Name: Optimizing Minimally Invasive Spine Surgery: A Fully 3D CT O-Arm Navigated Workflow in MIS TLIF (Video) | JoVE Journal
Uploaded: 2025-10-17T14:35:00.000+00:00
Duration: 8 min 34 s
Description: Learn a fully navigated 3D CT O-Arm workflow for minimally invasive transforaminal lumbar interbody fusion. This standardized protocol improves surgical accuracy and efficiency in spinal procedures.

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5 minutes

We thank the surgical and radiology teams at Stavya Spine Institute for their contributions. No external funding was received for this study.

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
<ol>
	<li>Explain procedure risks, benefits, and alternatives to each patient, and obtain written informed consent.</li>
	<li>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.</li>
	<li>Record preoperative functional status with the Oswestry disability index (ODI) and the numerical rating scale (NRS) for both leg and back pain.</li>
	<li>Record the indications and applicability of the single-level fusion for the disease.</li>
</ol>
2. Operating room setup and imaging
<ol>
	<li>Under general anesthesia, position the patient prone on a padded, radiolucent spinal table. Secure the patient with chest and pelvic bolsters and non-constrictive cross-body straps to prevent movement. Ensure that there are no pressure points or abdominal compression.</li>
	<li>Prepare and drape the surgical field using standard aseptic technique.</li>
	<li>Set up the 3D CT imaging system, navigation workstation, and a high-definition optical visualization system (loupe: set magnification to 2.5x, exoscope, or microscope: set magnification to 5-10&#215;).</li>
	<li>Register the navigation instruments with the system to ensure accurate tracking.</li>
	<li>Attach the dynamic reference frame (DRF) to the skin, proximally at the lower thoracic region, using a non-absorbable suture material; check rigid anchorage.</li>
	<li>Acquire a baseline CT spin using the standard lumbar protocol (parameter: 120 kVp, 200 mAs, 512 &#215; 512 matrix, 1 mm slice thickness). 
	NOTE: The radiology staff must wear complete lead protection and remain behind the console, outside the radiation field, during image acquisition. The anesthetist temporarily suspends ventilation, and the entire surgical team moves to a designated sterile, radiation-free zone outside the operating room.</li>
	<li>Register the acquired 3D image dataset to the navigation system. Use 1-2 anatomic points to interpolate and verify an error &#8804;1 mm before proceeding.</li>
</ol>
3. Navigated surgical steps
<ol>
	<li>Mark paramedian skin incisions 4-6 cm lateral to the midline at the surgical level using navigation guidance with pedicle access kit (PAK) needle, overlay on the screen.</li>
	<li>Target the junction of the facet and transverse process with as lateral an entry projection as possible. Incise skin and underlying fascia longitudinally to a length of approximately 4 cm with a No. 22 scalpel blade.</li>
	<li>Under navigation, advance a 13 G, 150 mm PAK needle to the junction of the facet and transverse process as shown in Figure 1. Enter the center of the index pedicle in both axial and sagittal planes, ensuring a safe trajectory and enhancing convergence.</li>
	<li>Continuously check intraoperative navigation screens to confirm that the needle tip remains contained within the cortical bone. In cases of smaller pedicles, plan and accept a lateral entry with medial convergence and an extra-pedicular trajectory. Remove the stylet, then railroad and secure a 1.0 mm nitinol steel guide wire through the sheath of the PAK needle into the vertebral body, ensuring the tip is firmly anchored at the bony entry point in the pre-decided trajectory.</li>
	<li>During guide wire introduction, emphasize tactile feedback and the firm feel of cancellous bone resistance. At the same time, avoid excessive pressure to prevent anterior (ventral) crossing of the guide wire, which could lead to neurovascular injury. Once secured, remove the PAK needle sheath.</li>
	<li>Bilaterally place and secure four guide pins into the four pedicles of the segment, then bend and tether them to the drapes using Allis forceps, keeping them away from the central operative field as shown in Figure 2. 
	&#8203;CAUTION: Advance instruments slowly and visualize the trajectory to avoid medial, lateral, or inferior breach4,10.</li>
