Lumbar Fusion Through the Back, Often Minimally Invasive
When a slipping, unstable or collapsed disc in the lower back is pinching nerves and causing pain, a transforaminal lumbar interbody fusion (TLIF) can often correct the problem by freeing the nerves and stabilizing the spine, often through small incisions.
What Is a TLIF?
A transforaminal lumbar interbody fusion, or TLIF, is a type of lumbar fusion done from the back. “Transforaminal” means the disc is reached from one side through the foramen, the opening where a nerve exits the spine. This path lets the surgeon remove the disc and relieve pressure on the nerves while moving the spinal nerves as little as possible.
The damaged disc is removed and replaced with a spacer (cage) filled with bone graft, and screws and rods hold the spine steady while the bone heals. Because it allows direct decompression of the nerves and a fusion through the same approach, TLIF is one of the most common and versatile fusion techniques, and it can be used at any level of the lower back, including L5-S1.
Dr. Grunch most often performs TLIF using minimally invasive techniques. A minimally invasive TLIF uses an incision of about 3 centimeters on one side instead of the 3- to 6-inch incision of open surgery, and the muscles are gently separated rather than cut. Learn more about minimally invasive fusion.
Who Needs a TLIF?
- Spondylolisthesis, where one vertebra slips forward over another
- Spinal stenosis or foraminal stenosis combined with slipping or instability
- Spinal instability or a level that moves abnormally on flexion and extension X-rays
- Severe degenerative disc disease or a collapsed disc causing back and leg pain
- A disc herniation that has come back more than once at the same level
- Adjacent segment disease or a failed previous fusion
A worn disc on an MRI alone doesn’t mean you need a fusion. Dr. Grunch makes sure your imaging matches your symptoms, and she also offers lumbar disc replacement and decompression without fusion when those are better choices.
Treatments to Try First
- Physical therapy: core strengthening and a structured exercise program
- Medications: anti-inflammatory medications, muscle relaxers or nerve pain medications
- Injections: epidural steroid injections, facet injections or radiofrequency ablation
- Activity changes and weight management to reduce stress on the spine
When these no longer keep you active, or nerves are being compressed by slipping or instability, surgery can often correct the problem.
How a TLIF Is Done
- Anesthesia and monitoring: You’ll be fully asleep and lying face down. Nerve monitoring is used to protect the nerves during surgery.
- Reaching the spine: Through a small incision on one side of the back, the muscles are gently separated to reach the spine.
- Decompression: Part of the facet joint and any bone or ligament pressing on the nerves are removed to free them.
- Removing the disc: Working through the foramen, the disc is removed and the bone surfaces are prepared so they can fuse.
- Placing the spacer: A spacer filled with bone graft is placed to restore disc height and alignment.
- Stabilizing: Screws and rods are placed, often through small incisions with image guidance, to hold the level steady.
- Closing: The incisions are closed with dissolvable stitches and skin glue.
Watch an animation of how a minimally invasive TLIF is done:
Video: MAS TLIF Patient Animation, courtesy of NuVasive (YouTube)
Benefits and Risks
Benefits
- Relief of back and leg pain from slipping, instability or a collapsed disc
- Direct decompression of pinched nerves and a fusion through one approach
- Can be used at any lumbar level, including L5-S1
- With minimally invasive techniques, smaller incisions, less blood loss and a faster return to activity
Risks
- Infection or bleeding
- Nerve injury or a spinal fluid leak, which are uncommon
- The bones not fusing (nonunion), which is more common in people who smoke
- Screw or spacer loosening, which can require another surgery
- Extra wear at the levels above or below the fusion over time (adjacent segment disease)
- Risks related to anesthesia, including blood clots
Why Choose Dr. Betsy Grunch for Your TLIF
- Duke-trained: Dr. Grunch completed her neurosurgical residency and a spine research fellowship at Duke University School of Medicine, one of the top neurosurgery programs in the country, where she received the Spine Young Investigator Award.
- Minimally invasive by design: Minimally invasive spine surgery, including transforaminal approaches through Kambin’s triangle, is one of her signature areas, so you can get back on your feet sooner.
- Every approach: She performs TLIF, PLIF, ALIF and LLIF and chooses the approach that best fits your anatomy rather than using one technique for everyone.
- Fusion only when you need it: She also performs lumbar disc replacement and decompression without fusion, so a fusion is recommended only when it’s truly the best option for you.
- Experience you can count on: She has been in practice since 2013 and performs 400 to 600 surgeries a year, more than 5,000 procedures over her career.
- Second opinions and revisions: She regularly sees patients who had spine surgery elsewhere and want a second opinion or need a revision.
- A teacher at heart: As “Ladyspinedoc,” she is known for explaining spine conditions clearly. You’ll leave your visit understanding your imaging and every option in front of you.
What to Expect
Before surgery
You’ll meet with Dr. Grunch or one of her physician assistants to review your imaging, your exam and your goals, and to decide together whether a TLIF is right for you. Our team will coordinate any pre-operative testing, review your medications (including blood thinners you may need to pause) and walk you through the day of surgery so nothing is a surprise. Smoking and nicotine slow bone healing and can cause a fusion to fail, so stopping before surgery is strongly recommended. Our office can help.
