Open TLIF using the T-PAL (Synthes)

  • Introduction- The T-PAL is a Synthes TLIF system that is kidney shaped PEEK implant. The supposed benefits of a TLIF are less nerve root retraction though most TLIF’s are performed in much the same way as a PLIF
  • Positioning
    • Prone, Open Jackson table
  • Prep and Landmarks
    • Identify: Midline
  • Incision and approach
    • Incision: Extend you incision from the spinous process above to the spinous process below your construct (ex. L4-5 TLIF incision from L3 to S1)
    • Dissection: identify facet complex and TP on the side you are going to perform a TLIF. Identify pedicle screw entry points on contralateral side
  • Operative details
    • Using monopolar cautery perform a subperiosteal dissection of the spinous process, lamina, and facet complex. Also identify the pedicle entry point for the level above by following the pars superiorly and laterally (use caution to avoid violating the superior facet).
    • Perform a Gill operation (medial facetectomy) on the TLIF side. You can use an osteotome to complete the facetectomy but use caution to not injury the underlying nerve root. Also do not violate the pedicle for the inferior level (do not take off much of the L5 superior facet for a L4-5 PLIF as you will ruin your L5 pedicle screw)
    • Decompress the traversing and exiting nerve root and assure that you have an adequate decompression for your discectomy
    • Place a nerve root retractor, open the annulus with an 11-blade. Start with a 7mm shaver and hammer in until flush with end of endplate. Make sure that your orientation is correct and you don’t dig into the endplate. Rotate both directions and use an interspace rongeur (pituitary) to remove the disc material. Increase size of shavers to full prepare the disc space. At the end of each shaver pull your hand lateral (pushing the shaver medially) to prepare the contralateral disc space.  Also make sure to shave all the way posteriorly.
    • After shaving, use a down pushing curette, box curette, and endplate shaver
    • If you shaved to 10mm, take a 9mm spacer/cutter. Hammer it in until the spacer is near the end of the endplate. Rotate the handle counter-clockwise, bring your hand medially, and hammer the spacer so it curves laterally. Keep hammering until you can see the window. Use the slap hammer to remove the spacer
    • Use the funnel to pack some graft anteriorly (don’t put too much or it will be hard to place the implant)
    • Place the implant in the same way you paced the spacer. There are two horizontal markers that need to line up to assure that it is in a horizontal position. Once you have it in position pull the ring down and unscrew counter clockwise
    • Finish packing bone into the interspace
    • Place pedicle screws
  • Postop Orders
    • Dilaudid PCA, One dose of post-op antibiotic



Joseph MillerTLIF- T-PAL

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