Dr. Erick Kazarian, MD
NYU Langone Spine Surgery — Patient Information
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Endoscopic TLIF
Endoscopic Transforaminal Lumbar Interbody Fusion (Endoscopic TLIF)
Endoscopic transforaminal lumbar interbody fusion (endoscopic TLIF) is a next-generation approach to lumbar spinal fusion that combines the structural goals of a traditional TLIF with the tissue-sparing advantages of endoscopic surgery. Instead of a large midline incision and extensive muscle dissection, Dr. Kazarian performs the procedure through small tubular portals using a high-definition endoscopic camera and specialized instruments. This minimally invasive technique allows for disc removal, nerve decompression, interbody cage placement, and pedicle screw fixation — all while preserving the surrounding muscles, ligaments, and soft tissues to a far greater degree than conventional open surgery.
Endoscopic TLIF is most commonly recommended for patients with degenerative disc disease, spondylolisthesis, spinal stenosis, or recurrent disc herniations who require a fusion procedure but want to benefit from a significantly faster recovery, less blood loss, and reduced postoperative pain compared to traditional open fusion surgery. By working through the natural foramen (the opening where the nerve root exits the spine), Dr. Kazarian can access the disc space, decompress the nerves, and place an interbody cage without the need to retract or strip the paraspinal muscles from the bone. Robotic-guided pedicle screws and rods are then placed through the same small portals used for the endoscopic work — meaning the entire procedure is completed without a large open incision.
The result is a true spinal fusion that achieves the same structural goals as traditional open TLIF — restoring disc height, correcting alignment, decompressing the nerves, and stabilizing the spine — but with significantly less tissue trauma and a much faster recovery. Where traditional open fusion patients typically spend two to four days in the hospital and require three to six months before returning to full activity, endoscopic TLIF patients are often discharged within one to two days and return to daily activities weeks sooner. Our surgical team is committed to providing you with the most advanced, least invasive approach to achieve lasting relief and spinal stability.
Images & Diagrams
Pre-Operative Instructions
Careful preparation before your endoscopic TLIF surgery helps ensure the safest possible procedure and supports a smooth recovery. Please follow these instructions closely and contact our office with any questions.
Review all current medications and supplements with Dr. Kazarian.
2 weeks before surgeryStop blood thinners (warfarin, aspirin, Plavix), NSAIDs (ibuprofen, naproxen), and herbal supplements (fish oil, vitamin E, ginkgo) as directed. If you take diabetes medications, you will receive separate dosing instructions. GLP-1 receptor agonists (Ozempic, Wegovy, Mounjaro, Trulicity, Saxenda) must be stopped 7 days before surgery due to the risk of aspiration under anesthesia. Do not stop any medication without Dr. Kazarian's approval.
Obtain medical clearance from your primary care physician and any relevant specialists.
2-4 weeks before surgeryThis may include blood work, an EKG, and a health review. Bring clearance letters and your CPAP machine (if applicable) on surgery day.
Do not eat or drink anything after midnight the night before surgery.
After midnight the night before surgeryThis includes water, coffee, gum, and mints. You may take approved medications with a small sip of water.
The NYU perioperative team will call you the day before surgery with your arrival time.
Day of surgeryLocation: NYU Langone Kimmel Pavilion, 424 East 34th Street, Manhattan. Bring a valid photo ID, insurance card, and medication list.
Arrange for a responsible adult to drive you home and stay with you for several days.
Arrange before surgery dayYou cannot drive after general anesthesia. Expect a 1-2 day hospital stay. Have someone available at home for at least the first week.
What to Expect on Surgery Day
Knowing what will happen before, during, and after your endoscopic TLIF can help ease any anxiety and allow you to focus on your recovery. Here is a step-by-step overview of your surgical experience.
Check-In and Pre-Surgical Preparation
You will arrive at the hospital approximately two hours before your scheduled surgery. Our nursing team will verify your identity, review your medical history and current medications, and place an intravenous (IV) line. You will change into a hospital gown, and the surgical site on your lower back will be confirmed and marked. Dr. Kazarian and the anesthesiologist will visit you to review the procedure, answer any remaining questions, and ensure you feel comfortable and informed before heading to the operating room.
Anesthesia and Positioning
Endoscopic TLIF is performed under general anesthesia, which means you will be completely asleep and will not feel anything during the operation. Once in the operating room, the anesthesia team will administer medication through your IV and place a breathing tube to support your airway. You will be carefully positioned face-down on a specialized surgical table. Specialized monitors will track your heart rate, blood pressure, oxygen levels, and spinal nerve function throughout the entire procedure.
