What is a TLIF?
Transforaminal: through the foramen or openings in the spine where the nerves travel
Interbody: between the vertebral bodies
Fusion: process of stopping motion between two bones to improve stability
A TLIF is a fusion procedure that is done through the back of your lower back. The goal of this procedure is to decompress (remove pressure from) the spinal cord/spinal nerves and fuse the area so that it grows together as one unit.
The Procedure
Anesthesia & Induction
- Your anesthesiologist will talk to you about the specifics of his/her plan for the procedure. You will find out what medications and what type of anesthesia will be used to keep you pain free and comfortable throughout the operation.
- In general, most patients will undergo general anesthesia during spine procedures meaning you will be asleep and wont remember or feel any pain during the procedure itself. Patients may have pain upon waking up from anesthesia, but this will be managed with intravenous and oral pain medications.
- After a breathing tube is placed and you are fully asleep, you will be positioned on the operating room table.
- Surgery will not begin until you are asleep and given pain medications so that you don’t feel any pain during the procedure.
- A skin incision is made on lower aspect of your back.
Performing the Decompression
- Before removing the diseased/herniated disc and/or bone spurs, Dr. Webb will confirm that he is operating at the correct level by taking an x-ray while you are asleep.
- When the level is confirmed, Dr. Webb will then begin the decompression (removing the areas of compression from your spinal cord) portion of the procedure.
- The disc that is pressing on your spinal cord/nerves will be removed with the use of special instruments and tools.
- Dr. Webb will then ensure that your spinal cord and nerves are free from compression.
Performing the Fusion
- After the spinal cord has been decompressed and all the diseased disc material removed, this area/void needs to be replaced with something so that it can fuse together.
- This area will now be replaced with bone graft material and a metal or plastic cage.
- The bone graft will help this level to fuse.
- The metal or plastic cage will indirectly decompress your spinal cord and nerves by “jacking open” your disc space.
- This is similar to “jacking up” and changing your tires on your car after a flat tire. When your car is “jacked up”, there is more room for the tire to be placed and also relieves pressure off of the tire. Similarly, in spine surgery, when a metal or plastic cage is placed in between your bones, this “jacks up” the space that houses your spinal cord and nerves, giving them more room.
Closure
- The retractors that held the muscles apart will now be removed and will be allowed to fall back into their normal position.
- Dr. Webb uses absorbable sutures to close your wound. These sutures do not typically need to be removed and will absorb on their own.
Frequently Asked Questions
What to expect after surgery?
After surgery you will be transferred to the recovery room, also called the PACU (post anesthesia care unit). After you have awaken from the anesthesia, you will then be transferred to your hospital room. This is typically when your family members can visit you.
Either the same day or the following morning after surgery, a physical and/or occupational therapist will begin your therapy. During your hospital stay, you will be given medications to help with pain and IV antibiotics to minimize the risk of infection. Most patients go home the same day of surgery but some patients may spend 1-2 nights in the hospital and are discharged home after:
- You are tolerating a diet
- Your pain is controlled
- After you have worked with and passed physical therapy.
Walking after surgery is highly encouraged, even the same day of surgery!
What kind of recovery can I expect after surgery?
Recovery from ALIF surgery generally takes 12 weeks, but patients continue to heal for up to a year after surgery. This is because the bones have to fuse together which takes around 3 months. Every patient is different.
When can I return to work and/or activities?
Walking is highly encouraged, immediately after surgery and throughout your postoperative period. Most patients can return to a light desk job or household activities by 2-3 weeks after surgery. Patients with jobs that require heavy lifting, strenuous labor, or high impact activities such as running, biking, skiing, sports will not be allowed to return until Dr. Webb clears you, usually around 8-12 weeks.
How long will the surgery take?
The length of the surgery varies depending on each individual patient’s circumstances and spinal complexity. The more levels of the spine that need to be addressed or the more severe the spinal stenosis (narrowing), the longer the procedure will take. Dr. Webb will take however long it takes to complete the surgery in the safest and most efficient manner, but generally takes anywhere between 3-5 hours.
Will I be in a lot of pain after surgery?
Everyone responds to pain differently depending on their tolerance for pain, prior pain medication usage, and other factors to include how quickly or slowly your body metabolizes the medication in your liver or kidneys. Most patients tend to be sore at the incisional site from surgery, but their pain is manageable with IV and oral pain medications. Before surgery, you will be given a “cocktail” of medications which studies have shown to decrease the amount of pain medication that is needed after surgery. After surgery, you will be able to receive oral pain medications every 4-6 hours supplemented by IV medication for breakthrough pain. At discharge, you will be given a prescription for oral pain medication, a muscle relaxant, and a stool softener. Please make sure to include a laxative, as your oral pain medications can make you constipated at times.
Can I walk after surgery?
Yes, Dr. Webb encourages walking as soon as you wake up from anesthesia. The more you walk, the better. While in the hospital, a physical therapist will work with you and teach you how to walk, get in and out of bed, to and from the bathroom.
What restrictions will I need to abide by after surgery?
In general, we recommend you follow the “No BLT” (bending, lifting >10 pounds, or twisting) protocol for 6 weeks following surgery. If you do have to lift an object, following proper lifting mechanics is essential.
Can I remove my dressing after surgery?