Procedure day
Surgery usually takes two to four hours, depending on the number of levels. Many patients go home the day after surgery, and some need a night or two longer. You’ll be up and walking the day after surgery, and physical therapy will help you get moving safely before you go home.
Recovery timeline
- First two weeks: Leg pain often improves quickly. Back soreness is normal. Walk several times a day and wear your brace when you’re up.
- Four to six weeks: Your follow-up visit, with X-rays to check healing. Many people with desk jobs return to work in three to six weeks.
- Six to twelve weeks: Restrictions are gradually lifted, and physical therapy may begin to strengthen your core.
- Six to twelve months: The bones continue to fuse. Most patients are back to their normal activities.
Every patient heals differently. Your exact timeline will depend on your symptoms, the number of levels fused, your job and your overall health.
Caring for yourself at home
- Back brace: Wear your brace whenever you’re out of bed and moving around.
- Walking: Walk 30 to 60 minutes a day, broken into 10- to 15-minute sessions, and try not to sit for more than 30 minutes at a time.
- Restrictions for about six weeks: No bending at the waist, no twisting and no lifting more than 10 pounds. That includes vacuuming, laundry, golf, yard work and lifting young children or grandchildren. Let others help you at home.
- Your incisions: If your incisions are closed with skin glue, you may shower the day after surgery; if they have stitches or staples, wait three days. Don’t scrub, don’t use ointments or creams, and don’t soak in a bath, hot tub or pool for six weeks.
- Medications: Most patients use pain medication and a muscle relaxer for four to six weeks. Avoid anti-inflammatory medications such as ibuprofen, naproxen, meloxicam, celecoxib and diclofenac, which can interfere with fusion. Blood thinners are held for 5 to 7 days after surgery until Dr. Grunch’s team tells you to restart them. Take pain medication with food, avoid alcohol while taking it, and use a daily stool softener.
- Bone growth stimulator: If one is prescribed, the manufacturer will contact you after surgery.
- Driving: You may drive once you are no longer taking narcotic pain medication, and you may ride as a passenger before then.
- Follow-up: Your follow-up visit is about four to six weeks after surgery. Any outside stitches or staples are removed at 10 to 14 days.
Learn how a bone growth stimulator can support your fusion:
Video: Spinal Fusion Patients: Are You Using a Bone Growth Stimulator?, from Dr. Grunch on her Ladyspinedoc channel (YouTube)
Call the office at 470-293-9800 if you have a fever over 101°F, redness, warmth or significant drainage from the incision, calf pain or swelling, constipation that medication doesn’t relieve, new trouble controlling your bladder or bowels, or worsening pain down your leg. Call 911 for chest pain or shortness of breath.
Download your patient instructions
Print these sheets or save them to your phone so you have them before and after surgery:
- About your surgery: Transforaminal Lumbar Interbody Fusion (TLIF) (PDF)
- Post-operative guidelines: Posterior or Lateral Lumbar Fusion (PDF)
You’ll find instructions for other procedures on our Patient Resources page.
Frequently Asked Questions
What’s the difference between a TLIF and a PLIF?
Both are done from the back. A PLIF reaches the disc from both sides of the spinal canal, while a TLIF reaches it from one side through the foramen, which means less movement of the spinal nerves. TLIF is the more common choice today.
How big are the incisions?
With a minimally invasive TLIF, the main incision is about 3 centimeters, plus a few small incisions for the screws. Open surgery uses a single larger incision down the middle of the back.
Will I lose flexibility in my back?
Fusing one or two levels has only a small effect on overall motion, because most bending comes from the hips and the other levels of the spine. Most people don’t notice a big difference in daily life.
Why can’t I take ibuprofen after a fusion?
Anti-inflammatory medications can slow bone healing and interfere with fusion. Dr. Grunch’s team will tell you when it’s safe to restart them.
How long does it take for the fusion to heal?
The screws and spacer hold the spine steady right away, but the bone takes about six to twelve months to fully fuse. Not smoking, good nutrition and staying active all help.
Take the First Step Toward Relief
If back or leg pain from a slipping or unstable spine is keeping you from living your life, you have options. Whether you need a treatment plan, a second opinion or a clear explanation of your imaging, Dr. Grunch and the Southern Neurosurgery team are here to help.
Call 470-293-9800 to schedule an appointment or contact us online.
Have a question first? Ask our virtual assistant anything, 24/7.
We see patients across metro Atlanta and North Georgia at our offices in Gainesville, Sandy Springs and South Atlanta (Riverdale). Find the office nearest you.
Related pages: Lumbar fusion · ALIF · LLIF · Minimally invasive fusion · Spondylolisthesis · Revision fusion
This page is for educational purposes only and is not medical advice. It does not replace individualized care from a licensed physician. Please talk with your own doctor about your symptoms. If you have bladder or bowel changes, groin numbness or rapidly worsening weakness, call 911 or go to the nearest emergency room.