Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 3958  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (1,748 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

  In this Article
 »  Abstract
 »  Endoscopic Spine...
 »  Minimally Invasi...
 »  Robotic Spine Su...
 »  Enhance Recovery...
 »  References
 »  Article Figures

 Article Access Statistics
    PDF Downloaded29    
    Comments [Add]    

Recommend this journal


Table of Contents    
Year : 2022  |  Volume : 70  |  Issue : 8  |  Page : 104-107

The Future of Minimally Invasive Spine Surgery

1 Neurosurgery, Endoscopic Spine Surgery Center, Seoul Bumin Hospital, Seoul, South Korea
2 Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, College of Medicine, Yonsei University, Seoul, South Korea

Date of Submission10-Jul-2022
Date of Acceptance11-Sep-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Yoon Ha
Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, College of Medicine, Yonsei University, Seoul 120-750
South Korea
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.360930

Rights and Permissions

 » Abstract 

Minimally invasive spine surgery (MISS) is an important option for spinal operations, with advantages including rapid recovery and preservation of normal structures. As the number of geriatric patients is increasing, the role of MISS might expand in the future. MISS techniques and approaches continue to be developed, and recent trends in MISS development include the refinement of surgical approaches and techniques, as well as systems related to newly developed techniques, rather than spinal implants. Among the various techniques for MISS, endoscopic spine surgery, including uniportal and biportal endoscopic approaches, is the focus of vigorous research efforts that may lead to further expansion of the indications of endoscopic spine surgery. Endoscopic spine surgery will be an important part of spine surgery. Lateral lumbar interbody fusion and endoscopic lumbar interbody fusion may play meaningful roles in the MISS fusion area. Robotics and augmented reality are also likely to be important technological modalities in spine surgery in the future.

Keywords: Fusion, future, endoscopy, minimally invasive
Key Messages: The future of minimally invasive spinal surgery will be based on robotic surgery, endoscopic spine surgery, and virtual reality technologies.

How to cite this article:
Heo DH, Ha Y, Yi S, Chung H. The Future of Minimally Invasive Spine Surgery. Neurol India 2022;70, Suppl S2:104-7

How to cite this URL:
Heo DH, Ha Y, Yi S, Chung H. The Future of Minimally Invasive Spine Surgery. Neurol India [serial online] 2022 [cited 2023 Feb 3];70, Suppl S2:104-7. Available from: https://www.neurologyindia.com/text.asp?2022/70/8/104/360930

The advantages of minimally invasive spine surgery (MISS) include minimizing the traumatization of normal structure, shortening the hospital stay, enhancing recovery after surgery, reducing postoperative wound pain, and improving cosmetic outcomes. In the past, the development of MISS focused on the development of spinal implants or instruments, such as percutaneous pedicle screws, cortical screws, and dynamic stabilization implants including interspinous devices, facet joint replacement, and dynamic pedicle screws with rods. In contrast, more recent trends in MISS involve the development of surgical approaches and techniques, as well as systems related to surgical techniques, such as endoscopic spine surgery and robotics. We would like to describe the present and future of MISS.

 » Endoscopic Spine Surgery Top

Among the newly developed technologies of MISS, endoscopic spine surgery has been vigorously developed. In the past, endoscopic spine surgery was usually only attempted for the treatment of lumbar disc herniation. More recently, with the development of biportal endoscopic systems and large-working-channel interlaminar endoscopy, endoscopic posterior laminotomy or laminectomy has become available. Endoscopic bone work, including laminectomy or foraminotomy, has played a very important role in expanding the indications of the endoscopic approach. The biportal endoscopic approach or uniportal endoscopic approach using large-working-channel interlaminar endoscopy can be used to effectively perform posterior laminectomy, laminotomy, and foraminotomy. Therefore, the indications of the endoscopic approach include lumbar central or lateral recess stenosis and foraminal stenosis [Figure 1]. Unilateral laminotomy with bilateral decompression using the biportal or uniportal endoscopic approach has been performed for the treatment of lumbar central stenosis and lateral recess stenosis. Compared to microsurgery or conventional surgery, endoscopic decompressive laminotomy has advantages such as a shorter hospital stay, early recovery after surgery, and less postoperative wound pain. Endoscopic decompressive laminectomy may be commonly used for lumbar stenosis in the near future.
Figure 1: Expansion of indications for endoscopic spine surgery

Click here to view

The indications of endoscopic spine surgery are still being expanded [Figure 1].[1] Endoscopic bone work using a drill, various sizes of Kerrison Rongeurs, and curettes could be performed at cervico-thoracic lesions as well as lumbosacral lesions. The ability to perform endoscopic laminectomy or laminotomy effectively allows various lesions to be treated endoscopically. Cervical central stenosis, cervical foraminal stenosis, cervical foraminal disc herniation, thoracic disc herniation, thoracic stenosis, and extradural cystic lesions may also be the indications for the uniportal or biportal endoscopic spine approaches. Endoscopic surgery, including the uniportal and biportal endoscopic approaches, will become more common in the future, and the indications for endoscopic surgery will be expanded.