	<li>For standard lateral recess stenosis (LRS) decompression or over-the-top (OTT) decompression, make a separate medial fascial incision through the same skin incision. Use the PAK needle under navigation to determine the site of this 2 cm fascial incision, which is usually 2-3 cm from the spinous process. The target is to place a guide wire onto the index facet with navigation guidance in LRS unilateral decompression cases (relatively straighter trajectory). For OTT, the target point is the spino-laminar line (converging trajectory).</li>
	<li>Sequentially dilate the paraspinal muscle layers with 12 mm, 16 mm, and 20 mm dilators over the guide wire. Dock a 22 mm tubular quadrant retractor over the dilators onto the facet as shown in Figure 3 and secure it to the table-mounted arm.</li>
	<li>Adjust the retractor to the facet and lamina according to the pathology and surgical target, for either LRS decompression or OTT decompression.</li>
	<li>Bring in the microscope, exoscope, or use loupe magnification ergonomically. Achieve hemostasis and remove peri-laminar and peri-facetal soft tissue. Perform bone decompression using an ultrasonic bone scalpel blade set at medium amplitude (~22.5 kHz) with continuous irrigation maintained at 70% flow rate to prevent thermal injury.</li>
	<li>Excise the hypertrophic facet component and ligamentum flavum to achieve unilateral or bilateral decompression of the target. Perform foraminal decompression or disc fragment excision when needed to release the neural tissue.</li>
	<li>With adequate hemostasis, enter the disc space by performing a block-shaped annulotomy within the safe Kambin&#39;s triangle.
	<ol>
		<li>Use curettes in the standard fashion to prepare the end plates by removing the cartilage and debulking the disc. Remove disc material using pituitary forceps. Confirm the end points by a grating sensation of the end plate and punctate bleeding bone.</li>
		<li>Use a sequential shaver-sizer to determine the size of the interbody spacer cage and to distract the interbody space. Insert 5-10 cc of morselized autograft (locally harvested during decompression) into the prepared disc space through a funnel.</li>
		<li>Use the sized cage on a navigated cage holder-impactor. Place the selected poly-ether-ether-ketone (PEEK) or titanium interbody cage (8-13 mm in height, 28-32 mm in length as decided by the sizer and projection image) into the prepared interbody space under navigation in a safe trajectory as shown in Figure 4, positioned adequately in the centero-ventral location between both endplates, firmly contained within the biconcave disc space.</li>
	</ol>
	</li>
	<li>Reconfirm decompression and remove any remaining debris by giving a wash. Remove the tubular retractor assembly.</li>
	<li>Place cannulated pedicle screws (5.5-7.5 mm diameter, 40-55 mm length), based on sizing using navigation as shown in Figure 5, bilaterally over guide wires, verifying trajectory and length to cross two-thirds of the vertebral length. Confirm tactile feedback for proper purchase. Remove the guide wire as the screws cross the pedicle.</li>
	<li>Determine the required rod length intra-operatively using a calibrated rod-caliper, aligned between the screw tulip heads through percutaneous extensions. This method allows accurate measurement without fluoroscopic assistance. Introduce the pre-contoured lordotic measured rod percutaneously with a rod inserter tool.</li>
	<li>After placement, verify proper engagement of the rod within each screw tulip using a rod position checker. Once confirmed, perform sequential tightening of the set screws with a torque-limiting driver under compression mode (default setting: 8 Nm).</li>
	<li>Perform a final 3D CT spin to confirm hardware position. Acceptable criteria include proper screw and cage placement, absence of medial or inferior breach, and congruent implant alignment with the spinal midline. Use shielding for radiation safety, and follow all measures as done for preoperative spine CT imaging.</li>
	<li>Irrigate the wound and achieve meticulous hemostasis. Place a sub-fascial 10 Fr drain at the medial intermuscular site. Close the fascia with continuous 1-0 absorbable sutures, the subcutaneous tissue with interrupted 2-0 absorbable sutures, and the subcuticular layer with 3-0 fast-absorbing sutures.</li>
	<li>NOTE: Routinely check the navigation reference frame for movement; recalibrate if drift is suspected.</li>
</ol>

