Surgical Approach and Spinal Anesthesia Associated with Improved Clinical and Radiologic Outcomes in a Population of Single-Level TLIF Patients: A Retrospective Review of a Single Surgeon Series

Introduction: There are three main variations of the transforaminal lumbar interbody fusion (TLIF): the minimally-invasive TLIF (MIS-TLIF), the transfacet LIF (TF-LIF) or the percutaneous LIF (perc-LIF). There remains an unclear consensus on the utility of these different MIS techniques, as well as the role of spinal anesthesia and erector spinae plane (ESP) blocks as it relates to radiographic and clinical outcomes.

Methods: A retrospective analysis of the electronic medical records of a single fellowship trained surgeon was performed for all patients receiving single-level perc-LIF, MIS-TLIF, or TF-TLIF between 2018 and 2023. Variables collected included pre-operative and post-operative radiographic measures, as well as clinical outcomes, and data were analyzed using a multivariable regression model.

Results: 94 total patients undergoing TLIF surgery were identified (TF: 17; MIS: 31; Percutaneous: 46). In our regression model accounting for other clinical and radiographic variables, the transfacet approach was associated with greater change in spondylolisthesis (vs. MIS, p = 0.026) and posterior disc height (vs. MIS, p = 0.005) while the percutaneous approach was associated with lower estimated blood loss (vs. MIS, p = 0.004). Compared to general anesthesia, the use of spinal anesthesia across all TLIF groups was associated with reduced intraoperative opioid utilization (p = 0.007) and greater change in spondylolisthesis (p = 0.038) while the use of an erector spinae plane (ESP) block was associated with reduced length of stay (p = 0.044), greater change in spondylolisthesis (p < 0.001), and lower post-op opioid utilization (p < 0.001).

Conclusion : The TF-LIF approach demonstrated comparable blood loss to the percutaneous approach, with significantly improved radiographic measures compared to MIS-TLIF. Both spinal anesthesia and the use of an ESP block were significantly associated with improved clinical and radiographic outcomes. These findings provide novel perspectives and a direct comparison of how surgical approach and other operative factors impact TLIF outcomes.