Dr. Webb prefers that you keep all dressings on until he sees you back in the clinic, which is usually 2 weeks after surgery. Your wound will be closed typically with absorbable sutures that do not need to be removed and will absorb on their own. At times, dressings can have some “strikethrough” meaning you can see speckles of either blood or fluid through the dressing which is considered normal after surgery (especially the more you get up and move around). Most wounds take about 10-14 days to heal and fully close. Keeping your dressing in place for during this time ensures that your wound is not introduced to the outside world and minimizes your chance of infection. If your dressing becomes saturated, please reinforce this dressing and/or call our office.
Can I get my dressing wet after surgery?
Activities such as bathing, swimming, and hot-tubs should be avoided after surgery until you are given the clearance by Dr. Webb. This is usually after your wound is healed. Showers are usually allowed right after surgery depending on which dressing is used to protect your incision after surgery.
Can I drive or fly after surgery?
Driving after surgery is allowed once you are off all narcotics. Dr. Webb recommends that you start back driving by starting in an empty parking lot to ensure your braking time has returned. You can be a passenger in a car or fly immediately after surgery. If you are driving or flying long distances, Dr. Webb recommends that you stop and get up every 30 mins to pump your calves and walk around. Having surgery places you at risk for blood clots. This is to ensure that you do not get a blood clot.
My leg pain got better right after surgery but then started hurting again. Is this normal?
Yes, this is called “nerve stretch pain” which is common after TLIF procedures. During surgery, Dr. Webb will indirectly decompress the nerves with the use of the interbody cage. This can cause the nerves to become irritable as they become “stretched” with the cage. This takes time to get better. It usually takes weeks but sometimes this can take months to improve. If this pain becomes unbearable, let our office know and nerve medication can be prescribed.
What is the recovery process after surgery?
Most patients will receive relief right after waking up from surgery and for others, this may take some time (depending on how long the nerve has been compressed). Most patients notice improvement up to 3 months but full recovery may take up to 12-18 months.
When can I resume my home medications after surgery?
Generally, any heart and blood pressure medications are continued throughout the surgical period. There are a certain number of immunosuppressive medications that must be stopped 1-2 weeks prior to surgery and restarted 1-2 weeks after. Blood thinners are usually held a few days before and restarted a few days after surgery. A discussion with your treating physician may help answer some of these questions.
How long will I stay in the hospital after surgery?
Very few patients may be candidates to go home the same day of surgery. Most patients undergo what is called “same day surgery” meaning they will be in the hospital for 23 hours or less. Some patients require an additional 1-2 days in the hospital for logistical, pain, or medical reasons.
Will I need physical therapy one discharged from the hospital?
Physical therapy is important to “rehab” you back to your pre-surgery state. Our physical therapists will begin working with you in the hospital either the same day of surgery or the following morning. You may be given a prescription for outpatient physical therapy or home physical therapy, usually started after your incisions have healed and xrays show stability of your implants.
What complications should I be aware of?
Inadequate relief of symptoms
- Dr. Webb is very particular about making sure we target the right level of your spine that may be causing your symptoms.
- Inadequate relief of symptoms after surgery could be due to a number of things including: multiple levels that are degenerated or worn out that will not be addressed in surgery, surgery done on the wrong level, or advanced and severe spinal cord compression that may be irreversible.
- Injections are confirmatory and are very predictive of how well you will do with surgery. These spinal injections, usually done before surgery in the conservative treatment period, are essential in determining which level of your spine is the cause of your symptoms.
- Just because you have multiple degenerated areas of your spine according to your imaging studies (MRI, X-ray, etc.), does not mean every level needs an operation.
Nerve damage, causing leg weakness or pain
- There are small nerves that control the muscles in your legs and foot that are close to where Dr. Webb will be working.
- Dr. Webb carefully works around these nerves and ensures they are not damaged during surgery.
- If these nerves become irritated during surgery (sometimes just by touching or moving them), these nerves may cause pain for weeks to months after surgery until the nerve recovers. During this time, Dr. Webb may prescribe you nerve medication or steroids to help calm the inflammation down.
Dural tear
- The dura is the outer layer of the spinal cord. Sometimes, this layer can be especially thin in certain patients and very friable. During surgery, if there is a small tear in this layer, Dr. Webb will attempt to repair it. This is a not a very common complication, but definitely one that needs to be known.
- Sometimes after a dural tear is repaired, Dr. Webb may ask that you lay flat for 24 hours after surgery. This is done to give the repair time to heal and to ensure his repair does not come apart.
- Fortunately, multiple studies have shown that having a dural tear repair does not affect your outcome from surgery.
Infection
- Very low risk (<1%) but this risk is increased if you are overweight, immunosuppressed, on chronic steroids, or diabetic.
- Antibiotics will be given before surgery starts and also given for 24 hours after surgery while you are in the hospital to decrease the risk of infection.
Bleeding
- Very low risk, but increased if you are taking blood thinners, fish oil, herbal medications or have a clotting disorder.
- These medications will need to be stopped before surgery.
- Sometimes, a special tube called a drain will be placed during surgery. This tube is to collect any blood or fluids that can collect after surgery. This drain will be removed before you leave the hospital, usually the next day after surgery.
Spinal cord or Nerve damage
- Low risk
- A neuromonitoring technician is a professional trained in the monitoring of your nerves and spinal cord.
- This person (along with a Neurologist) is part of the team that will be taking care of you during surgery and will help Dr. Webb monitor your nerves and spinal cord throughout the procedure.
- You will be able to meet this person the morning of surgery and ask any questions about their role in your care.
- Generally, after you are asleep from anesthesia, this technician will place small wires on your legs and arms so that the nerves and spinal cord and be monitored during surgery.