Surgical procedure for spinal access and excessive bone removal

Transforaminal Lumbar Interbody Fusion (TLIF)

A transforaminal lumbar interbody fusion (TLIF) is a procedure that can be performed using minimally invasive spine surgery. It is a type of surgery in which the lumbar spine is approached through an incision in the back. The name of the procedure is derived from:

• Transforaminal (through the foramen)
• Lumbar (lower back)
• Interbody (between two vertebrae)
• Fusion (stabilization using bone graft and implants)

Traditionally, open spine surgery involves a central incision to expose the spine. Often a TLIF may be performed using minimally invasive spine surgery, a treatment that involves two small incisions and muscle dilation. The muscles surrounding the spine are gently separated rather than cut. A minimally invasive approach preserves the surrounding muscle and blood supply and minimizes scarring. Depending on our condition, I will determine which type of procedure you will require. Before your surgery date, you will undergo a pre-operative medical evaluation and surgical risk assessment by the hospitalist group where your surgery will take place. You will be instructed to stop taking weight loss supplements, herbals, aspirin, non-steroidal medications and anti-coagulants several days prior to surgery to help reduce blood loss.

Why is a TLIF performed?

For spinal access and excessive bone removal: You will lie face down, slightly tilted to one side on the operating table. I will make a small incision in the skin of your back over the vertebra(e) to be treated. You will have either a two to six-inch incision, for an open surgery or two small incisions, for a minimally invasive fusion.

X-ray equipment is used in the operating room to visualize the spine. If the nerve root or spine requires visualization, part of the lamina (the “roof” of the vertebra) may need to be removed. This is called a laminectomy. The facet joints, which are also directly over the nerve roots, sometimes need to be trimmed or removed to give the nerve roots more room. That procedure is called a facetectomy.

For bone graft material placement and instrumentation placement: The nerve roots are then moved to one side and the disc material removed from the front (anterior) of the spine. A bone graft is then inserted into the disc space. The bone graft material acts as a bridge, or scaffold, and grow. Screws and rods are also inserted to stabilize the spine and prevent shifting while the bone graft heals and fuses together. The ultimate goal of the procedure is to restore spinal stability. I then close the incision, which typically leaves behind only a small scar or scars.

After Surgery

You will spend one to two nights in the hospital following surgery. To keep swelling to a minimum there may be a small drain in your back next to the incision. It is connected to a receptacle that is clipped to your hospital gown. Your nurse will monitor the amount of drainage overnight, and my physician assistant will remove the drain before you go home from the hospital. The area will be covered with a bandage or small dressing. You may have a Foley catheter in your bladder for urination, which would have been placed when you were under anesthesia in the operating room. It is removed the next day following surgery. Patients are apprehensive about this, but it does not hurt.

Soon after surgery, if you can tolerate liquids, you may try the regular food as tolerated. Go easy at first—it is normal to feel nauseated after having general anesthesia. Let your nurse know if you feel nauseated.

You will be provided physical therapy for walking while in the hospital. Most people are strong enough to go home directly from the hospital with assistance from friends or family.

Some people need a walker for the first few days following surgery until they are stronger and more confident with walking. If you already have a walker at home or plan to borrow one, please bring it with you on the day of surgery so that the hospital physical therapist can make any necessary adjustments. If you don’t already have a walker, one will be provided for you to take home if needed.

Pain Medications: In the hospital your pain control will be transitioned from intra-venous self-administered medication (push button) to pain pills. You will be provided a prescription for the oral pain medication that works for you, which may be obtained on the way home from the hospital. Please remember that narcotic pain medications cause the intestines to move more slowly, which allows more time for your body to reabsorb water from your intestines. This can cause your stool to become dry and hard, thus causing constipation. It is recommended to take an over-the-counter stool softener (Colace, Miralax, Senekot-S, Dulcolax or Milk of Magnesia) while you are taking narcotic pain medication and to drink plenty of fluids. Your pain medication may contain an ingredient called acetaminophen or APAP. That is the generic name for Tylenol. Keep track of how many tablets you take a day and do not exceed 4,000 mg of acetaminophen in a 24-hour period. Excessive use of Tylenol can cause liver damage. After your surgery, do not take non-steroidal medications, such as, Motrin, Aleve, ibuprofen, Relafen, Indocin and Naprosyn for three to six months. These medications inhibit bone fusion healing. I will let you know when it is okay to resume this class of medication.

Wound Care: Keep your incision clean and dry. There will be sutures at the top and bottom of your incision that may need to be removed at your first post-op appointment. At times, I choose to use “skin glue” called Dermabond that does not require external sutures. If you feel the edges of this clear coating, do not peel or pick. It will come off over time. There may also be strips of tape across your wound called Steri-strips. Please leave these in place, even if they begin to curl up at the edges. They will be removed by me or my assistant at your first post-op appointment. Once you no longer notice drainage on the dressing, you don’t need to wear a dressing. Do not apply any ointments, peroxide or betadine to the incision, as these may inhibit new skin cell growth and delay complete healing of your incision.

Bathing: No tub bathing or swimming for six weeks; but you may shower two or three days following your surgery. Let water run over the incision, while turning away from the full force of the stream, pat it dry and then let it air dry.

Nutrition: Drink a can of Boost or Ensure nutritional supplement at each meal until you are back to eating three regular, nutritious meals per day. Proteins are the building blocks of healing.

Initial Activity at Home:

• No bending, twisting, stooping or lifting over five to ten pounds for at least eight weeks after surgery
• Sleep on your back or side with pillows under or between the knees
• First week: Walk short amounts in the house every 10 to 15 minutes. Stairs are okay with help
• Second week: Repeat first week but outside, weather permitting
• Third week: Walk up to a half mile per day, divided doses
• Fourth week: Walk up to one mile per day, divided doses
• Third month: Walk up to three miles per day
• No driving for the first two weeks and must be off narcotic pain meds before driving
• Use good body mechanics (always bend with your knees to lift or to pick something up from the floor)
• Physical therapy may be prescribed for you later in your recovery, depending on your progress

Follow-up: Your first post-op appointment will be about two weeks after surgery; however, if you have concerns prior to this date, I will see you back sooner as needed. The tiny suture knots at each end of your incision will be painlessly removed and X-rays may be taken. Subsequent follow-up appointment intervals will be based on how you are progressing.

Return-to-Work: Status is determined on each individual’s progress, depending on the type of work you do and depending on the baseline of your health and activity level prior to the surgery. In general, you may expect to be off work for the first two weeks following your surgery. You may then qualify for light duty sit-down work depending on your progress. It may take three to six months before you can return to physically demanding work, such as construction or heavy lifting. You should not drive a car, operate heavy machinery or make important decisions while you are still taking narcotic medications.