TLIF WITH DECOMPRESSION (Level 1 and level 2) cost in India

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What is TLIF?

Transforaminal lumbar interbody fusion (TLIF) is a contemporary approach to spinal fusion surgery. It is an operation performed on the lower back to remove an intervertebral disc and join two or more spinal bones (vertebrae) together using screws and a cage.

 A TLIF Involves:

1. Decompression of the nerves in the lower back
2. Removal of a facet joint
3. Removal of the intervertebral disc
4. Stabilization of the disc level by inserting screws into the bones above and below (pedicle screws)
5. Fusing the spine by inserting a cage filled with bone into the disc space (interbody fusion)

A TLIF offers important advantages over the alternative surgical techniques of both a posterior lumbar interbody fusion (PLIF) and posterolateral instrumented fusion.

A TLIF IS ADVISED FOR SOME PATIENTS WHO MAY HAVE THE FOLLOWING CONDITIONS:

• Disc prolapsed causing pressure on the nerve roots, when one or more of the following conditions exist:

1. There has been previous surgery
2. There is significant discogenic back pain (back pain arising from the disc)
3. There is instability of the spine
4. Surgery to simply remove the disc and take pressure of the nerves would be likely to cause instability

• Lumbar canal and/or lateral recess stenosis, when one or more of the following apply:
  1. There is also significant discogenic back pain (back pain arising from the disc)
  2. There is instability of the spine
  3. Surgery to simply take pressure of the nerves would be likely to cause instability
• Foramina stenosis (decompression for this problem may cause instability unless a fusion is performed at the same time)

1. Discogenic lower back pain
2. Facet joint pain which has not responded in a sustained fashion to facet joint blocks and radiofrequency denervations
3. Spondylolisthesis (slip of one vertebra on another)

Surgery is usually recommended when all reasonable conservative measures (pain medications, nerve sheath injections, physical therapies, braces etc.) have failed. In cases of significant instability or neurological problems, surgery may be the most appropriate first treatment option.

Investigtions

• CT scan
• usually an early investigation
• shows the anatomy of the bone and joints very well
• MRI scan
• gives more detailed information about the discs and nerves
• CT Myelogram
• usually performed if an MRI cannot be carried out for some reason
• Standing X-rays and X-rays taken bending forward and backward (flexion-extension X-rays)
• to assess for potential spondylolisthesis and instability
• Nerve conduction studies and/or a nerve sheath injection with local anaeasthetic
• to confirm which nerve (or nerves) is causing the symptoms
• Facet joint blocks and/or a nuclear medicine scan (lumbar SPECT)
• if pain arising from the facet joints is suspected
• Provocative lumbar disco gram
• if pain arising from an intervertebral disc is suspected
• Nuclear medicine bone scan
• if cancer of the spine is suspected
• Bone density scans (DEXA scan)
• if osteoporosis is suspected

Benefits

• Reduction of leg pain, numbness, tingling and weakness
• Reduction of back pain
• Stabilization of an unstable spine
• Medication reduction
• Prevention of deterioration
• Improved lower back and leg function
• Improved work and recreational capacity
• Improved quality of life

Generally, the symptom that improves the most reliably after surgery is leg pain. Back pain also often improves, but occasionally can be worse. The next symptom to improve is usually weakness. Your strength may not return completely back to normal, however. Improvement in strength generally occurs over weeks and months. Numbness or pins and needles may or may not improve with surgery, due to the fact that the nerve fibres transmitting sensation are thinner and more vulnerable to pressure (they are more easily permanently damaged than the other nerve fibers). Numbness can take up to 12 months to improve, if it does so.

Risks involved in TILF

• Fail to benefit symptoms or to prevent deterioration
• Worsening of pain/weakness/numbness
• Infection
• Blood clot in wound requiring urgent surgery to relieve pressure
• Cerebrospinal fluid (CSF) leak: this risk is much higher in revision (re-operation) surgery
• Surgery at incorrect level (this is rare, as X-rays are used during surgery to confirm the level)
• Blood transfusion
• Injury to bowel or abdominal blood vessels when the disc is being removed
• Screw and/or cage breakage, movement, or malposition, sometimes requiring further surgery
• Recurrent nerve compression
• Nerve damage (weakness, numbness, pain) occurs in less than 1%
• Paraplegia (paralyzed legs)
• Incontinence (loss of bowel/bladder control)
• Impotence (loss of erections)
• Chronic pain (may require further surgery)
• Failure to fuse (pseudoarthrosis)
• Adjacent segment disease (deterioration of the disc above or below)
• Blindness (extremely rare)

