TLIF- With Pedicle Screw Fixation

Question 1

Positioning

Answer 1

Patient is put in the prone position, belly hangs to achieve lordosis

Question 2

Identify Correct Level

Answer 2

C-arm imaging to locate correct level/incision site.

Question 3

Prep/Drape

Answer 3

Patient is prepped and draped. Incision site is marked with a sterile marker

Question 4

Incision

Answer 4

a midline incision is made with a 15 blade. A bovie is used to control bleeding

Question 5

Retract

Answer 5

gelpies or weitlanders are used to spread open incision site and retract muscles

Question 6

Soft tissue removal

Answer 6

Cobb elevator is used to remove soft tissues off of transverse process and posterior arch

Question 7

Facetectomy

Answer 7

use an osteome and mallet to remove facets and create window on the affected side. Remove bone with Kerrison rongeur which can be used for autograft later.

Question 8

Keyhole Laminotomy

Answer 8

A Laminotomy is used to decompress cord and nerves and make an entry into disc space.

Question 9

Osteophyte Removal

Answer 9

Kerrison rongeur is used to remove an osteophytes around the disc space

Question 10

Distraction

Answer 10

use lamina spreaders or insert screws to distract off of. Use nerve root retractor to retract cauda equina and nerves out of the way/ protect dura. (Fluoroscopy)

Question 11

PLL

Answer 11

excise PLL with pituitary rongeur

Question 12

Annulotomy

Answer 12

a box annulotomy is perform with an 11 blade

Question 13

Discectomy

Answer 13

use a long angled scraper & pituitary rongeur to remove disc material

Question 14

Decorticate endplates

Answer 14

use angled/curved rasp and curette to scape endplates to get good bleeding bone for fusion. (Not too deep you don’t want subsidence)

Question 15

Trialing

Answer 15

You can insert paddle and confirm height with c-arm. Then Use trial cage with inserter and mallet. Confirm correct size using c-arm

Question 16

Final Cage

Answer 16

Attach banana cage to inserter. Fill with autograft/biologics. Insert as anterior and contralateral as possible. It should be in the anterior 1/3 of vertebral body. An impactor is used to further advance the cage

Question 17

Back Fill

Answer 17

Backfill with autograft and remove distraction

Question 18

Awl

Answer 18

Use an awl to punch through the cortex

Question 19

Gearshift

Answer 19

Gearshift is used to create pilot holes with the correct trajectory and length

Question 20

Ball Tip Probe

Answer 20

Ball tip probe is used to verify the integrity of the hole

Question 21

Tap

Answer 21

Tap is used to create threads which allow for good purchase in bone

Question 22

Screw Insertion

Answer 22

Insert screws with ratchet screw driver. repeat 3x. Using c-arm to verify correct length and trajectory

Question 23

Alignment

Answer 23

Align Tulip heads with head turner and select correct rod length using rod template.

Question 24

Rod insertion

Answer 24

Insert Rod using the rod holder. Load set screws and provisionally tighten.

Question 25

Reduction

Answer 25

Reduction if needed for spondylolisthesis. (Spondy reduction reducers, set screw inserter)

Question 26

Compress

Answer 26

Compress with compressor for good fusion to promote Wolff’s law and obtain lordosis.

Question 27

Torque

Answer 27

Apply torque to locking caps with counter torque and torque driver 90 in lbs

Question 28

Bone Graft

Answer 28

Bone Graft is put into lateral gutters

Question 29

Final Steps

Answer 29

Final C-arm is taken, irrigate, and then close