Among the various spinal endoscopic approaches, the use of biportal endoscopic spine surgery seems to be increasing. Biportal endoscopic surgery has the advantages of being similar to microsurgery, involving familiar surgical anatomy, and having a relatively short learning curve. The application of biportal endoscopic surgery is expected to increase further in the future [Figure 2].
Figure 2: Overview of biportal endoscopic spine surgery

Click here to view

One of the disadvantages of endoscopic spine surgery is the lack of stereognosis and the absence of a depth sensation. Vascular and neural injuries are possible during endoscopic spine surgery due to the use of two-dimensional endoscopic images. Three-dimensional (3D) endoscopic spine surgery has recently been attempted for lumbar degenerative disease.[2] Pathologic lesions can be clearly depicted using 3D endoscopy,[2] and the stereognosis of 3D biportal endoscopic surgery might have a good impact on patient safety [Figure 3]. In the future, 3D endoscopic surgery might be further developed and become an important surgical option.
Figure 3: Three-dimensional (3D) endoscopic spine surgery. Polarized glasses should be worn during the 3D endoscopic approach

Click here to view

 » Minimally Invasive Lumbar Interbody Fusion Top

Among the various surgical approaches of MISS fusion, two techniques for minimally invasive lumbar interbody fusion have recently received attention. The first is lateral lumbar interbody fusion—including oblique lumbar interbody fusion (OLIF)—and the second is endoscopic lumbar interbody fusion using the biportal or uniportal endoscopic approach.

In comparison to direct lateral lumbar interbody fusion through the transpsoas approach, OLIF was safely performed through the anterior psoas approach. OLIF can be performed from L1-2 to L5-S1.[3] OLIF may play an expanded role in the treatment of degenerative lumbar disease, adjacent segment disease, revision cases, traumatic lesions, and adult deformities.[3],[4]

Another emerging MISS fusion technique is endoscopic lumbar interbody fusion. In the past, endoscopic lumbar interbody fusion was performed through Kambin's triangle.[5] Therefore, endoscopic lumbar interbody fusion had limitations and technical difficulties. The posterior lateral approach for endoscopic lumbar interbody fusion was recently introduced. Posterior lateral endoscopic lumbar interbody fusion can be performed using the biportal endoscopic approach or large-working-channel uniportal endoscopy.[6] The posterolateral approach is similar to MISS transforaminal lumbar interbody fusion (TLIF). It is possible to perform direct neural decompression and large cage insertion through laminectomy and facetectomy, as in MISS TLIF. Endoscopic endplate preparation is another advantage of endoscopic lumbar interbody fusion.[1],[5] To date, endoscopic lumbar interbody fusion surgery has usually been performed with one- or two-level fusion. In the future, endoscopic lumbar interbody fusion may be attempted for adult deformities as well as in multi-level fusion surgery.

In the coronavirus disease 2019 (COVID-19) pandemic, ambulatory spine surgery centers or day surgery centers became increasingly important. Endoscopic surgery and endoscopic fusion surgery will play more important roles at ambulatory spine surgery centers.

Many spinal instrumental companies have produced expandable cages. The purposes of expandable lumbar interbody cages are expansion of the fusion bed and restoration of disc height and lordosis, for which these cages are advantageous.[7] Another advantage of expandable lumbar interbody cages is that they can be safely and easily inserted. If expandable cages are used in OLIF or endoscopic lumbar interbody fusion, synergistic effects might be obtained. In the field of MISS lumbar interbody fusion, endoscopic fusion and OLIF are expected to play a major role in the future.

