Case Study: Transforaminal Lumbar Interbody Fusion

(TLIF) of Right L4-S1 in a 55-year-old Female

A 55-year-old female presented to our office with complaints of worsening lower back pain with radiation to the right buttock and posterior thigh. She first noticed the pain a year ago when she was involved in a motor vehicle accident. The pain subsequently worsened limiting her daily activities.  

The pain is described as a sharp pain shooting down her right leg. The pain is especially worse on activities such as bending, sitting, getting up from a chair, walking, and climbing stairs. The intensity of the pain is described as severe (9/10).  The pain interferes with her sleep. 

The pain is associated with numbness and tingling in the right lower extremity. She denies any weakness in the lower extremities or any bowel bladder abnormality. The patient is currently unemployed on disability. Her past surgical history is significant for lower spine surgery 10 years ago and a total hip replacement was done 4 years ago. 

Her medical history is significant for hypertension, hyperlipidemia, and hypothyroidism. She is currently taking metoprolol, pravastatin, and thyroxine.  She had previously tried physical therapy along with hot and cold therapy. She received epidural and selective nerve root injections a year ago. 

The patient is a former smoker and consumes moderate alcohol occasionally. She denies any known medical allergies. On physical examination, the patient is calm, conscious, cooperative, and well oriented to time, place, and person. Lower spine examination reveals tenderness over the right paraspinal musculature. 

The range of the lumbar spine was limited secondary to pain. There is no tenderness on palpating the spinous processes. The straight leg raise test is positive at 60 degrees on the right side. There are no signs of erythema, swelling, ecchymosis, or draining sinus tracts.

Examination of the bilateral hips revealed no signs of tenderness over the trochanters with a full range of motion of both hips. The power sensory examination of the bilateral lower extremities was unremarkable with 5/5 strength and normal bulk and tone except right EHL 4/5. The sensory dermatomes were intact bilaterally except dorsal right foot Ist webspace. The deep tendon reflexes were symmetrical bilaterally. The power sensory examination of the bilateral upper extremities was unremarkable. 

X-ray of the lumbar spine was reviewed with the patient. The X-ray revealed severe degenerative changes at L5-S1 and 5 mm anterolisthesis at L4-5.

Preoperative X-ray LS spine in AP and Lateral Views Preoperative X-ray LS spine in AP and Lateral Views 2

Preoperative X-ray LS spine in AP and Lateral Views.

MRI of the lumbar spine was done to evaluate the L5 nerve root compression location. CT scan of the lumbar spine to review the bony anatomy and allow surgical planning. The patient had previously undergone an LS-S1 microdiscectomy approximately 15 years ago.

MRI revealed slight straightening of the lumbar spine. Lower lumbar discogenic degenerative disease with central canal stenosis resulting in impingement of the descending L5 and S1 nerve roots, respectively at L4-L5 and L5-S1 levels. The exiting right L4 nerve root is also impinged upon at L4-L5 and the exiting right L5 nerve root is impinged upon at L5-S1.

Lower lumbar facet arthrosis most present at L4-L5 where there is severe left greater than right arthrosis and a moderate left facet joint effusion.

MRI showing sagittal and axial sections MRI showing sagittal and axial sections 2

MRI showing sagittal and axial sections.

The patient had exhausted all conservative management options and was advised Minimal Invasive (MISS) Transforaminal Lumbar Interbody Fusion (TLIF) surgery. Risks, benefits, and alternatives were discussed thoroughly with her and her daughter. She agreed to go ahead with the surgery.

The patient was brought to the operating room and sedated under general endotracheal tube intubation.  He was then placed in a prone position with adequate padding under all bony prominences.  

His lower lumbar spine region was then prepped and draped in a usual sterile fashion and we then proceeded to use fluoroscopic imaging to identify the area for Wiltse approach for the minimal invasive transforaminal lateral interbody fusion.  

Once we are satisfied with the positioning, we then chose a point approximately 3 cm lateral to the midline and approximately 4 cm in length.  Once initial skin incision was made, we then used electrocautery to dissect down along the planes and identified the lumbar fascia.  We then incised along the fascia and placed a stay suture within the fascia.  

We then used blunt dissection to split the muscle fibers and palpated the edge of the transverse process.  Once we are satisfied with the positioning on the fluoroscopic imaging, we then proceeded to use a Jamshidi needle onto the lateral tips of the facet joints except for the L4 region where it was placed along the corner of the transverse process and the facet in order to avoid injuring the L3-L4 facet joint.  

All needles were placed under fluoroscopic imaging and once we were satisfied with the positioning, we then evaluated his nerve monitoring and found there to be no changes within any of the needle positions.  We then proceeded to place a guidewire into the vertebral body and then removed the Jamshidi needle.  

We then secured the guidewires onto the edge of the patient’s bed and turned our attention towards performing the decompression and interbody fusion procedures.  We then used a microscope to began our decompression at the L4-L5 region.  

