieve the
necessary lateral-to-medial trajectory for pedicle cannulation. The Jamshidi needles
are then docked on the 9 and 3 o’clock positions of the left and right pedicles,
respectively. There are common variations on how this step is done. For some, there
is no dissection and the needles are passed right after incision. Others perform a
Wiltse-type dissection to get to the junction of the lateral facet and the transverse
process. K-wires are then passed and after removal of the Jamshidi needle, serial
dilation follows. Next, the holes are typically tapped and then the screws are placed.
Triggered EMG is often used during Jamshidi needle placement, tapping, and screw
placement to lower the risk of screw malpositioning and neural impingement.
There are two basic variations of MIS retractor systems used in TLIF: tubular
retractor systems (e.g., Quadrant®, Medtronic Corp.) and pedicle-based refractor
systems (e.g., MAS TLIF®, Nuvasive Corp.). With tubular retractor systems, the
pedicle screws are typically placed after decompression and cage placement in
order to avoid interference with proper docking of the tubular dilators. With pedicle-
based retractor systems, pedicle screws are placed prior to decompression in order
to serve as anchor points for the cephalad and caudad retractor blades. If needed,
medial and lateral retractor blades are then placed to facilitate wider exposure of
working corridor to the disc space.
Decompression
At this point, the operating microscope is typically brought in, and the remaining
soft tissue is removed with a combination of electrocautery and pituitary rongeurs
to expose the lamina and facet complex. First, the inferior articulating process is
18 Minimally Invasive Transforaminal Lumbar Interbody Fusion
156
removed using the high-speed drill or bayoneted osteotomes by making a series of
cuts: (a) horizontally across the pars interarticularis, (b) longitudinally along the
lamina just medial to the facet complex, and (c) separating the facet joint articula-
tion. This releases the inferior articulating process which, after careful dissection
away from the synovium and ligamentum avum, is then removed en bloc with a
pituitary rongeur. The superior articulating facet is then drilled away or removed in
a piecemeal fashion using a Kerrison rongeur. Morcellized bone may be collected
for later use as autograft. Finally, the ligamentum avum is removed to expose the
thecal sac and neural elements. While not necessary, we advocate exposure of both
the exiting and traversing nerve roots so that they can be clearly seen and avoided
during disc preparation and cage placement. This exposure of the two nerve roots,
and the disc space within Kambin’s Triangle, is only possible after a complete bony
decompression from the inferior edge of the cephalad pedicle and the superior edge
of the caudad pedicle. In cases of severe central stenosis, a contralateral decompres-
sion can also be achieved after angling the retractor across midline.
Cage Placement
The approach corridor to the disc space occurs within Kambin’s Triangle with its
lateral boundary of the exiting nerve root, its medial boundary of the traversing nerve
root, and its inferior boundary of the caudal pedicle. A generous annulotomy is per-
formed and the disc space is prepped. Pituitary rongeurs, rasps, curettes, and rotating
paddle shavers are used to help accomplish this. Meticulous care must also be taken
to avoid violating the endplates to mitigate the risk of subsidence as the cages are
typically placed on the weakest part of the endplate. At the same time, as these sur-
faces are the primary fusion surface, the endplates must be thoroughly debrided of
cartilaginous disc material. One of the most common causes of non- union or cage
malpositioning in MIS-TLIF is poor disc space preparation. Thus, the surgeon must
take time to perform a complete discectomy and adequate endplate preparation. The
space is then sized with either the paddle shavers or interbody trials.
Bone graft is typically packed into the prepped disc space and tamped to the
contralateral side so as not to impede interbody graft placement. Most MIS TLIF
systems have a funnel which can be packed with graft and introduced into the disc
space, greatly facilitating adequate graft volumes. We typically aim for delivery of
12cc or more of grafting material. The graft is then tamped to the contralateral side
of the disc space. The interbody graft or cage is then packed with grafting material
and impacted into the disc space.
As with open TLIF, a variety of sizes and shapes of intervertebral spacers exist.
The so-called bullet cages may be the easiest to place via an MIS corridor. Banana
or boomerang cages, while more technically demanding to place, may offer two
theoretical benets: (a) decreased risk of subsidence as the graft abuts the more
compact of the apophyseal ring anteriorly, and (b) greater potential restoration of
segmental lordosis due to the more anterior location of the spacer. Finally, expand-
able intervertebral spacers can be quite advantageous in tight spaces where exces-
D. Vincent and J. A. Thomas
157
sive retraction might be necessary to place a static graft. These devices may also
allow for greater correction of foraminal height and segmental lordosis. Back-lling
the space and or interbody device with grafting material is then an option.
