Vol 10 | Issue 2 | July-December 2024 | page: 48-52 | Abhishek Kothari, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti

https://doi.org/10.13107/jmt.2024.v10.i02.254

Author: Abhishek Kothari [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]

[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.

Address of Correspondence
Dr. Abhishek Kothari,
Sancheti institute for orthopedics and rehabilitation PG College, 16, Shivajinagar, pune -411005, Maharashtra
E-mail: dr.abhishekkothari@gmail.com

Abstract

Background: Transforaminal lumbar interbody fusion (TLIF) is commonly used to treat degenerative lumbar conditions that produce mechanical back pain, radiculopathy or instability. The procedure aims to decompress neural elements, restore disc height and provide segmental stability while limiting neural retraction. This study prospectively evaluates clinical and radiographic outcomes after TLIF in a tertiary centre, and examines how spinopelvic alignment change relates to patient-reported outcomes.
Methods: Consecutive patients with symptomatic lumbar canal stenosis and low-grade spondylolisthesis treated with TLIF between October 2019 and December 2021 were enrolled. Baseline assessment included VAS for back and leg pain, Oswestry Disability Index (ODI) and SF-36. Radiographs and MRI were used for preoperative planning; standing lateral films were used to calculate pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and PI–LL mismatch. Standardised surgical techniques, postoperative care and follow-up at 6 and 12 months were used for outcome assessment.
Results: Of 48 enrolled, 40 patients completed one-year follow-up. Significant improvements were seen in VAS, ODI and SF-36 domains at one year. Many patients showed measurable correction of PI–LL mismatch. Clinical gains were frequent; however, the magnitude of radiographic change did not uniformly predict the degree of symptomatic improvement.
Conclusion: TLIF produced consistent clinical benefit at one year with low complication rates. While sagittal alignment correction often accompanied improved function, imaging gains alone did not guarantee greater symptomatic relief, highlighting the multifactorial nature of recovery after fusion.
Keywords: TLIF, Lumbar canal stenosis, Spondylolisthesis, Oswestry Disability Index, Spinopelvic alignment

Introduction:

Transforaminal lumbar interbody fusion (TLIF) has become a widely used technique for addressing degenerative lumbar disorders that produce neural compression, segmental instability or chronic mechanical back pain. TLIF permits direct posterior decompression while allowing placement of an interbody graft or cage through a unilateral transforaminal corridor, thereby reducing the need for extensive neural retraction that characterized earlier posterior interbody techniques. This technical advantage helped TLIF gain popularity as an option that balances safe neural decompression with restoration of anterior column support and segmental stability. [1-6]
Historically, surgeons relied on posterolateral fusion and posterior lumbar interbody fusion (PLIF) for many degenerative indications; however, PLIF involves greater bilateral neural manipulation and has been associated with certain approach-related risks. Modern outcome assessment emphasises patient-reported measures such as VAS, ODI and SF-36 because radiographic fusion alone does not fully capture the patient’s functional recovery and quality of life. At the same time, restoration of sagittal balance — often summarized by spinopelvic parameters such as pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and PI–LL mismatch — has gained attention for its association with long-term function and adjacent-segment health. Surgeons now balance the goals of neural decompression and fusion with alignment objectives to optimise both short- and long-term outcomes. [2][4][6]
The available literature suggests TLIF is effective and broadly safe in selected patients, yet questions remain about how well radiographic correction predicts patient-centred improvement. This study was designed to prospectively evaluate clinico-radiological outcomes after TLIF in patients with lumbar canal stenosis and low-grade spondylolisthesis, and to explore the relationship between changes in spinopelvic parameters and clinical recovery. [1-6]

Review of Literature
Multiple comparative studies and meta-analyses have examined TLIF relative to other fusion strategies (PLIF, ALIF and posterolateral fusion). Overall, these syntheses report broadly similar fusion rates across interbody techniques but note differences in approach-related morbidity, operative times and the capacity to restore segmental lordosis. Several series show TLIF may carry a lower risk of neural retraction-related complications compared with PLIF while achieving comparable clinical outcomes and fusion efficacy. [7-13]
Randomized trials and cohort studies focusing on degenerative spondylolisthesis have shown that adding fusion to decompression can offer better medium-term improvements in pain and function for selected patients, although the balance between benefit and the risk of reoperation depends on careful patient selection. Not all patients with lumbar stenosis require fusion — the decision rests on instability, deformity, and individual symptom profiles. Meta-analyses highlight that minimally invasive variants of TLIF reduce blood loss and early morbidity while maintaining similar fusion and symptomatic results when compared with open techniques in appropriate hands. [7][8][9]
The role of sagittal balance and spinopelvic parameters in predicting outcomes after lumbar fusion has been increasingly studied. Excessive PI–LL mismatch and sagittal malalignment have been associated with worse health-related outcomes and a higher incidence of adjacent-segment disease in some series, prompting surgeons to incorporate alignment goals into surgical planning. However, multiple reports caution that radiographic correction alone does not uniformly translate into proportional improvements in pain or disability; clinical recovery is mediated by neurological status, chronicity of symptoms, paraspinal muscle condition, comorbidities and psychosocial factors. Thus, integrated assessment of clinical and radiographic outcomes is essential when evaluating the true benefit of fusion procedures. [14- 20]