Endoscopic Disc Removal and Nerve Decompression
Dr. Kazarian makes small incisions and introduces a tubular working channel and a high-definition endoscopic camera to the spine. Using the camera's magnified view, the damaged disc material is carefully removed and any bone spurs or tissue compressing the nerves are cleared away. The endoscopic approach provides excellent visualization while preserving the surrounding muscles, ligaments, and bony structures. The foramen is widened as needed to ensure the nerve root is completely decompressed.
Interbody Cage Placement
Once the disc space has been prepared, a precisely sized interbody cage packed with bone graft material is placed into the disc space through the working channel. The cage restores proper disc height and spinal alignment while the bone graft promotes fusion between the vertebrae over the coming months. The endoscopic camera confirms optimal cage positioning in real time.
Robotic-Guided Pedicle Screw Fixation
To stabilize the fusion, Dr. Kazarian places pedicle screws through the same small portals used for the endoscopic decompression — no additional incisions are needed. A state-of-the-art robotic navigation system maps your unique spinal anatomy in three dimensions and guides each screw along a pre-planned trajectory with sub-millimeter accuracy. Connecting rods are then secured to the screws to lock the treated segment in place. Because the screws are placed through the existing portals, the entire fusion procedure — decompression, cage placement, and screw fixation — is completed through the same minimally invasive approach.
Closure and Recovery Room
The small incisions are closed with sutures and sterile dressings are applied. You will be taken to the post-anesthesia recovery area where nurses will monitor your vital signs, pain level, and neurological function in your legs and feet. Pain medication will be provided to keep you comfortable. Most patients are encouraged to stand and walk with assistance within hours of surgery. The majority of patients are discharged within one to two days.
Risks & Potential Complications
All surgical procedures carry some degree of risk. Dr. Kazarian takes every precaution to minimize these risks, and serious complications are uncommon with endoscopic TLIF. The minimally invasive nature of the procedure generally results in lower rates of blood loss and infection compared to traditional open fusion. Understanding the potential risks helps you make an informed decision.
Infection
There is a small risk of infection at the surgical site. The minimally invasive approach with smaller incisions generally reduces this risk compared to open surgery. Antibiotics are given before and after surgery as a preventive measure. Signs of infection include increasing redness, swelling, warmth, or drainage from the incisions, as well as fever.
Blood Loss
Endoscopic TLIF typically involves less blood loss than traditional open fusion due to the tissue-sparing technique. Significant blood loss requiring a transfusion is rare. Your surgical team monitors blood loss closely throughout the procedure.
Cerebrospinal Fluid Leak
The protective membrane (dura) surrounding the spinal cord and nerves may occasionally be opened during surgery, allowing spinal fluid to leak. If this occurs, it is typically repaired during the procedure. In rare cases, additional treatment may be needed after surgery.
Adjacent Segment Disease
After fusion, the spinal segments above and below the fused area may experience increased stress over time. This can lead to degeneration at those neighboring levels, potentially causing new symptoms months or years after surgery.
Neurologic Injury
There is a small risk of injury to the spinal nerves during surgery, which could result in new or worsened numbness, tingling, weakness, or pain in the legs. Dr. Kazarian uses the endoscopic camera's magnified visualization and nerve monitoring to minimize this risk.
Hardware Failure
The screws, rods, or interbody cage used to stabilize the spine can occasionally loosen, shift, or break before the fusion has fully healed. If this happens, additional surgery may be needed.
Nonunion (Pseudarthrosis)
In some cases, the bone may not fully fuse as expected. Factors such as smoking, diabetes, and poor nutrition can increase this risk. If nonunion occurs, a revision surgery may be recommended.
Need for Additional Surgeries
While endoscopic TLIF has a high success rate, there is a possibility that additional surgeries may be needed in the future due to nonunion, hardware issues, adjacent segment disease, or other factors.
Recovery
Recovery from endoscopic TLIF is generally faster than traditional open lumbar fusion due to the minimally invasive approach that preserves muscles and soft tissues. While the biological process of bone fusion still requires six to twelve months, patients typically experience less postoperative pain, require less narcotic medication, and return to daily activities sooner. Following Dr. Kazarian's activity guidelines, wearing your brace as directed, and attending all follow-up appointments are key to a successful outcome.