Rod Placement
Rods are then sized with calipers. The rods are contoured. A tissue blade is then
passed to facilitate rod passage. The rods are passed with particular attention being
paid to staying subfascial on the rod pass. It is also important to avoid over-sizing
the rods to avoid suprajacent facet impingement. Proper rod contouring can help
maximize lordosis.
Lordotic Restoration
As stated previously, positioning has a signicant inuence on preservation and
restoration of lordosis. The Jackson table and similar frames facilitate hyperexten-
sion of the lumbar spine. Using pillows to extend the hips and ex the knees further
exerts a lordotic force on the lumbar spine. Maximizing the fulcrum effect of the
interbody device is accomplished in two ways: anterior placement of the interbody
device and avoiding oversizing (as the intact, taught anterior longitudinal ligament
will resist lordosis). Existing MIS system compressors have some utility but often
fail to provide maximal, angular compressive force.
Multilevel Cases
It is possible to perform multi-level MIS TLIF. Two level cases are quite common,
and, with the tubular retractor method, the surgeon simply dilates and places the
tube over each of the facets for the levels to be fused. With the pedicle screw-based
systems, the blades on the pedicles are simply rotated 180° to treat each level. Three
or more levels are possible but not commonly done. Frequently, MIS-TLIF will be
done at L5/S1 as a second phase while placing the pedicle screws to back up lateral
lumbar interbody fusions (LLIF) of L4/5 and more cephalad levels.
Spondylolisthesis Reduction
Spondylolisthesis correction on single level cases can be challenging. Distraction of
the disc space by the interbody graft will often at least partially correct the listhesis.
Similarly, prone positioning can inuence the listhesis. Posterior translation of the
18 Minimally Invasive Transforaminal Lumbar Interbody Fusion
158
pedicle screw towers on the cephalad screws while deploying the cage (particularly
expandable cages) can be helpful on single-level cases. On multi-level cases, under-
bending the rod and sequentially reducing the middle vertebral body are an effective
method for correction of spondylolisthesis.
Grafting
While the primary fusion by design occurs within the disc space and is outlined
above, contralateral facet and laminar fusion are popular adjuncts. Dilators are typi-
cally docked on the facet or laminar surface and the microscope is used for visual-
ization. The high-speed drill is used to decorticate the surfaces, and grafting material
is packed onto them.
Outcomes andComplications
MIS-TLIF has been proven to be a safe and effective alternative to open TLIF [26,
27]. Reduced blood loss, infection rate, hospital stay, postoperative narcotic usage,
and return to work have been demonstrated in the literature [14–16]. Fusion rates
have been shown to be comparable to traditional fusion techniques [28].
The challenging learning curve associated with minimally invasive spinal proce-
dures in general is particularly relevant for MIS-TLIF [29, 30]. The extended work-
ing distance, constricted eld of view, paucity of orienting structures, and the
disparity in screw placement technique (vs percutaneous versus open screw place-
ment) can create a barrier to adoption. With experience, the surgeon experience is
typically felt to be less physically demanding with this minimally invasive
technique.
The limited incision size and muscle sparing nature of this procedure help mini-
mize wound complications. This is particularly relevant to healing challenged treat-
ment populations, especially the obese and diabetic [22–24].
There is a pervasive current trend toward shifting surgical treatment to the outpa-
tient setting. MIS-TLIF has been proven to be a safe, effective, and lower-cost pro-
cedure in the outpatient model in contradistinction to open fusion [31].
While initially spinal deformity was felt to be a relative contraindication, increas-
ingly MIS-TLIF is being employed in corrective strategies. It can be a useful adjunct
in the minimally invasive treatment of spinal deformity when implemented along
with lateral interbody fusion and long-segment percutaneous constructs. This is par-
ticularly true at L5/S1 and even L4/5in cases of anterior psoas anatomy precluding
the lateral approach.
Complications of MIS-TLIF are in general similar to those of its open analog and
include pseudoarthrosis, hardware failure, cerebrospinal uid leak, subsidence,
neural injury, and vascular/visceral injury. Due to the limited exposure of MIS- TLIF,
D. Vincent and J. A. Thomas
159
some of these potential complications take on a unique character and deserve spe-
cial attention. Pseudoarthrosis is a concern in this operation as the grafting surfaces
are inherently more limited than those afforded by an open procedure. As stated
earlier, meticulous care must be taken during disc preparation so that the endplates
are clean and abraded but remain intact. The disc space is the sole fusion surface in
this operation in most cases. Advances in biologics cannot make up for poor carpen-
try. Facet/laminar fusion is another adjunct to help achieve solid arthrodesis but the
disc space remains the primary fusion surface. While a thorough direct decompres-
sion is part of MIS-TLIF, there is an indirect component that comes from distraction
of the interspace. Subsidence can result in recurrent stenosis and is best avoided by
appropriate patient selection (avoiding patients with poor bone quality), careful
endplate preparation, and avoidance of graft oversizing (which includes over expan-
sion of expandable grafts). Cerebrospinal uid leak, while thankfully uncommon in
MIS-TLIF, can be challenging to address due to the narrow and deep working cor-
ridor. Repair techniques are the same as those used in open procedures except that
primary closure is not always feasible due to the aforementioned working corridor.
