Updated: 10/4/2016

Single Level Lumbar Decompression and Fusion (TLIF)

Preoperative Patient Care


Outpatient Evaluation and Management


Obtain focused history and performs focused exam

  • interpret neurological exam
  • describe key physical exam maneuvers (lumbar nerve root function)
  • concomitant and associated orthopaedic injuries
  • extends examination to nonspinal differential diagnostic possibilities
  • vascular claudication
  • hip arthritis


Appropriately orders and interprets advanced imaging studies

  • CT scan
  • myelogram
  • MRI findings
  • central stenosis
  • foraminal stenosis
  • identifies nerve root anatomy
  • correlates clinical and imaging findings to form clinical diagnosis


Prescribes and manages nonoperative treatment

  • medical management
  • attempts medical management of lumbar radiculopathy (NSAIDs, gabapentin)
  • orders appropriate diagnostic and therapuetic selective nerve root or epidural steroid injections
  • attempts trial of physical therapy
  • make referrals to other professionals


Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention


Provides, modifies and adjusts procedure and patient specific post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • repeat xrays of lumbar spine
  • look for evidence of fusion
  • advance spine restrictions and activity levels
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
  • repeat xrays of lumbar spine to identify fusion

Advanced Evaluation and Management


Provides complex non-operative treatment

  • individualized care
  • shared decision making
  • comprehensive informed consent


Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for complex cases

  • multilevel stenosis with deformity


Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for complex cases

  • multi-level stenosis with deformity


Capable of surgically treating simple complications

  • drainage of hematoma
  • debridement of infection

Preoperative H & P


Obtain history and perform basic physical exam

  • need to carefully document neurological status of bilateral lower extremities
  • strength, sensation, reflexes, and primary symptoms


Order basic imaging studies

  • obtain biplanar films of the L-spine


Screen medical studies to identify and contraindications for surgery

  • confirms no recent infection contraindicating surgery (UTI)


Perform operative consent

  • documents failure of nonoperative measures such as physical therapy and epidural streoid injections
  • describe complications of surgery including
  • persistent radiculopathy due to inadequate decompression
  • dural tear
  • iatragenic nerve root injury
  • segmental instability due to aggressive facet capsule and joint excision
  • superficial, deep wound infection
  • meralgia parasthetica due to compression of LFCN

Operative Techniques


Preoperative Plan


Identifies area of decompression on preoperative imaging


Template instrumentation on preoperative imaging studies.


Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • Lumbar Instrumented Fusion System
  • decompression with instrumented fusion is indicated in presence of segmental instability (spondylolisthesis, degenerative scoliosis)
  • structural interbody spacers
  • titanium cages
  • polyetheretherketone cages
  • Autologous or allograft bone for fusion


Room setup and equipment

  • table
  • radiolucent Jackson spine flat top table
  • neuromonitoring
  • neuromonitoring leads to upper and lower extremities
  • C-arm
  • c-arm perpendicular to table
  • can take initial Lat fluoro of lumbar spine to localize level
  • highest point in iliac crest marks L4-5 interspace but overlying soft tissue can push you closer to L3-4 interspace
  • microscope
  • microscope in from opposite side of C-arm


Patient positioning

  • prone with arms at 90° max abduction and flexion to prevent axillary nerve injury
  • foam padding on chest so that nipples are pointing midline straight down
  • pads over ASIS and gel pads on knees
  • foley in place
  • bilateral TED hose and SCDs

Dissection to Spinous Process


Localize level of incision with anatomic or radiographic landmarks


Make midline incision.

  • midline incision with 10blade overlying the spinous processes between paraspinal muscles (erector spinae)
  • ~3-4cm in length for single level


Dissect subcutaneous tissue down to fascia

  • insert cerebellar retractors x2 for fascial exposure


Cauterize lumbodorsal fascia over spinous processes to just lateral of midline


Dissection to Transverse Process


Perform subperiosteal dissections

  • perform dissection with Cobb along spinous processes
  • perform subperiosteal dissection of the lamina in a cranial to caudal direction


Place probe under lamina to identify level radiographically


Expose the facet capsules

  • use Cobb to strip laterally along lamina until facet capsules exposed


Dissect out transverse process

  • dissect paraspinal muscle from intertransverse membrane


Place deep retractors for better visualization


Laminectomy and Decompression


Remove spinous processes of operative levels with rongeur

  • save as bone graft for fusion


Remove lamina and identify origin of ligamentum flavum

  • begin with decompression into canal into inferior half of lamina of cephalad vertebrae first with small curette
  • burr lamina and decompress medial aspect of facet on each side (2-3 mm of medial facet)


Resect ligamentum flavum

  • gently retract ligamentum flavum with woodsen elevator
  • resect remaining lamina and ligamentum with Kerrison rongeur of cephalad vertebrae
  • resect ligamentum from superior lamina of inferior lamina
  • use Kerrison to resect caudad lamina from inferior vertebra
  • use woodsen to protect dura and nerve roots during entire resection of ligamentum flavum


