Two-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion: Surgical Technique and Illustrative Cases

Transforaminal lumbar interbody fusion (TLIF) is a common procedure performed by spine surgeons. The indications for TLIF include back pain and radiculopathy as a consequence of canal or foraminal stenosis, degenerative disc disease, spondylolisthesis, or deformity. Minimally invasive techniques (MIS) have proven to be effective for single-level TLIF and are associated with less blood loss, fewer wound complications and infections, faster recovery, and decreased hospital cost. To date, there is very little data on 2-level MIS TLIF. We present our technique for 2-level MIS TLIF with case illustrations and a review of the literature. 1. Introduction Lumbar arthrodesis is generally indicated in the treatment of spondylotic diseases of the spine including spondylolisthesis, degenerative disc disease, facet arthropathy, and scoliosis. While posterolateral fusion has been shown to be clinically efficacious and safe, many advocate interbody fusion because it affords the luxury of placing the graft under compression forces, can greatly restore lordosis and disc height, and permits indirect decompression and foraminal distraction [1–7]. Lumbar interbody fusion was first described by Cloward [8, 9] in 1952 via a posterior approach (PLIF), which proved effective in achieving interbody fusion but required significant nerve root and thecal sac retraction [10]. Harms and Rolinger subsequently described a less invasive approach in 1982 via transforaminal route (TLIF) [11]. This approach provides a more lateral point of access to the disc space, thus limiting retraction of the neural elements. While clinical outcomes have been favorable with both of these approaches, the amount of muscle dissection and retraction required to expose the spine was thought to adversely affect patient recovery [12–18]. As an alternative to these standard open techniques and with technological advancements in illumination, retractors, and magnification, Foley et al. introduced the minimally invasive (MIS) TLIF in an attempt to reduce muscle injury associated with the standard subperiosteal exposure [1, 2]. This approach involved a paramedian incision and exploits natural anatomic corridors. As described, the MIS TLIF is an effective option for treatment of the aforementioned conditions that affect the lumbar spine. Minimally invasive or minimal access techniques offer several advantages over their traditional open counterparts. The amount of muscle dissection and retraction necessary to expose the spine in a standard approach leads to significant muscle damage and atrophy [12–15, 17, 18].