The suboptimal suturing ergonomics increase the risk of ensnaring neural elements.
Placing a small piece of Gelfoam® just inside the dura can stem the ow of CSF and
displace the neural elements away from the suture line. This technique is useful
even when suturing is not possible as it gives dural sealant (DuraSeal®) a surface to
adhere to. A lumbar drain is usually not necessary but meticulous closure of the
fascia up to the skin is paramount. In the authors’ experience, pseudomeningocele
has not been an issue.
Tips, Pearls, and Bailouts
• Measuring pedicle screw lengths preoperatively on the MRI or CT can be
very helpful and allows consideration of facet pathology for screw place-
ment. Maximizing lordosis by hyperextending the hips and exing the
knees with pillows is paramount as most of the MIS devices used for com-
pression are not as effective as their open iterations.
• Rotating the table away from the surgeon can be extremely helpful in
enhancing visualization, particularly of the contralateral side. If contralat-
eral decompression is necessary, leaving the ligamentum avum intact
until bone removal is complete facilitates thecal retraction and lowers the
risk of cerebrospinal uid leak.
• Again, the point of adequate discectomy and end plate preparation cannot
be stressed enough. The most common obstacle to proper cage insertion
and positioning is inadequate discectomy. Especially early on in the learn-
ing curve, the surgeon must be sure to take enough time to remove as much
disc material as possible from within the disc space. Special care must be
taken to remove the disc material from the contralateral, dorsal quadrant of
the disc space as this material is poorly visualized.
18 Minimally Invasive Transforaminal Lumbar Interbody Fusion
160
Summary
MIS-TLIF is a safe and reproducible technique for the treatment of spondylolisthe-
sis, foraminal stenosis, and recurrent disc herniation as well as in less common
indications where fusion is required. It results in signicantly less tissue trauma
than the traditional open version of the technique with literature-proven decreases
in blood loss, infection, postoperative narcotic usage, and hospital stay. Due to the
decreased incision size and tissue trauma, it is particularly suited for use in obese
and diabetic patients. This technique represents an important tool in the treatment of
degenerative spine disease.
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18 Minimally Invasive Transforaminal Lumbar Interbody Fusion
163© Springer Nature Switzerland AG 2020
J. R. O’Brien et al. (eds.), The Resident’s Guide to Spine Surgery,
https://doi.org/10.1007/978-3-030-20847-9_19
Chapter 19
Lateral Lumbar Interbody
Fusion L3–L4, L4–L5
KurtE.Stoll, DanielA.Marchwiany, DanielL.Cavanaugh,
andGurvinderS.Deol
History oftheDirect Lateral Approach
The rst laparoscopic lumbar discectomy was described in 1991 [1, 2], and
minimally invasive lumbar surgery has continued to evolve. Stemming from the
initial laparoscopic lumbar discectomy were the laparoscopic anterior lumbar
approach and mini-open anterior lumbar interbody fusion which were compli-
cated by sexual dysfunction, visceral damage, and large vessel bleeding [3, 4].
First described in 2001, the lateral lumbar interbody fusion (LLIF) also known
as extreme lateral interbody fusion (XLIF) has become increasingly popular as
it avoids the aforementioned complications of anterior intra-abdominal proce-
dures [3, 5]. Since the introduction of the LLIF technique, reported outcomes
include decreased blood loss, decreased operative times, short hospital stays,
and less postoperative pain [3, 6, 7] with comparable fusion rates to the anterior
lumbar interbody fusion (ALIF) [8, 9]. Furthermore, advantages include indi-
rect decompression, coronal and sagittal plane correction, and stabilization
through a less invasive approach [2]. Compared to the posterior approaches, the
LLIF does not require retraction of nerve roots or the cauda equina, and leaves
bony and ligamentous structures intact [10].
K. E. Stoll · D. A. Marchwiany · D. L. Cavanaugh
Department of Orthopaedics, University of North Carolina, Chapel Hill, NC, USA
G. S. Deol (
*)
Wake Orthopaedics, WakeMed Health and Hospitals, Raleigh, NC, USA