What is transforaminal spine fusion?
Your doctor may recommend spinal fusion to repair damaged discs and realign bones causing back or leg pain. There are several ways to reach the spine and perform a fusion. Your surgeon will discuss the best approach for your unique problem.
During transforaminal fusion, an incision is made off the middle of the back. The facet joint is removed to enlarge the foramen opening for the nerve (hence the name transforaminal). Bone spurs and ligaments are removed to decompress the nerve. The surgeon removes the damaged disc and fills the space between the bones with a spacer bone graft. The spacer restores the height between the bones and relieves pinched nerves. The graft becomes a bridge between the two bones tow promote fusion. The graft is strengthened with metal screws and rods.
As the body begins to heal, new bone grows around the graft. After 3 to 6 months, the graft should fuse the two vertebrae into one solid piece of bone. Like reinforced concrete, instrumentation and fusion work together.
TLIF fuses both the front disc space and the back facet joints, stopping all motion at the spine level.
Depending on the symptoms, a one-level or multi-level fusion may be performed. A one-level fusion joins two bones while a two-level fusion joins three bones. Fusion will take away some flexibility in your spine but most patients will not notice.
TLIF can be performed in a hospital or an outpatient surgery center. Patients often go home the next day for a level-one fusion, or in a couple of days for multi-level fusion. Recovery time can take up to 12 weeks.
Who is a candidate?
You may be a candidate for TLIF if you have:
- Degenerative disc disease
- Spondylolisthesis
- Mild to moderate scoliosis
- Symptoms that have not improved with physical therapy or medication
You are NOT a candidate for TLIF if you have:
- Severe osteoporosis
- Problems that would prevent bone fusion
- Prior Fusion at that level
The surgical decision:
If you are a candidate for spinal fusion, the surgeon will explain your options. Consider all the risks and benefits as you make your decision. Fusion is performed only after other treatments have been explored. It will stop the motion in the painful area of your spine, allowing increased function and the return to a more normal lifetime – though one that may not be totally pain-free.
Your surgeon will also explain the various types of bone graft. These materials are placed within the remaining disc space and act as a kind of mortar between the bones as your body heals. Each type has advantages and disadvantages.
- Autograft is your living bone. The marrow contains bone-growing proteins. It can be collected from drillings during the surgery or taken from the hip as an iliac crest bone graft. The harvested bone is about a half inch thick. The entire thickness of bone is not removed, just the top half layer.
- BMA (bone marrow aspirate) is your living bone marrow, collected with a syringe from the hip (iliac bone) or vertebra. It is relatively painless compared to an iliac crest graft.
- Allograft is bone from an organ donor, collected and stored by a bone bank. The donor graft has no bone-growing cells.
- Cellular bone matrix is allograft from an organ donor that contains bone-growing stem cells. The putty is shaped and added to grafts.
- BMP (bone morphogenetic protein) is sometimes added to bone-graft material to stimulate bone growth naturally in the body.
What happens before surgery?
Presurgical tests (e.g., blood test, chest x-ray, electrocardiogram) will be done several days before surgery. In the doctor’s office, you will sign consent forms and provide your medical history (allergies, medicines, vitamins, bleeding history, anesthesia reactions, previous surgeries). Inform your healthcare provider about all the medications (over-the-counter, prescription, herbal supplements) that you are taking.
Continue taking the medications your surgeon recommend. Stop taking all non-steroidal anti-inflammatory medicines (Naprosyn, Advil, Motrin, Nuprin, Aleve, etc.) and blood thinners (Coumadin, Plavix, etc.) 1 to 2 weeks before surgery as directed by your doctor. As your doctor if you are unsure.
Stop smoking and drinking before surgery
The most important way to achieve a successful spine fusion is to eliminate tobacco use (cigarettes, cigars, pipes, chewing tobacco, and snuff/dip) before surgery.
Nicotine prevents bone growth and decreases successful fusion. Smoking risk is serious: fusion fails in 40% of smokers compared to 8% of non-smokers [1]. Smoking also decrease blood circulation, resulting in slower wound healing and increased risk of infection. Talk with your doctor about ways to help you quit smoking: nicotine replacements, pills without nicotine (Wellbutrin, Chantix), and tobacco counseling programs.
You should not drink alcohol 1 week before and 2 weeks after surgery to avoid bleeding problems.
Morning of surgery
- No food or drink.
- Shower using antibacterial soap. Dress is freshly washed, loose-fitting clothing.
- Wear flat-heeled shoes with closed backs.
- If you have instruction to take regular medication the morning of surgery, do so with small sips of water.
- Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
- Leave all valuables and jewelry at home (including wedding bands).
- Bring a list of medications (prescriptions, over-the-counter, and herbal supplements) with dosages and the times of day usually taken.
- Bring a list of allergies to medication or foods.
Arrive at the hospital 2 hours before (surgery center 1 hour before) your scheduled operation to complete the necessary paperwork and pre-procedure work-ups. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks. An intravenous (IV) line will be placed in your arm.