 » Robotic Spine Surgery and Other Emerging Technologies Top

Major spine companies have produced spinal surgery robot systems that help insert pedicle screws [Figure 4].[8] Spinal surgery robots allow the precise insertion of pedicle screws through small skin incisions and reduce radiation exposure.[8] Virtual reality (VR) and augmented reality (AR) are also emerging as relevant technologies for spine surgery.[9] VR can help in planning spine surgery, simulating surgery before real surgery, and training in surgical techniques. AR technology is also used in navigation systems of spinal surgery.[9] AR guidance in spine surgery showed the surgical anatomy and facilitated implant placement, such as pedicle screw insertion. Robotic, AR-guided, and VR-guided spine surgery may have positive effects on reducing radiation exposure, surgical guidance to pathologic lesions, and patient safety during spinal surgery.[10] These emerging techniques are likely to play an important role in the future, although efforts to improve their accuracy and reduce their costs are needed.
Figure 4: Overview of robotic spine surgery. A pedicle screw was inserted under robotic arm guidance

Click here to view

 » Enhance Recovery After Surgery Programs with MISS Top

Enhanced recovery after surgery (ERAS) programs have been widely accepted in the fields of cancer surgery, joint surgery, gynecological surgery, general surgery, and vascular surgery. In contrast, ERAS protocols may not be applied to traditional spine surgery, and MISS plays a very important role in the introduction of ERAS programs in spinal surgery.[11] The purpose of ERAS is to accelerate postoperative recovery and reduce perioperative complications. Furthermore, ERAS increases the satisfaction of both patients and surgeons.[12]

An ERAS program consists of preoperative, intraoperative, and postoperative management. Intraoperative management may be the most important part of ERAS, for which reason MISS procedures play a particularly meaningful role in ERAS programs. Endoscopic spine approaches have been recommended for ERAS.[12] ERAS programs are especially common at ambulatory spine surgery centers or day surgery centers and are expected to play an important role in spine surgery. In particular, if ERAS programs are implemented together with MISS, a more synergistic effect will be seen. While the development of surgical techniques and instruments is important in the MISS field, patient management programs such as ERAS programs will become even more important in the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Heo DH, Hong YH, Lee DC, Chung HJ, Park CK. Technique of biportal endoscopic transforaminal lumbar interbody fusion. Neurospine 2020;17(Suppl 1):S129-37.  Back to cited text no. 1
Heo DH, Kim JY, Park JY, Kim JS, Kim HS, Roh J, et al. Clinical experiences of 3-dimensional biportal endoscopic spine surgery for lumbar degenerative disease. Oper Neurosurg (Hagerstown) 2022;22:231-8.  Back to cited text no. 2
Kim H, Chang BS, Chang SY. Pearls and pitfalls of oblique lateral interbody fusion: A comprehensive narrative review. Neurospine 2022;19:163-76.  Back to cited text no. 3
Lin GX, Nan JN, Chen KT, Sun LW, Tai CT, Jhang SW, et al. Bibliometric analysis and visualization of research trends on oblique lumbar interbody fusion surgery. Int Orthop 2022;46:1597-608.  Back to cited text no. 4
Heo DH, Lee DC, Kim HS, Park CK, Chung H. Clinical results and complications of endoscopic lumbar interbody fusion for lumbar degenerative disease: A meta-analysis. World Neurosurg 2021;145:396-404.  Back to cited text no. 5
Kang MS, Heo DH, Kim HB, Chung HT. Biportal endoscopic technique for transforaminal lumbar interbody fusion: Review of current research. Int J Spine Surg 2021;15(Suppl 3):S84-92.  Back to cited text no. 6
Alvi MA, Kurian SJ, Wahood W, Goyal A, Elder BD, Bydon M. Assessing the difference in clinical and radiologic outcomes between expandable cage and nonexpandable cage among patients undergoing minimally invasive transforaminal interbody fusion: A systematic review and meta-analysis. World Neurosurg 2019;127:596-606.e1.  Back to cited text no. 7
Kim HC, Jeon H, An SB, Kim H, Hwang S, Cha Y, et al. Novel C-arm based planning spine surgery robot proved in a porcine model and quantitative accuracy assessment methodology. Int J Med Robot 2021;17:e2182.  Back to cited text no. 8
Farshad M, Spirig JM, Suter D, Hoch A, Burkhard MD, Liebmann F, et al. Operator independent reliability of direct augmented reality navigated pedicle screw placement and rod bending. N Am Spine Soc J 2021;8:100084.  Back to cited text no. 9
Perfetti DC, Kisinde S, Rogers-LaVanne MP, Satin AM, Lieberman IH. Robotic spine surgery: Past, present and future. Spine (Phila Pa 1976) 2022;47:909-21.  Back to cited text no. 10
Dietz N, Sharma M, Adams S, Alhourani A, Ugiliweneza B, Wang D, et al. Enhanced recovery after surgery (ERAS) for spine surgery: A systematic review. World Neurosurg 2019;130:415-26.  Back to cited text no. 11
Heo DH, Park CK. Clinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery. Neurosurg Focus 2019;46:E18.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


Print this article  Email this article
Online since 20th March '04
Published by Wolters Kluwer - Medknow