Surgery

A general anesthetic will be administered to put you to sleep. A breathing tube (‘endotracheal tube’) will be inserted and intravenous antibiotics and steroids injected (to prevent infection and post-operative nausea). Calf compression devices will be used throughout surgery to minimize the risk of developing blood clots in your legs. A catheter will be inserted into your bladder to prevent bladder distension during surgery and to monitor urine output. You will be placed face-down on the operating table on a special spinal frame.

Your skin will be cleaned with antiseptic solution and some local anesthetic will be injected. The skin incision is usually about 6-10cm in the middle of you lower back. It is vertical. The plane between your back muscles on each side of the spine is then followed down, and screws are inserted into the pedicles at the appropriate levels. The facet joint on one side is removed using a high-speed drill, and the nerve roots are identified and decompressed.

A microdiscectomy is performed. This is done by first cutting the outer annulus fibrosis (fibrous ring around the disc) and removing the nucleus pulposus (the soft inner core of the disc). Disc removal is performed using a combination of special instruments. The boundaries of the disc space (the vertebral end-plates) are then carefully prepared to facilitate fusion. Some bone from the facet joint is mixed with tricalcium phosphate and bone morphogenetic proteins, and this is packed into the empty disc space. An interbody cage (made of carbon fiber, PEEK, or trabecular metal) is filled with bone and inserted into the disc space. A small piece of fat is laid over the nerve roots to minimize scarring. Further bone is laid down over the laminae, as well as the opposite facet joint and transverse processes (posterior and posterolateral fusion). The screws are then connected by rods and, if a significant slip (spondylolisthesis) is present, this may be partially reduced.

During the procedure, several X-rays are performed to check that the operation is being carried out at the correct disc level, and that the screws and cages are in a satisfactory position. At the end of the procedure, the surgical field is checked for excessive bleeding or any other problems, and a final check is made to ensure that the nerves are no longer under pressure. The wound is closed with dissolving sutures or with staples.

After Surgery

It is usual to feel some pain after surgery, especially at the incision site. Pain medications are usually given to help control the pain. While tingling sensations or numbness is common, and should lessen over time, they should be reported to your neurosurgeon. Most patients are up and moving around within several hours of surgery. This is encouraged in order to keep circulation normal and avoid blood clot formation in the legs.

You will be able to drink after 4 hours, and should be able to eat a small amount later in the day. A CT scan will be performed the next day to check the position of the screws and cage. You will be discharged home when you are comfortable, usually after a short period of inpatient rehabilitation.

• You will need to wear a special brace for 3 months after surgery whilst you are sitting, standing or walking. 
• You should avoid sitting for more than 15-20 minutes continuously during this time. At 6-8 weeks it is likely that you will be able to return to work on “light duties” and to drive a motor vehicle on short trips.
• Bear in mind that the amount of time it takes to return to normal activities is different for every patient. Discomfort should decrease a little each day. Increases in energy and activity are signs that your post-operative recovery is progressing well. Maintaining a positive attitude, a healthy and well-balanced diet, and ensuring plenty of rest are excellent ways to speed up your recovery.
• Signs of infection such as swelling, redness or discharge from the incision, and fever should be brought to the surgeon’s attention immediately.
• You will be reviewed after 6-8 weeks by your neurosurgeon. Until then, you should not lift objects weighing more than 2kg, and should not engage in bending or twisting movements.
• The results of fusion surgery are not as good in patients who smoke or are very overweight. It is therefore important that you give up smoking permanently before your surgery and try to lose as much weight as possible.
• Increasing leg pain, weakness or numbness
• Worsening back pain
• Problems passing urine or controlling your bladder or bowels
• Problems with your walking or balance
• Fever
• Swelling, redness, increased temperature or suspected infection of the wound
• Leakage of fluid from the wound
• Pain or swelling in your calf muscles (ie. below your knees)
• Chest pain or shortness of breath
• Any other concerns

Contcact your surgeon If you Experience any of the above mentioned issues.