Prescribed Medications
| Medication | Type | Dosage | Frequency | When to Take |
|---|---|---|---|---|
| Flexeril (cyclobenzaprine) | Muscle Relaxer | 5 mg | Every 6 hours as needed | Take for moderate to severe muscle spasm or pain |
| Tylenol (acetaminophen) | Pain Reliever | 500–1000 mg | Every 6 hours as needed | Take for mild pain |
| Oxycodone | Opiate Pain Reliever | 5–10 mg | Every 4–6 hours as needed | Take for moderate to severe pain not controlled by Tylenol alone |
Always take medications exactly as prescribed by your surgeon. Do not combine pain medications without consulting your doctor.
Immediate Post-Operative Phase
Most patients are discharged within one to two days of surgery. The small incisions result in less postoperative pain compared to traditional open fusion. You will be encouraged to walk short distances several times a day. Many patients notice immediate improvement in leg pain and sciatica symptoms. Pain at the incision sites is generally mild to moderate and manageable with the prescribed medications.
- No bending at the waist, twisting the torso, or lifting anything heavier than five pounds
- Do not drive or operate machinery while taking narcotic pain medications
- Avoid prolonged sitting for more than 20 to 30 minutes at a time
- Do not soak the incisions in water — no baths, swimming pools, or hot tubs
- Walk short distances several times daily as tolerated, gradually increasing distance
Early Recovery Phase
Pain should continue to decrease steadily and your walking endurance will improve. Many patients transition from prescription pain medication to over-the-counter options within the first two to three weeks. Light daily activities become more manageable. Dr. Kazarian may recommend wearing a lumbar brace during this phase for additional support. Formal physical therapy often begins during this period with a focus on core stabilization and posture awareness.
- Continue to avoid bending, twisting, and lifting more than ten pounds
- Wear your lumbar brace as directed by Dr. Kazarian
- No strenuous household chores such as vacuuming, mopping, or yard work
- Avoid sitting for longer than 30 to 45 minutes without standing and walking briefly
- Do not begin any exercise program without clearance from Dr. Kazarian
Progressive Activity Phase
As your fusion site heals, you will gradually increase your activity level under the guidance of Dr. Kazarian and your physical therapist. Physical therapy will progress to include core strengthening, flexibility work, and functional training. Many patients are cleared to drive and may return to light or sedentary work during this phase. Dr. Kazarian will order imaging to assess the early progress of fusion.
- Lifting is typically limited to 15 to 20 pounds until cleared for more
- Avoid high-impact activities such as running, jumping, or contact sports
- Use proper body mechanics at all times when lifting
- Continue attending physical therapy sessions as prescribed
- Report any new or worsening back or leg pain to Dr. Kazarian
Fusion Maturation and Full Recovery
The bone graft continues to strengthen and mature for six to twelve months. Dr. Kazarian will use X-rays or CT imaging to evaluate fusion solidity. As confirmed fusion progresses, activity restrictions are gradually lifted. Most patients return to full activity once solid fusion is confirmed. Some patients continue to experience incremental improvement throughout the first year.
- Follow Dr. Kazarian's specific guidance on returning to heavy lifting and strenuous sports
- Maintain a regular exercise routine to support long-term spinal health
- Practice good body mechanics to protect your spine
- Attend all scheduled follow-up appointments to monitor fusion progress
Follow-Up Schedule
- 2 weeks after surgery: Incision check, wound healing assessment, and review of early recovery progress
- 6 weeks after surgery: Clinical evaluation of pain and neurological function, possible X-rays, discussion of return to driving and light work
- 3 months after surgery: X-rays to assess fusion progress, physical therapy progress review, and gradual return to more activities
- 6 to 12 months after surgery: Follow-up imaging to confirm solid fusion and final assessment of outcomes
When to Call Your Doctor
Contact our office immediately if you experience any of the following:
- Fever above 101.5 degrees Fahrenheit or worsening chills
- Increasing redness, swelling, warmth, or drainage from the incisions
- Sudden onset of severe back pain or new leg pain, numbness, or weakness that was not present immediately after surgery
- Difficulty with bladder or bowel function, including inability to urinate or loss of bladder control
- Chest pain, sudden shortness of breath, or significant swelling and tenderness in your calf or leg
- Pain that is progressively worsening rather than gradually improving
- Any signs of wound separation or incision edges pulling apart
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