Pushing the Limits of Minimally Invasive Spine Surgery-From Preoperative to Intraoperative to Postoperative Management

Abstract

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

Keywords: ERAS; TLIF; awake spine surgery; instrument navigation; minimally invasive; robotics; spine.

Figure 1

Axial T2-weighted MRI slice at L4–L5 (A) demonstrating severe bilateral lateral recess stenosis. Flexion (B) and extension (C) plain films demonstrating a grade 1 spondylolisthesis at L4–L5. CT-SPECT (D) depicting increased radiotracer uptake at the bilateral L4–L5 facet joints, left greater than right. Neurosegmentation of the left trans-Kambin’s triangle corridor ((E), green triangle), offering a maximum cannula diameter of 6 mm. Segmentation of the left transfacet corridor ((F), purple triangle), offering a maximum cannula diameter of 10 mm. Three-dimensional neurosegmentation of L4–L5 (G) showing the thecal sac (pink), left Kambin’s triangle (green triangle), left transfacet corridor (purple triangle), L4 nerve root (red), and bilateral L5 nerve roots (blue). Postoperative upright lateral lumbar plain film (H) demonstrating adequate hardware placement.

Figure 2

Analgesia distribution, left, and injection site, right, schematic for the quadratus lumborum block. (M: multifidus, L: longissimus, I: iliocostalis). Figure reproduced with permission from [31].

Figure 3

Cropped section of a preoperative lateral upright whole spine film (A) demonstrating the spondylolisthesis at L4–L5 and L5–S1. Preoperative sagittal (B) and axial (C) T2-weighted MRI slices demonstrating severe central canal and lateral recess stenosis, ligamentum flavum hypertrophy, and diffuse disc bulge. Postoperative upright lateral lumbar spine plain film (D).

Figure 4

Intraoperative pseudo-live instrument tracking, surgeon’s view (TrackX, Chapel Hill, NC, USA). (Left image), lateral projection depicting the trajectory of bilateral pedicle screws (green and blue dotted line). (Right image), AP projection of the bilateral pedicle screw trajectories (green and blue dotted line).

Figure 5

(A) Preoperative screw trajectory projections into Kambin’s triangle. (B) Sagittal trajectory planned as caudal as possible to avoid L4 nerve root violation. (C) Coronal trajectory into disc space at the mid-pedicle level, the largest safe area in Kambin’s triangle. Reproduced with permission from [63].

Figure 6

Intraoperative robotic trajectory planning (Globus ExcelsiusGPS^®, Globus Medical Inc., Audubon, PA, USA) for placement of L3–S1 pedicle screws, yellow, and iliac bolts, green. Reproduced with permission from [67].

Figure 7

Left (A) and right (B) iliac bolt placements in line with lumbar pedicle screws. Reproduced with permission from [67].