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Transforaminal Lumbar Interbody Fusion

The MAS (Maximum Access Surgery) TLIF procedure is a less disruptive, minimally invasive approach to traditional back surgery.

Rather than beginning from the center and spreading the muscles outward, Dr. Blankenship will start on an angle to the spine and bluntly split (rather than cut) back muscles on just one side. By minimizing the amount of muscle tissue disruption, the procedure attempts to reduce postoperative pain and give patients a quicker recovery.

When is the surgery performed?

Lumbar interbody fusion attempts to eliminate instability in the back due to:

  • Degenerated discs and/or facet joints that cause unnatural motion and pain
  • Loss of height of the disc space between the vertebrae that causes pinching of the spinal nerves exiting the spinal canal (foraminal stenosis)
  • Slippage of one vertebra over another (listhesis)
  • Change in the normal curvaure of the spine (scoliosis, hyper- or hypo-lordosis)

Indications / Contraindications

  • Neurologic symptoms such as leg pain, numbness, bladder dysfunction
  • Recurrent disc herniation
  • Spondylolisthesis (slippage of one vertebra over another)
  • Degenerative disc disease
  • Narrowing of space around nerves (stenosis)

How is the surgery performed?

Dr. Blankenship performs the surgery with the patient lying face down. An x-ray taken of your spine will show the location of the operative disc space. Dr. Blankenship will then insert an initial dilator and will use it to feel the bony target points on your spine. Once reached, another x-ray will be taken to confirm the target, and sequentially larger tubes will be advanced to widen the exposure. After the tubes are in place, Dr. Blankenship will place a tissue retractor into position, locked to the surgical table, and held open to provide lighted visibility and instrument access to the disc space. With the disc now visible, Dr. Blankenship will remove the disc and prepare the disc space for fusion.

Once the disc space is prepared, he will place an implant into the empty space to restore proper disc height and support the loads put on the spinal segment. With the implant in position, the retractor will be widened to expose the section that includes the vertebra above and below for placement of fixation instrumentation (pedicle screws). The retractor is removed once the screw construct is completed on that side, and Dr. Blankenship will implant the pedicle screws through a small incision on the opposite side.

The final result will be a construct with an interbody implant between the vertebral bodies where the fusion will occur, and pedicle screw fixation posteriorly to stabilize the spine. Dr. Blankenship will close the small incisions with a few stitches.


It’s normal for your incision wounds to be sore immediately after surgery. Because the procedure is less disruptive than conventional posterior surgery, most patients will be able to get up and walk around the evening after surgery. Before you are discharged, Dr. Blankenship will discuss with you and pain medications to take home as well as a prescribed program of activities. Generally, the MAS TLIF patients recover and return to normal activities quickly.

Dr. Blankenship will want to see you again in his office two weeks after surgery.

If you have any questions before then, simply call his office.

XLIF/TLIF and XLIF/Percutaneous Pedicle Screw Placement combinations:

In a significant number of patients the last movable disc in the spine (L5/S1) will require fusion along with higher segments. The lowest disc cannot be approached with the XLIF technique due to the location of the pelvic brim. In these cases a combined XLIF at the higher levels and then a TLIF at the L5S1 level would be required. Although the combination surgery is technically more difficult and more time consuming, it is generally safer and much less traumatic on the patient than larger solely open posterior procedures. Therefore, Dr. Blankenship considers it time well spent. In the majority of cases, the patient can still go home the next day. Even with multiple levels fused and multiple incisions made, the recovery is generally much less both from a standpoint of time and magnitude.

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