Materials and Methods
This single-centre prospective study enrolled consecutive patients who underwent TLIF for symptomatic lumbar canal stenosis with or without low-grade degenerative spondylolisthesis from October 2019 through December 2021. Institutional ethics approval and written informed consent were obtained. Inclusion criteria were age >20 years, clinical and MRI confirmation of neural compression and failure of conservative care (physiotherapy and medication) for at least six weeks. Exclusion criteria included active spinal infection, metastatic disease, high-grade spondylolisthesis, severe osteoporosis and inability to comply with follow-up.
Preoperative evaluation included detailed clinical assessment, neurological examination, VAS for back and leg pain, ODI and SF-36. Imaging included standing AP and lateral radiographs incorporating femoral heads (for spinopelvic measurements), flexion–extension films and MRI for neural element assessment. Spinopelvic parameters measured on standing lateral films included pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and lumbar lordosis (LL) to calculate PI–LL mismatch. Baseline comorbidities, smoking status and medication history were recorded.
Surgical technique: All procedures were performed under general anaesthesia via a midline posterior approach. Unilateral facetectomy and foraminotomy were performed on the symptomatic side to decompress nerve roots. Discectomy and endplate preparation were followed by insertion of an interbody cage packed with local autograft; pedicle screw fixation was applied bilaterally and rods contoured to achieve segmental correction. Fluoroscopic guidance confirmed implant position. Perioperative antibiotics and standard thromboprophylaxis were used.
Postoperative care included early mobilisation, drain removal as per output, staged physiotherapy and outpatient follow-up at 6 and 12 months. Outcome analysis compared preoperative and follow-up VAS, ODI and SF-36 scores using paired tests; radiographic changes in spinopelvic parameters were evaluated, and correlations between radiographic and clinical changes explored. Statistical significance was set at p<0.05.

Results
Forty-eight patients were enrolled; 40 completed one-year follow-up and formed the analysis cohort. The mean age was 52 years (range 38–72) with a modest female predominance. The majority underwent single-level fusion, most commonly at L4–L5. Common comorbidities included well-controlled hypertension and type-2 diabetes in a subset. Preoperative neurological deficits were present in several patients; most showed partial or full recovery by one year.
Clinical outcomes: Median VAS back pain decreased from 7 (preop) to 1 at one year; leg pain VAS showed a similar fall. Mean ODI improved markedly from roughly 68% preoperatively to about 18% at one year, indicating substantial reduction in disability. SF-36 physical and bodily pain domains improved significantly across the cohort.
Radiographic outcomes: Standing lateral films at one year demonstrated measurable changes in spinopelvic parameters in many patients, with a general tendency toward reduction in PI–LL mismatch after fusion. Complications were infrequent and consistent with published TLIF series: a small number of transient dural tears, one case of superficial wound infection managed conservatively, and no perioperative mortalities. Overall, the majority of patients achieved meaningful clinical improvement at one year.

Discussion
In this series, patients treated with TLIF for lumbar canal stenosis and low-grade spondylolisthesis experienced clear and sustained improvement in pain, disability and quality of life at one year. The reductions in VAS scores and the marked fall in ODI mirror findings reported in other clinical series, supporting TLIF’s role in achieving neural decompression, restoring disc height and providing segmental stability that together reduce mechanical back pain and radicular symptoms. [14][15]
Radiographs showed that many patients had measurable improvement in sagittal parameters, particularly a reduction in PI–LL mismatch. Restoration of a more favourable sagittal alignment is encouraging because several studies associate better alignment with improved long-term function and a lower risk of adjacent-segment problems. However, we also observed that imaging and symptoms do not always move in lockstep: several patients reported large functional gains despite only modest radiographic change, and a few with good radiographic correction reported only modest symptomatic relief. This mismatch highlights that radiographic correction is important but not by itself determinative of patient experience. [18][19][20]
There are several plausible reasons for this discordance. Duration and chronicity of preoperative symptoms, severity of preoperative neurological deficit, condition of the paraspinal muscles, and patient comorbidities (for example diabetes or peripheral neuropathy) influence neural recovery and pain perception. Psychosocial factors and expectations also shape reported outcomes, as do rehabilitation and return-to-activity practices after surgery. Classic descriptions of the multifactorial nature of low back pain remind us that structural correction addresses a single domain within a broader biopsychosocial context. [16][17]
Clinically, these observations suggest a balanced approach: aim for reasonable sagittal correction during fusion, but prioritise individualized goals based on the patient’s overall health, symptom history and functional needs rather than pursuing perfect radiographic numbers alone. Careful patient selection, meticulous surgical technique, prompt mobilisation and a structured rehabilitation programme appear to contribute substantially to favourable recovery. Limitations of our study include single-centre design, modest sample size and one-year follow-up, which constrain assessment of long-term fusion durability and late adjacent-level disease. Larger, longer studies would help identify which preoperative and intraoperative factors most reliably predict when radiographic improvement will translate into durable, patient-centred benefit. [18][19][20]

Conclusion
TLIF produced consistent and meaningful improvements in pain, disability and quality of life at one year in this cohort of patients with lumbar canal stenosis and low-grade spondylolisthesis. Radiographic correction of sagittal alignment often accompanied clinical gains, yet imaging improvement alone did not guarantee a larger symptomatic benefit for every patient. Recovery after TLIF is multifactorial: careful patient selection, realistic and individualized alignment goals, meticulous surgical technique, and a structured rehabilitation plan are all important contributors to favourable outcomes. The low complication rates observed suggest TLIF is a reliable option in experienced hands. Further research with larger cohorts and longer follow-up is needed to better characterise predictors of sustained clinical benefit and the long-term relationship between alignment, fusion status and adjacent-segment health.

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Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India
Year of Acceptance of Thesis: 2019

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