What happens during surgery?
This surgery generally takes 1 to 2 hours, depending on how many spine levels are treated.
- Step 1: Prepare the patient
- Step 2: Make the incision
- Step 3: Remove the facet joint
- Step 4: Remove the disc
- Step 5: Prepare the disc space
- Step 6: Insert the bone graft
- Step 7: Insert pedicle screws
- Step 8: Close the incision
What happens after surgery
Patients typically go home the next day. Be sure to have someone at home with you the first 24 to 48 hours to help.
Follow these home care instructions for 2 weeks after surgery.
Restrictions
- Avoid bending/twisting your back for 6 weeks.
- Do not lift anything heavier than 5 pounds.
- No strenuous activity including yard work, housework, and sex.
- DON’T SMOKE, vape, dip, chew or use nicotine products. It prevents new bone growth and may cause your fusion to fail.
- Don’t drive until after your follow-up appointment.
- Don’t drink alcohol. It thins the blood and increases the risk of bleeding. Also don’t mix alcohol with pain medicines.
Incision Care
- Wash your hands thoroughly before and after cleaning your incision to prevent infection.
- If you have Dermabond (skin glue) covering your incision, you may shower the day after surgery. Gently wash the area daily with soap and water. Pay dry.
- If you have staples, steri-strips, or stitches, you may shower 2 days after surgery. Gently wash the area with soap and water every day. Pat dry.
- If there is drainage, cover the incision with a dry gauze dressing. If drainage soaks through two or more dressings in a day, call the clinic.
- Don’t soak the incision in a bath, pool, or tub.
- Dress in clean clothes after each shower. Sleep with clean bed linens. No pets in the bed until your incision heals.
- Some clear, pinkish drainage from the incision is normal. Watch for increased volume of drainage or spreading redness. An infected incision may have colored drainage and begin to separate.
- Staples, steri-strips, and stitches will be removed at your follow-up appointment.
Medications
- Take pain medications as directed by your surgeon. Reduce the amount and frequency as your pain subsides. If you don’t need the pain medicine, don’t take it.
- Narcotics can also cause constipation. Drink lots of water and eat high-fiber foods. Laxatives and stool softeners such as Dulcolax, Senokot, Colace, and Milk of Magnesia are over-the-counter options.
- If painful constipation does not get better, call the doctor to discuss other medicine.
- Don’t take anti-inflammatory pain relievers (Advil, Aleve) without your surgeon’s approval. They prevent new bone growth and may cause your fusion to fail.
- You may take acetaminophen (Tylenol).
Managing Pain
- Ice your incision 3-4 times per day for 15-20 minutes to reduce pain and swelling.
- Don’t sit or lie in one position longer than an hour unless you are sleeping. Stiffness leads to more pain.
Activity
- Get up and walk 5-10 minutes every 3-4 hours. Gradually increase your walking time, as your are able.
Bracing
- If you were given a brace, wear it at all times except when sleeping, showing, or icing the incision.
When to Call Your Doctor
- Fever over 101.5° F (unrelieved by Tylenol)
- Unrelieved nausea or pain
- Signs of incision infection, such as redness, swelling, or drainage.
- Rash or itching at the incision (allergy to Dermabond skin glue)
- Swelling and tenderness in the calf of one leg
- New onset tingling or numbness in the arms or legs.
- Dizziness, confusion, nausea, or excessive sleepiness.
Recovery and Prevention:
Schedule a follow-up appointment with your surgeon for 2 to 4 weeks after surgery. Recovery to resume daily activities is usually 2 to 4 weeks. Several weeks later, X-rays may be taken to ensure the fusion is occurring. At your follow up, the surgeon will decide when you may return to work.
Fusion takes time. Follow the “BLT” of spine surgery recovery by limiting your bending, lifting and twisting for 2 to 3 months. Work modifications may be necessary.
Recurrences of pain are common. The key to avoiding recurrence is prevention:
- Proper lifting techniques
- Good posture during sitting, standing, moving, and sleeping
- Appropriate exercise program
- An ergonomic work area
- Healthy weight and lean body mass
- A positive attitude and relaxation techniques
- No smoking
What are the risks?
No surgery comes without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia.
Specific complications related to TLIF may include:
- Vertebrae fail to fuse
- Hardware fracture – Metal screws and plates break before the bones are completely fused.
- Bone graft migration and settling – in rare cases, the bone graft moves from its correct position.
- Transitional syndrome – Fusion causes extra stress and load transferred to the discs and bones above or below the fusion segment. The added wear and tear can eventually degenerate the adjacent level and cause pain.
- Nerve damage or persistent pain
To schedule an appointment or have your questions answered, please contact our spine specialists at 515.875.9560.
Sources:
- Bose B: Anterior cervical instrumentation enhances fusion rates in multilevel reconstruction in smokers. J Spinal Disord 14:3-9, 2001.