Perform a lateral recess/foraminal decompression

  • locate the pedicle
  • locating pedicle key to safe decompression
  • superior facet much closer to nerve root
  • expose the pedicle
  • use a kerrison to undercut medial edge of superior facet of caudad vertebra until medial edge of pedicle visualized
  • identify osteophytes that could impinge exiting nerve root around pedicle
  • undercut remaining superior facet using kerrison rongeur
  • if not fusing no more than 50% superior facet should be resected
  • dural sac/nerve root may be retracted to see if there is bulging disc is present

Instrumentation with Pedicle Screws


Identify entry point for instrumentation

  • landmark for pedicle screws is inferolateral aspect of the intersection of facet and transverse process
  • for sacrum landmark is base of facet at S1 (superolatral to sacral foramen)


Decorticate entry site

  • use a burr
  • place gearshift probe into pedicle track ~30mm until significant resistance is felt (anterior cortex of vertebral body)


Verify entry point

  • insert balltip probe to check floor, medial, inferior walls of pedicle
  • check for canal/nerve root
  • place metallic markers into tracts of all screws to check with fluoro
  • once markers confirmed in correct locations advance gearshift 40-50mm
  • tap 5mm and recheck with balltip probe


Insert pedicle screws

  • (i.e. L4, 6.5x50mm screws; L5, 7.5x40mm screws)


EMG test all screws to ensure no pedicle wall breach

  • can test nerve first to get baseline reading
  • no screw should trigger less than 10-15mA response


Place contoured rods

  • place 2 contoured rods (i.e. 6.0mm rods, use hand benders) for desired lordosis into screw tulips
  • insert set screws
  • distract across rods using hand distractors and tighten set screws

Facetectomy and Disk Preparation


Complete unilateral facetectomy

  • use an osteotome to expose the inferior articular process of the cephalad vertebra
  • dissect the superior articular process of the caudal vertebra from the ligamentum flavum
  • resect the lateral aspect of the hemilamina and the caudal portion of the pars interarticularis using kerrison rongeurs


Prepare disk space

  • mobilze the thecal sac using a nerve root retractor.
  • use a scalpel to incise a rectangular region of the annulus lateral to the traversing nerve root
  • this creates a window to the disk space
  • serially introduce shavers or dilators into the disk space and rotate
  • use curettes and rongeurs to perform a thorough diskectomy.

Interbody Arthrodesis


Trial implant

  • use graft trials to determine the size of the interbody spacer
  • confirm size with fluoroscopy
  • pack the anterior and lateral aspects of the disk space with morselized bone graft
  • use a graft impactor to maximize the amount of graft that can be use
  • reintroduce the trial to ensure that the morsalized graft has not block the pathway for insertion


Place implant

  • remove the trial then place the interbody spacer as anterior and central as possible
  • place additional graft into the posterior aspect of the disc space behind the implant


Confirm the implant position with AP and lateral radiographs


Prepare Arthrodesis and Wound Closure


Decorticate the surrounding bony structures

  • decorticate surrounding transverse processes, facet joints, and pars with burr


Place autograft

  • pack posterolateral gutters with autologous/allograft graft


Tighten instrumentation

  • final tighten set screws and placecross connector between pedicle screws and tighten


Confirm Final Implant Position

  • take final AP/Lat of screws and rods to confirm position and lordosis


Irrigation and Hemostasis

  • flush out spine with saline bulb irrigation
  • can use betadine wound lavage or vancomycin powder to decrease infection risk
  • use Floseal for hemostasis
  • place hemovac drain under fascia


Close Fascia

  • close fascia with 0-vicryl
  • need water tight closure and need to decrease dead space for hematoma


Superficial closure

  • subcutaneous with 2-0 vicryl
  • skin closure with buried 3-0 monocryl



  • soft incision dressings over spine

Postoperative Patient Care


Perioperative Inpatient Management


Writes appropriate admission orders

  • IV fluids
  • advance diet when return of flatus
  • pain meds
  • antibiotics
  • wound care
  • changes dressing on POD #2
  • identify CSF leak
  • foley catheter out when ambulating
  • serial neurovascular exams
  • check appropriate labs


Appropriately orders and interprets basic imaging studies

  • review postoperative radiographs and identifies mal-positioned pedicle screws


Appropriate medical management and medical consultation


Inpatient physical therapy

  • weight-bearing as tolerated, physical and occupational therapy
  • no heavy lifting and limited flexion/extension


Discharges patient appropriately

  • pain meds
  • wound care
  • outpatient PT
  • schedule follow up in 2 weeks

Complex Patient Care


Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for highly complex cases

  • revision surgery


Develops unique complex postoperative management plans when indicated


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