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As with all spinal fusion
surgeries, the PLIF and TLIF procedures involve adding bone graft or bone graft
substitute to an area of the spine to set up a biological response that causes
the bone to grow between the two vertebral elements and thereby stop the motion
at that segment.In an attempt to improve the results of fusion surgery, fusion of the disc has been performed to directly address the most common source of pain. Unlike the posterolateral gutter fusion, the PLIF achieves spinal fusion by inserting bone graft and possibly instrumentation directly into the disc space. The disc excision and fusion can be performed anteriorly, or through a posterior approach. When the posterior approach is used to remove and fuse the disc, this is called a PLIF, Posterior Lumbar Interbody Fusion.
An alternative approach is used to minimize retraction of the dura. By
resecting the facet joint, a farther lateral approach can be used to remove the
disc. This approach, with removal of the facet, is called a TLIF -
Transforaminal Lumbar Interbody Fusion.
THE GENERAL PROCEDURE:
1. First, the spine is approached through a
three-inch to six-inch long incision in the midline of the back and the left
and right back muscles (erector spinae) are stripped off the lamina on both
sides and at multiple levels.
2. After the spine is approached, to perform the
PLIF procedure (shown below), the lamina is removed (laminectomy) which allows
visualization of the nerve roots. The facet joints, which are directly over the
nerve roots, are usually undercut to give the nerve roots more room and more room
for performing the fusion and/or instrumentation. For the TLIF procedure (shwon
below), the entire facet joint is removed.
3. The nerve roots are then retracted to one
side and the disc space is cleaned of the disc material. Bone graft is then
inserted into the disc space with or without interbody cages. For a standard
PLIF procedure, the bone graft and/or instrumentation is performed on both
sides. For the TLIF procedure, the disc space is accessed from one side,
reaching over to remove and replace the disc on the other side.
The TLIF approach is shown below, with removal of the disc. Bone graft, bone from the bone bank, or instrumentation in the form of a cage can be placed through this approach.
The PLIF and TLIF approach has an
advantage over the posterolateral gutter fusion in that the large spinal
muscles do not need to be dissected off the transverse processes, so there is
less scarring of the muscle and associated pain for the patient. The major
advantage of PLIF and TLIF is that there is significantly more surface area for
fusion in the disc space as compared to the posterolateral gutter.
However, the PLIF requires
substantial retraction of the nerve roots to gain access to the disc space.
Significant traction can injure the nerve root and has the potential to result
in chronic leg pain and back pain. The pain associated with this type of nerve
root injury can be severe, and there are no effective options for treatment.
The TLIF requires less retraction of the dural sac, but nerve injury can occur
at the level of the nerve cell bodies (dorsal root ganglion). Pain associated
with manipulation of the DRG can also be very severe and debilitating.
Fortunately, these complications are rare with meticulous care of the nerves.
There are numerous veins
(epidural veins) over the disc space, and surgery in this area creates the
potential for excessive blood loss during the surgery.
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Recurrent pain after a successful
spinal fusion procedure is more likely due to a “transfer” lesion at the motion
segment above or below the fusion, because stress is transferred to the next
level and may cause that vertebral segment to degenerate and breakdown.
Nonunion rates of between 0% and
20% have been quoted in the medical literature. Nonunion rates are higher for
patients who have had prior surgery, patients who smoke or are obese, patients
who have multiple level fusion surgery, and for patients who have been treated
with radiation for cancer.
Other than nonunion, the risks of
a spinal fusion surgery include infection or bleeding. These complications are
fairly uncommon (approximately 1% to 3% occurrence).
Post-Operative Care
Most patients are usually able to go home 1-3 days
after surgery. Patients will typically stay longer, approximately 2-5 days, if
an anterior spinal surgery is also performed. Before patients go home, physical
therapists and occupational therapists work with patients and instruct them on
proper techniques of getting in and out of bed and walking independently.
Patients are instructed to avoid bending at the waist, lifting (more than five
pounds), and twisting in the early postoperative period (first 2-4 weeks) to
avoid a strain injury. Patients can gradually begin to bend, twist, and lift
after 4-6 weeks as the pain subsides and the back muscles get stronger.
Brace
Patients are generally not required to wear a back
brace after surgery. Occasionally, some patients may be issued a soft or rigid
lumbar corset that can provide additional lumbar support in the postoperative
period, if necessary.
Wound Care
The wound area can be left open to air. No bandages
are required. The area should be kept clean and dry.
Shower/Bath
Patients can shower immediately after surgery, but
should keep the incision area covered with a bandage and tape, and try to avoid
the water from water hitting directly over the surgical area. After the shower,
patients should remove the bandage, and dry off the surgical area. Patients
should not take a bath until the wound has completely healed, which is usually
around 2 weeks after surgery.
Driving
Patients may begin driving when the pain has
decreased to a mild level, which usually is between 7-14 days after surgery.
Patients should not drive while taking pain medicines (narcotics). When driving
for the first time after surgery, patients should make it a short drive only
and have someone come with them, in case the pain flares up and they need help
driving back home. After patients feel comfortable with a short drive, they can
begin driving longer distances alone.
Return to Work and Sports
Patients may return to light work duties as early
as 1-2 weeks after surgery, depending on when the surgical pain has subsided.
Patients may return to moderate level work and light recreational sports as
early as 1-2 months after surgery, if the surgical pain has subsided and the
back strength has returned appropriately with physical therapy. Patients who
have undergone a fusion at only one level may return to heavy lifting and
sports activities when the surgical pain has subsided and the back strength has
returned appropriately with physical therapy. Patients who have undergone a
fusion at two or more levels are generally recommended to avoid heavy lifting,
laborious work, and impact sports.
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