<ol><li>Phan, K., Hogan, J. A., Mobbs, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Cost-effectiveness+of+minimally+invasive+versus+open+transforaminal+lumbar+interbody+fusion%5BTitle%5D)+AND+%22Clin+Spine+Surg%22%5BJournal%5D)">Cost-effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion.</a> Clin Spine Surg. 30 (4), E219-E229 (2017).</li>
<li>Yang, J. S., Hyun, S. J., Kim, K. J., Jahng, T. A., Kim, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Minimally+invasive+TLIF+with+O-arm+navigation+versus+without+navigation%3A+Comparison+of+clinical+and+radiologic+outcomes%5BTitle%5D)+AND+%22Asian+Spine+J%22%5BJournal%5D)">Minimally invasive TLIF with O-arm navigation versus without navigation: Comparison of clinical and radiologic outcomes.</a> Asian Spine J. 17 (2), 258-266 (2023).</li>
<li>Costa, F., Ortolina, A., Attuati, L., Cardia, A., Ortolina, M., Fornari, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Radiation+exposure+during+navigated+percutaneous+procedures%3A+A+prospective+comparative+study%5BTitle%5D)+AND+%22Eur+Spine+J%22%5BJournal%5D)">Radiation exposure during navigated percutaneous procedures: A prospective comparative study.</a> Eur Spine J. 22 (Suppl 6), S943-S948 (2013).</li>
<li>Kulkarni, A. G., Bohra, H., Nanda, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+and+technical+considerations+of+3D+intraoperative+imaging+and+navigation+in+minimally+invasive+spine+surgery%5BTitle%5D)+AND+%22Asian+Spine+J%22%5BJournal%5D)">Clinical and technical considerations of 3D intraoperative imaging and navigation in minimally invasive spine surgery.</a> Asian Spine J. 16 (4), 579-587 (2022).</li>
<li>El Tecle, N. E., Dahdaleh, N. S., Hitchon, P. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Minimally+invasive+transforaminal+lumbar+interbody+fusion%3A+A+comparison+of+techniques+and+outcomes%5BTitle%5D)+AND+%22World+Neurosurg%22%5BJournal%5D)">Minimally invasive transforaminal lumbar interbody fusion: A comparison of techniques and outcomes.</a> World Neurosurg. 91, 228-236 (2016).</li>
<li>Shin, B. J., James, A. R., Njoku, I. U., Hartl, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pedicle+screw+accuracy+using+O-arm+navigation+versus+freehand+technique+in+MIS+TLIF%3A+Systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22J+Neurosurg+Spine%22%5BJournal%5D)">Pedicle screw accuracy using O-arm navigation versus freehand technique in MIS TLIF: Systematic review and meta-analysis.</a> J Neurosurg Spine. 36 (1), 1-11 (2022).</li>
<li>Rajasekaran, S., Kamath, V., Shetty, A. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraoperative+navigation+in+spine+surgery%3A+A+review+and+update%5BTitle%5D)+AND+%22J+Clin+Orthop+Trauma%22%5BJournal%5D)">Intraoperative navigation in spine surgery: A review and update.</a> J Clin Orthop Trauma. 10 (6), 904-910 (2019).</li>
<li>Tian, N. F., Xu, H. Z. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Image-guided+pedicle+screw+insertion+accuracy%3A+A+meta-analysis%5BTitle%5D)+AND+%22Int+Orthop%22%5BJournal%5D)">Image-guided pedicle screw insertion accuracy: A meta-analysis.</a> Int Orthop. 33 (4), 895-903 (2009).</li>
<li>Lian, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Total+3D+Airo%C2%AE+navigation+facilitates+the+entire+MIS-TLIF+procedure%2C+eliminating+fluoroscopy%5BTitle%5D)+AND+%22Biomed+Res+Int%22%5BJournal%5D)">Total 3D Airo® navigation facilitates the entire MIS-TLIF procedure, eliminating fluoroscopy.</a> Biomed Res Int. 2016, 5027340(2016).</li>
<li>Tian, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Guidelines+for+navigation-assisted+spine+surgery+emphasize+the+importance+of+a+standardized+workflow+to+enhance+clinical+efficiency+and+precision%5BTitle%5D)+AND+%22Front+Med%22%5BJournal%5D)">Guidelines for navigation-assisted spine surgery emphasize the importance of a standardized workflow to enhance clinical efficiency and precision.</a> Front Med. 14, 518-527 (2020).</li>
<li>Pennington, Z., Cottrill, E., Lubelski, D., Sciubba, D. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Techniques+and+complications+of+minimally+invasive+surgery+in+obese+patients%5BTitle%5D)+AND+%22Neurosurg+Clin+N+Am%22%5BJournal%5D)">Techniques and complications of minimally invasive surgery in obese patients.</a> Neurosurg Clin N Am. 33 (2), 147-158 (2022).</li>
</ol>

