TLIF is a procedure performed under general anaesthetic and, once this has taken hold, the patient will be turned onto their front to allow the surgeon access to the back of the spine. An incision of around 3cm will be made at the level of the problematic vertebrae and the surgeon will use a series of dilators to push the spinal muscles and tissues aside before inserting a tubular retractor to allow surgical access. It may be necessary to cut the spinal muscles in order to reach the back of the spine, but the TLIF approach is usually minimally invasive and allows for a lateral (side) route into the disc space reducing muscle and nerve trauma. In minimally invasive back surgery the use of an endoscope can help the surgeon to visualize the spine and this is passed through the tubular retractor along with the small, specialized surgical instruments, or inserted through a separate small incision at the side of the spine.
The surgeon removes the facet joint on one side in order to reach the disc space and then excises the degenerated disc material before preparing the bone graft and interbody spacer. In conventional PLIF surgery a portion of the facet joint is removed on either side of the spine allowing access through a much narrower space (which can increase the risk of nerve damage).
The surgeon will use pedicle screws to stabilize the spine during the procedure and the interbody spacer will be prepared for insertion. Various types of interbody spacer or cage exist, including models made from bone, titanium, polymer and some bioresorbable materials.
If an autograft is being used then the surgeon will make a small incision above the hip bone at the back of the pelvis (iliac crest) and extract a small amount of bone to use for the fusion. The spacer, or interbody cage, will be packed with chips of bone (either from the patient or using donor bone from a bone bank), and this will be inserted into the disc space in order to restore the height between the vertebrae. The back of the spine then has additional bone positioned in the lateral gutters of the vertebrae and pedicle screws, rods, and plates are used to affix the bone graft. Once the instrumentation is in place the surgeon will remove the retractors and ease the spinal muscles back into place. The incision will be closed and a surgical dressing applied; in most cases the operation takes around three and a half hours. The patient will then be taken to recovery in order to be monitored as they come round from the anaesthetic.
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