Awake Endoscopic Transforaminal Lumbar Interbody Fusion

Abstract

The transforaminal interbody fusion (TLIF) is a time-tested procedure for treating various lumbar degenerative pathologies. This approach leverages an access route through Kambin's triangle that typically requires a partial or total facetectomy for access to the disc space and neural decompression. Since its first published description in the early 1980s, the procedure has undergone extensive refinements concomitant with technology and technique advancements. Traditional open TLIF is effective but associated with adverse perioperative effects due to the amount of muscle dissection necessary for exposure, including increased blood loss, hospital length of stay, and extended recovery times. The transition to more minimally invasive, paramedian approaches has sought to reduce the burden of these consequences. Spinal endoscopy has witnessed a resurgence over the past decade paralleled by advancements in higher resolution optical systems along with more robust and enduring endoscopic instrumentation. This development, combined with increased awareness of healthcare economic costs, problems with narcotic dependency surrounding open spine surgery, and admission restrictions to hospitals during pandemic times, has fueled a push for “ultra” minimally invasive variants of the traditional TLIF. Patients, payors, and hospitals alike expect shorter inpatient stays, earlier mobilization and discharge from the hospital, as well as narcotic independence faster than ever before. To this end, awake endoscopic TLIF has recently been described with efficacious results to comply with these broader factors. In this chapter, the authors explain their awake endoscopic TLIF step-by-step and demonstrate the clinical advantages and the noninferiority data to traditional MIS TLIF based on their clinical series's one-year outcomes data.