The authors declare no conflict of interest.

Our experience with a fully navigated 3D O-Arm-guided approach to MIS TLIF highlights and reinforces its capacity to combine precision, reproducibility, and safety7,8. 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...

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 times1,2,3,4,5,6. Recent advances in intraoperative navigation and three-dimensional (3D) computed tomography (CT) imaging have improved pedicle screw accuracy and reduced complication rates7,8. Most existing literature focuses on discrete aspects of navigated MIS TLIF, such as pedicle screw accuracy or radiation exposure reduction9,10,11, with little emphasis on a fully integrated, uninterrupted navigated workflow from preoperative imaging to decompression, cage placement, screw fixation, and final verification.
This workflow is most suitable for adults aged 18-80 years with symptomatic lumbar degenerative pathology such as single-level degenerative spondylolisthesis, lumbar stenosis, or disc degeneration, provided pedicle anatomy is preserved. Contraindications include advanced osteoporosis, severe deformity, or prior instrumentation at the same level.
This retrospective study, conducted at a tertiary spine center, evaluated 44 patients who underwent fully navigated MIS TLIF. In total, 176 pedicle screws were placed using a sequential, navigation-guided workflow customized for TLIF and decompression. The designed workflow was used to evaluate outcomes of a fully navigated 3D CT-assisted MIS TLIF, focusing on implant accuracy, perioperative safety, functional improvements, and workflow efficiency compared against published benchmarks. The findings highlight the clinical reliability and reproducibility of a fully navigated O-arm-assisted MIS TLIF protocol, while also providing novel qualitative evidence of enhanced workflow not previously described in the literature.

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

optimizing minimally invasive spine surgery: a fully 3d ct o-arm navigated workflow in mis tlif

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

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.

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...

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.

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has become increasingly popular due to reduced tissue trauma, decreased blood loss, ...

Our study assesses the outcome of fully navigated CT assisted MIS TLIF in single level regenerative lumbar disorder. Switching from conventional real-time imaging to XR.Integrating the workflow of decompression fixation and imaging in a single procedure is a challenge. To begin, place the patient under general anesthesia and position them prone on a padded radiolucent spinal table.Secure the patient with chest and pelvic bolsters and non constrictive cross body straps to prevent movement. Confirm that there are no pressure points or abdominal compression. Prepare and drape the surgical field using the standard aseptic technique.Set up the 3D computed tomography, imaging system, navigation workstation, and high definition optical visualization system. Adjust the loop magnification to 2.5 times or the exoscope or microscope magnification to five to 10 times. Attach the dynamic reference frame proximally at the lower thoracic region using non-absorbable suture material and check for rigid anchorage of the frame.Acquire a baseline computed tomography spin using the standard lumbar protocol with 120 kilovolts peak, 200 milliamp your seconds, a 512 by by 512 matrix and one millimeter slice thickness. Register the acquired 3D image dataset to the navigation system. Use one to two anatomical points to interpolate and verify that the error is less than or equal to one millimeter before proceeding.Using navigation guidance and the pedicle access kit needle overlay on the screen mark paramedian skin incisions four to six centimeters lateral to the midline at the surgical level. Target the junction of the facet and transverse process with as lateral and entry projection as possible. Using a number 22 scalpel blade.Incise the skin and underlying fascia longitudinally to a length of approximately four centimeters. Under navigation, advance a 13 gauge 15 millimeter pedicle access kit needle to the junction of the facet and transverse process. Enter the center of the index pedicle in both axial and sagittal planes.While ensuring a safe trajectory and enhancing convergence continuously check intraoperative navigation screens to confirm that the needle tip remains within the cortical bone. In cases of smaller pedicles except a lateral entry with medial convergence and an extra particular trajectory, remove the stylet and railroad a one millimeter nitinol steel guide wire through the sheath of the pedicle access kit needle into the vertebral body confirming placement with tactile feedback and resistance of cancellous bone. Once secured, remove the pedicle access kit needle sheath place, and secure four guide pins bilaterally into the pedicles of the segment.Then bend and tether them to the drapes using Alice forceps to keep them away from the central operative field For decompression, make a separate medial facial incision through the same skin incision under navigation guidance to determine the site, usually two to three centimeters from the spinous process. Place a guide wire onto the index facet for lateral recess stenosis. Unilateral decompression cases sequentially dilate the paraspinal muscle layers with 12, 16 and 20 millimeter dilators over the guide wire and dock a 22 millimeter tubular quadrant retractor over the dilators onto the facet.Now secure the quadrant retractor to the table mounted arm to achieve targeted lateral recess stenosis decompression, or over the top decompression. Perform the steps shown under magnification and illumination using a sized cage on a navigated cage holder impactor place the selected polyether ether ketone or titanium interbody cage into the prepared interbody space under navigation with a safe trajectory, remove the tubular retractor assembly from the surgical site. Then using navigation guidance, place cannulated pedicle screws bilaterally over the guide wires based on appropriate sizing.Confirm tactile feedback for proper screw purchase, and remove the guide wire as the screws cross the pedicle. Using a calibrated rod caliber determine the required rod length interoperatively by aligning it between the screw tulip heads through percutaneous extensions. Next, introduce the pre contoured lordotic measured rod percutaneously using a rod inserter tool, verify proper engagement of the rod within each screw tulip using a rod position checker.Perform sequential tightening of the set screws with a torque limiting driver under compression mode at eight Newton meters. Acquire a final 3D computed tomography spin to confirm hardware position, proper screw and cage placement and congruent implant alignment with the spinal midline. Irrigate the wound and achieve meticulous hemostasis.Place a sub facial number 10 French drain at the medial intermuscular site. Finally, close the fascia with continuous 1-0 absorbable sutures. The subcutaneous tissue with interrupted 2-0 absorbable sutures and the subcuticular layer with 3-0 fast absorbing sutures.In this series, 44 patients underwent fully navigated minimally invasive transforaminal lumbar interbody fusion. Most surgeries were performed at L4 to L5 level accounting for 72.72%The oswestry disability index improved from around 38.68 preoperatively to around 12.5 at final follow-up. And the numeric rating scale for back and leg pain improved from around 8.68 and 8.65 to 0.79 and 0.81 respectively.The average operative time was around 124.14 minutes with a mean blood loss of around 100.45 milliliters. Screw accuracy was high with 6.8100000000000005%Gertzbein Grade 1 breaches, and 3.4%Modified Park Grade 1 facet violations. Our protocol addresses the entire MIS TLIF work protocol beyond just pedicle screws.It provides continuous uninterrupted navigation for skin incision, port placement, screw, and cage placement, which is beyond the usual sequential navigation or partial navigation. The future research will focus on validating integrated navigation for large cohort of patients in multilevel spinal pathologists and different spinal pathologists.