We first identified the L4 lamina and performed a hemilaminectomy procedure.  We were able to identify the dura as well as the exiting L4 nerve and we then identified the intervertebral disc space.  There was a very large osteophyte complex along the L4-L5 region as well as the L5-S1 area.  

We then continued our dissection using the Midas burr to also perform a hemilaminectomy of the L5-S1 region beginning with the L5 lamina and exiting up through the L5-S1 foramina.  We were able to visualize the L5 nerve and completely decompress the nerve from any overlying tissue.  We then identified the intervertebral disc space.  

The disc space was significantly narrow with a notable amount of scarring around the dura to the disc.  Once the decompression was complete and we were completely satisfied with the exposure, we then turned our attention towards the interbody fusions.  

A size #15 blade was used to make an opening incision along the posterolateral annulus and we then proceeded to perform a microdiscectomy procedure.  We used curettes from a Medtronic system and once we are satisfied with the discectomy, we then turned our attention towards placing an appropriately sized interbody implant.  

Based on fluoroscopic imaging, we felt that a size #12 implants would be satisfactory and therefore we proceeded to obtain a crescent PEEK cage measuring 30 x 12 mm and packed it with demineralized bone matrix as well as BMP.  We then proceeded to place the cage into position.  The edge of the inferior L4 vertebral body was removed using an osteotome in order to allow for the entry of the implant.  

Once we are satisfied with the positioning of the implant, we then evaluated its position on the both AP and lateral planes and proceeded to place bone graft posteriorly behind the implants within the intervertebral body.  We then washed up the area with normal saline and reevaluated the nerve root and dura.  

There were no signs of compression and we are really satisfied with the positioning and alignment of the interbody fusion implants and bone graft. We then turned our attention towards the L5-S1 region.  Similarly, we used a size #15 blade to create an annulotomy and then proceeded to place several curettes in order to perform a microdiscectomy and prepare the intervertebral space for an implant.

We used the left side screws to distract the space open, but noted that there was very minimal opening.  Similar to the L4-L5 region, we used an osteotome along the edge of the inferior L5 vertebral body in order to obtain an entry point.  We then proceeded to place a size 30 x 9 mm crescent PEEK cage into position also using BMP and demineralized bone matrix into the implant.  

We then evaluated the L5 exiting nerve root as well as the traversing S1 nerve root and the dura and found it to be completely decompressed. We were completely satisfied with the positioning and alignment of the implants and turned our attention towards the fixation of the rod and screws.

We first began with the left side and placed a size #60 mm length rod into position.  We then secured it and ensured that there was an adequate amount of lumbar lordosis.  We then also secured the right side rod with a similar length into position.  

We then obtained final fluoroscopic images and were completely satisfied with our fixation and alignment.  We then washed out the wounds with normal saline and vancomycin instilled into the wound. We proceeded to close the layers with a size #2 Vicryl sutures for the fascia layer followed by size #2-0 Vicryl suture for the subcutaneous skin and a running #4-0 Monocryl suture for the subcuticular layer.  

Steri-Strips and dry dressings were placed onto the wound and the patient was then safely returned back to the recovery room.  There were no intraoperative complications reported by the anesthetist.  The nurses reported a correct instrument count.

Intraoperative Fluoroscopic Images   Intraoperative Fluoroscopic Images 2

Intraoperative Fluoroscopic Images.

The patient will be allowed to weight bear as tolerated in the postoperative. We will ask him to refrain from nonsteroidal anti-inflammatories. The patient required only VTE prophylaxis while in the hospital. Paitent was discharged home after 4 days of hospital stay. He was followed as outpatient to an uneventful recovery. He was able to perform activities of daily living soon after the surgery and was back to baseline in about 10 weeks.

Postoperative X-ray in AP and Lateral views   Postoperative X-ray in AP and Lateral views 2

Postoperative X-ray in AP and Lateral views.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
Anna Acker
22:46 07 Sep 23
Dr Vedant Vaksha had done emergency surgery in 2020 after a traumatic injury.His office at Complete Orthopedics handled the continued care thereafter.Dr V and his staff had been Professional and friendly throughout the process, taking the time to explain all the questions on how to proceed and what to expect.Whenever I needed to speak with Dr V or the office they were a phone call away, without waiting or calling several numbers like in so many other medical offices.The office was accommodating to scheduling to my needs at all times. Dr Vedant Vaksha earned the following5 out of 5 stars, highly recommended.
John Kuey
20:58 05 Sep 23
Dr. Vaksha helped me recover from an injury. I am very thankful that he took the time to explain the best treatment for my injury. Also thankful for the wonderful office staff!
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22:30 02 Aug 23
The office is wonderful!… Dr Paresh was very helpful and attentive and made my sister in laws recovery so much better.. Thank you for everything
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17:48 14 Jul 23
The ladies are very welcoming, the service is great, the doctor is very professional and caring and the building is super clean. I really like to come here, the atmosphere is very friendly... Come and you will love it too.
Joan Carasco
14:41 30 Jun 23
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.