Optimizing Minimally Invasive Spine Surgery: A Fully 3D CT O-Arm Navigated Workflow in MIS TLIF

Summary

This study presents a standardized, fully navigated 3D CT O-Arm-guided workflow for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), aiming to improve workflow, surgical accuracy, and efficiency with full utility of 3D navigation in maximum steps.

Abstract

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has become increasingly popular due to reduced tissue trauma, decreased blood loss, and faster recovery compared to traditional open procedures. The integration of 3D CT-based intraoperative navigation has significantly enhanced surgical precision and workflow optimization, potentially leading to better outcomes. However, workflow optimization has not been qualitatively or quantitatively assessed in MIS TLIF, and there may be an increase in setup and waiting times between surgeries in exchange for improved precision.

In this retrospective study at a tertiary spine center, 44 patients undergoing fully navigated MIS TLIF were evaluated. A total of 176 pedicle screws were inserted using a sequential, navigation-guided workflow tailored to TLIF and decompression. Surgical accuracy, functional outcomes, perioperative safety, and workflow efficiency were assessed. The findings revealed significant improvements in Oswestry disability index (ODI) and numerical rating scale (NRS) scores, minimal blood loss, short operative times, and high screw placement precision (6.81% Grade 1 breaches). This article supports the clinical reliability and reproducibility of a fully navigated O-arm-assisted MIS TLIF protocol, offering qualitative evidence of improved workflow not previously reported.

Introduction

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) offers several advantages over conventional open spinal surgery, including reduced muscle damage, less intraoperative blood loss, and quicker recovery times^1,2,3,4,5,6. Recent advances in intraoperative navigation and three-dimensional (3D) computed tomography (CT) imaging have improved pedicle screw accuracy and reduced complication rates^7,8. Mos....

Protocol

This study protocol was reviewed and approved by the Institutional Ethics Committee, protocol code: SSHRI/CS/NS/3 D,CT,TLIF/AK/74/04.25, and registered under the Clinical Trial Registry of India (CTRI/2025/04/085975). Written informed consent was obtained from all participants preoperatively.

1. Preoperative planning

1. Explain procedure risks, benefits, and alternatives to each patient, and obtain written informed consent.
2. Acquire dynamic lumbar spine X-rays (anteroposterior, lateral, flexion-extension lateral views) and MRI (T1, T2, Short Tau Inversion Recovery [STIR]) of the lumbar spine.
3. Record preoperative ....

Results

The primary focus of this study was to assess the ease of performing a fully navigated MIS TLIF, which could not be objectively quantified. The setup and waiting times were not prospectively measured in minutes for each case in our series. While no formal time-motion analysis was performed, surgeons and staff qualitatively reported a noticeable reduction in mid-procedure pauses in other workflows where the decompression and interbody fusion work is completed in 2D image guidance, followed.......

Discussion

Our experience with a fully navigated 3D O-Arm-guided approach to MIS TLIF highlights and reinforces its capacity to combine precision, reproducibility, and safety^7,8. By anchoring the workflow around navigated pedicle screw placement and confirmation with intraoperative 3D imaging, the chances of technical error are significantly reduced⁹. These observations echo earlier reports, which have shown that 3D navigation can deliver high accura.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Absorbable suture – continuous 1-0	Vicryl (Polyglactin 910)	JE00H[HR26]
Absorbable suture – interrupted 2-0	Vicryl (Polyglactin 910)	J310H[HR26]
Absorbable suture – subcuticular 3-0	Monocryl (Poliglecaprone 25)	W9930[DS24]
Antiseptic solution (povidone-iodine/chlorhexidine)	Betadine	12008-OR
Disc shavers	Medtronic	SMALL-9569453, MEDIUM-9569454, LARGE-9569455
Fenestrated titanium pedicle screws	Medtronic	9012037 SERIES
Interbody cage (PEEK or titanium, 7–9 mm × 28–32 mm)	Medtronic	8557000 series
Magnification system (exoscope)	Zeiss	6640
Medtronic MISS blade retractor	Medtronic	875-149
Medtronic Nav PAK needle	Medtronic	PK1011
Nitinol guide wire	Medtronic	N351804
O-arm surgical imaging system	Medtronic O-arm	BI-700-00028-230
Pituitary forceps	Medtronic	9569525
Radiolucent padded spinal table with bolsters	Stan	CT-OT-01
Sequential dilators	Medtronic	Medtronic METRx II Dilator Set 9560430 series
StealthStation S8 system	Medtronic	9735670
Sterile drapes	Surgiwear	D106
Titanium rods (5.5 mm)	Medtronic	9015503
Torque-limiting driver (set at 8 Nm)	Medtronic	7480146
Ultrasonic bone scalpel (20 kHz, medium setting)	Misonix	110-31-1120
Wound drain (10 Fr subfascial)	Romovac	RD-1010