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Research

JoVE Journal

Medicine

The purpose of this article is to provide image-guidance for minimally invasive transforaminal interbody fusion.

Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion

This article presents a standardized surgical technique for robotic-assisted pedicle screw placement by using robotic-assisted navigational systems. We present a step-by-step protocol and describe the workflow and precautions of this procedure.

A Spine Robotic-Assisted Navigation System for Pedicle Screw Placement

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

C-arm-free oblique lumbar interbody fusion at the L5-S1 level (OLIF51) and simultaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This technique does not expose the surgeon or operating staff to radiation hazards.

C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

The technique described in this article is well-suited to the Mini-ALIF procedure, allows for excellent exposure and decompression, and facilitates microscope-assisted manipulation.

Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

The protocol introduces a novel mini-open TLIF, which can significantly reduce intraoperative blood loss, achieving minimally invasive outcomes with enhanced recovery.

Novel Mini-open Transforaminal Lumbar Interbody Fusion

The protocol offers a valuable method detailing each step of the FE-TLIF procedure. With proper education, FE-TLIF can be effectively learned, leading to favorable clinical outcomes.

Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion

Lateral-PLIF is an advanced posterior lumbar interbody fusion technique allowing safer cage insertion with minimal neural manipulation. This article outlines the step-by-step procedure, highlighting the benefits of the bilateral approach, optimal cage orientation, high fusion rates, and low complication risks, offering a promising alternative to traditional PLIF.

Lateral-PLIF for Lumbar Spinal Arthrodesis: A Detailed Step-By-Step Surgical Technique

Here, we present a protocol to perform full-endoscopic trans-Kambin triangle lumbar interbody fusion (KLIF). The protocol utilizes a posterolateral approach via Kambin’s triangle for safe expandable cage insertion and neural decompression while preserving dorsal facet structure and minimizing soft tissue trauma.

Full-Endoscopic Trans-Kambin Triangle Lumbar Interbody Fusion: Surgical Technique

Learn a fully navigated 3D CT O-Arm workflow for minimally invasive transforaminal lumbar interbody fusion. This standardized protocol improves surgical accuracy and efficiency in spinal procedures.

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

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