Evolution of Minimally Invasive Transforaminal Lumbar Interbody Fusion: Improving Patient Safety and Outcomes

S instability, spondylolisthesis, and degenerative disc disease have long been recognized as surgically treatable causes of lower back and radicular leg pain.7,18 Since Cloward introduced the posterior lumbar interbody fusion in 1952, minimally invasive alternatives to lumbar spine fusion have been sought in hopes of offering a less invasive alternative that achieves comparable outcomes to open surgery with reduced blood loss, lower risk of infection, and lower risk of postoperative complications.12 In 1982, two major advances toward achieving these goals were realized when Magerl9 published the first report of a percutaneous screw placement technique, and Harms and Rolinger6 published the first description of the open transforaminal lumbar interbody fusion (TLIF). The open TLIF was noted to have several advantages over posterior approaches, including a reduced need for retraction of the thecal sac and nerve root, preservation of the contralateral anatomy, and reduced risk associated with revision surgery secondary to the avoidance of epidural fibrosis.6,9,13 The primary drawback to the open TLIF approach is that it requires significant paraspinal muscle dissection and retraction, resulting in substantial postoperative pain and short-term disability. Throughout the 1990s, surgeons continued to refine and modify techniques to make lumbar fusions less invasive. These efforts culminated in the development of a minimally invasive surgery (MIS) TLIF approach in 2002.4 In the decade since Foley4 first described the MIS TLIF, dozens of studLumbar degenerative disc disease is a leading cause of emergency department visits and missed work days in the United States. There are many surgical techniques that treat the neural compression and instability responsible for the symptoms of low back pain and leg pain caused by lumbar degenerative disc disease. As with other areas of spine surgery, an intensive effort has evolved to develop minimally invasive surgical (MIS) approaches to the spine to decrease the morbidity associated with these procedures. One of the greatest success stories of minimally invasive surgery for lumbar degenerative disc disease is MIS transforaminal lumbar interbody fusion (TLIF). This surgical technique has led to decreased blood loss, shorter operative times and hospital stays, and improved overall patient outcomes. One of the previous drawbacks to the MIS TLIF has been the large amount of radiation required to safely and successfully perform these surgeries. However, a low-dose radiation protocol has recently been developed at Barrow Neurological Institute that significantly reduces the amount of ionizing radiation to which both the patient and the surgical team are exposed during an MIS TLIF operation. As these and other surgical and diagnostic advances are made, patient outcomes will undoubtedly continue to improve.