**Abstract**

Minimally invasive spine surgery (MIS) transforaminal lumbar interbody fusion (MI-TLIF) has been utilized to treat a variety of spinal disorders. Like other minimally invasive spine surgery techniques and technology, the MI-TLIF approach has the potential to limit the morbidity associated with larger exposures required for open surgery. The MI-TLIF approach has a number of advantages over many other minimally invasive spine surgery approaches including direct decompression of neural elements, collection of morselized autograph from the surgical site to achieve high fusion rates, restoration of spinal canal diameter, foraminal diameter, disk height, and reduction of spondylolisthesis. In this chapter, we discuss a novel technique for performing MI-TLIF developed by the senior author who is a leading minimally invasive spine surgeon. The technique and technology illustrated in this chapter were developed out of a recognition of a need to reduce the learning curve for performing MI-TLIF, as well as need for a cost-effective method that provides a high fusion rate, excellent clinical outcomes, and low complication rate. The indications, surgical planning, postoperative care, complications, and patient outcomes in a large series will be reviewed using this novel MI-TLIF technique.

**Keywords:** minimally invasive spine surgery (MIS), minimally invasive transforaminal lumbar interbody fusion (MI-TLIF), degenerative disk disease, spondylolisthesis, lumbar stenosis, recurrent disk herniation

## **1. Introduction**

Over the last two decade, the use of spine instrumentation options has become the standard of care for the treatment of a variety of spinal disorders [1–6]. Lumbar spine surgery indications continue to evolve as more clinical outcomes studies become available [7–10]. Indications include lumbar stenosis, lumbar spondylolisthesis with and without stenosis, degenerative disk disease (DDD), lumbar scoliosis, and recurrent disk herniations. There are a variety of surgical options including open fusion and instrumentation, posterior lumbar interbody fusion (PLIF), minimally invasive transforaminal lumbar interbody fusion (MI-TLIF), oblique lateral interbody fusion (OLIF), abdominal lumbar interbody fusion (ALIF),

### **Figure 1.**

*Preoperative A. sagittal and B. axial T2-weighted MRI images showing L4–5 grade 1 spondylolisthesis with associated stenosis. Postoperative C. sagittal, D. axial CT, and E. postoperative incision following MI-TLIF approach showing adequate central canal decompression, restoration of disk height, and normal sagittal alignment.*

extreme lateral interbody fusion (XLIF), and others. In this chapter, we will review a novel MI-TLIF technique, discuss surgical nuances related to the procedure, and review a large clinical series using this technique and technology.

MI-TLIF is a minimally invasive spine technique that has gained tremendous acceptance in the surgical community. The number of publications utilizing the MI-TLIF technique testifies to its popularity compared with other minimally invasive spine surgery (MIS) fusion techniques [11–13]. The rationale behind the MI-TLIF procedure is the advantage of direct neural decompression, reduced neural retraction during the procedure, and compression of interbody graft material to promote arthrodesis [14–16]. Additionally, the posterior approach permits collection of drilled morselized autograph bone for fusion material, which when placed into the intervertebral disk space promotes arthrodesis (**Figure 1**). Further, the technique and instrumentation that have been developed preserve the disk annulus and contain the injected bone graft material. By placing this bone graft material under load, arthrodesis is promoted according to Wolff's law. On comparative studies, MI-TLIF was shown to be superior to other techniques in terms of bone fusion rates, complications rates, and biomechanical properties [17–23]. Most of the proponents of this approach support the concept of preserved anatomical structures avoiding instability, while restoring sagittal alignment [24]. Using the same posterior approach, percutaneous pedicle screws can be applied bilaterally which further promotes fusion rates.

### **2. Indications for MI-TLIF**

Indications for fusion and instrumentation include degenerative disk disease (DDD), spondylolisthesis with or without stenosis, lumbar stenosis, scoliosis, and instability due to trauma/tumor resection (**Figure 2**) [25].

*Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Novel Technique… DOI: http://dx.doi.org/10.5772/intechopen.105187*

**Figure 2.** *Lateral plain X-ray radiograph and illustration of spondylolysis with pars interarticularis defect.*

There a number of relative contraindications for selecting this approach including severe osteoporosis, active infection, and uncontrolled bleeding disorders. However, we have found that patients with osteoporosis can be effectively treated using this technique. Obesity was initially a relative contraindication; however, as more clinical outcomes studies, including our series, have become available, this can now be considered as an accepted indication when other techniques are not appropriate [26].
