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Lumbar Interbody Fusion technology is a mainstream surgical method for treating lumbar degenerative diseases. Various surgical approaches include anterior ALIF, lateral OLIF, DLIF/XLIF, and posterior TLIF and PLIF. Introduce the lumbar spine TLIF/PLIF technique.
This article does not focus on how to operate the technology but discusses some technical background, including the origin of the technology, advantages and disadvantages, indications, etc.
What is TLIF
TLIF (Trans-foraminal Lumbar Interbody Fusion) is currently the mainstream surgical procedure in clinical practice. If you are new to spinal surgery, you may not know other LIFs, but you must know TLIF.
TLIF technology enters the target intervertebral disc from the posterior intervertebral foramen space. It performs intervertebral space treatment on the segment, such as intervertebral disc decompression, intervertebral space preparation, and bone graft fusion.
TLIF Technique
What is the difference between PLIF and TLIF?
The introduction of TLIF technology must be inseparable from PLIF (Posterior Lumbar Interbody Fusion). PLIF and TLIF technical solutions are close, and it is difficult to completely distinguish them. In many cases, what we do clinically may be a hybrid.
The PLIF technique was born during World War II. It exposes the spinal canal by resecting the lamina, spinous process, ligamentum flavum, and other structures, relieves nerve compression, and implants bone in the intervertebral space to achieve intervertebral fusion.
Richard Jaslow first clearly proposed the method of performing bone graft fusion between vertebral bodies after discectomy, which is regarded as the first year of the birth of PLIF technology.
The surgical approach of PLIF requires the resection of structures such as the posterior lamina, spinous process, and interspinous ligament, and pulling the nerve to one side to a certain extent, thereby exposing the target intervertebral disc structure.
PLIF Technique
Its potential advantage is that it can effectively retain the facet joint structure of the upper and lower vertebral bodies, and there is no relatively firm fixation method for the early spine, and traditional fixation methods such as laminar hooks cannot provide very effective fixation and holding force. One advantage can well compensate for the shortage of spinal internal fixation mechanics.
However, the potential disadvantages of PLIF are also very obvious because the facet joint structure needs to be preserved to maintain the mechanical stability of the spine, and the nerve must be stretched to a certain extent when dealing with the intervertebral space.
In the lower part of the lumbar spine, usually the segment below L3, moderate nerve stretching does not cause serious consequences. Still, the nerve is very fragile for upper intervertebral disc herniation, such as the level above L2, where the cone is usually located. The vertebral disc Nerve damage may be caused by the vibration of the excision of the plate or slight compression of the spinal canal. Operations such as pulling the nerve should be absolutely contraindicated. Currently, there is no room for the application of PLIF technology.
Another potential problem with PLIF is that the stabilizing structures behind the vertebral body, the PLC, are resected during the procedure, and the latter structure of the PLC has been given increasing attention as knowledge of the mechanical stability of the spine.
It is based on the background of the defects mentioned above of PLIF technology that TLIF technology came into being. TLIF technology, a trans-foraminal approach, as the name implies, enters the lumbar intervertebral space from the area of the intervertebral foramen. This area is also the Kambin safety triangle commonly used in trans-foraminal endoscopy.
Kambin safety triangle
The intervertebral disc and intervertebral space can be well exposed within this triangular space. For superior intervertebral disc herniation, such as the lumbar 1/2 level, or the thoracic spine, the intervertebral foramen or the more lateral approach of the intervertebral foramen can be used to treat the nerve root and dural sac with little or no traction pull.
In terms of clinical indications, mastering TLIF/PLIF technology can deal with almost all lumbar-related diseases, such as lumbar degenerative diseases, lumbar segmental instability, spondylolisthesis, scoliosis, pseudarthrosis, spinal revision, vertebral tube narrowing, etc.
The TLIF technique is a trans-foraminal approach, which only needs to resect part of the facet joints without extensive resection of the PLC structure so that the PLC structure can be well preserved.
The only disadvantage is that the upper and lower facet joints must be knocked out for good exposure. In the current situation where pedicle screws are commonly used, knocking out the facet joints has little impact on the subsequent stability and fusion of the spine.
TLIF is further advanced and can also deal with most intervertebral space infections, vertebral tumors, and other relatively frontal lesions
Of course, as a surgical technique, TLIF will definitely have some relative contraindications, such as nerve root variation listed in the literature, patients with osteoporosis, active infection, dural adhesions, etc. Still, more precisely, these are Contraindications to lumbar fusion, not just TLIF.
It must be noted that everything has its own pros and cons, and TLIF technology cannot be over-mythologized. The wide range of TLIF indications does not mean that it has no shortcomings.
Compared with anterior ALIF or lateral OLIF, posterior TLIF enters the intervertebral space through the spinal canal, which naturally interferes with the structures in the spinal canal to a certain extent. Correspondingly, this technique has a high incidence of postoperative nerve traction reactions, dural tear Cleft, nerve root traction injury, and even rupture risks exist.
During the operation, the paraspinal muscles need to be stripped. Postoperative scarring of the muscles will also affect the function of the postoperative lumbar paraspinal muscles. Some patients may experience intractable low back pain.
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Summary
As a commonly used clinical technique, TLIF has become the cornerstone of spinal surgery due to its good technical adaptability, safer nerve protection, satisfactory intervertebral space treatment and fusion rate, etc.
Even today, when various LIFs emerge in an endless stream, TLIF should still be one of the basic skills that spine surgeons need to master proficiently and firmly and continue to pass on and shine.