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Minimally invasive spine surgery with endoscopy, navigation, robotics, and artificial intelligence: Clinical evidence and future directions
Dong Li, Xiao-Dong Tang, Zhi-Peng Li, Wei-Ping Fu, Peng-Yu Lu, Zhen Shi, Qi Zhang, Sen Fang, Bo-Kang Lv, Wen-Jie Ruan, Chang-Jiang Zhang, Rui-Bo Wang
Dong Li, Xiao-Dong Tang, Zhi-Peng Li, Wei-Ping Fu, Zhen Shi, Qi Zhang, Sen Fang, Bo-Kang Lv, Chang-Jiang Zhang, Rui-Bo Wang, Second Department of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
Dong Li, Xiao-Dong Tang, Zhi-Peng Li, Wei-Ping Fu, Zhen Shi, Qi Zhang, Sen Fang, Bo-Kang Lv, Chang-Jiang Zhang, Henan Provincial Key Discipline of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
Zhi-Peng Li, Chang-Jiang Zhang, Tianjian Laboratory of Advanced Biomedical Sciences, Zhengzhou University, Zhengzhou 450001, Henan Province, China
Peng-Yu Lu, First Department of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
Wen-Jie Ruan, Postgraduate Training Base Alliance, Wenzhou Medical University, Wenzhou 325035, Zhejiang Province, China
Co-first authors: Dong Li and Xiao-Dong Tang.
Co-corresponding authors: Chang-Jiang Zhang and Rui-Bo Wang.
Author contributions: Li D, Tang XD, and Wang RB conceptualized and designed the review; Li D, Tang XD, Li ZP, and Fu WP performed the literature search, screened and synthesized key articles, and drafted the initial manuscript; Lu PY, Shi Z, Zhang Q, Fang S, Lv BK, and Ruan WJ prepared the figures and tables, assisted with reference management, and contributed to manuscript refinement; Wang RB proposed the overall framework and core arguments of the article, provided critical intellectual input, and undertook major revisions of the manuscript; Zhang CJ offered clinical guidance, critically reviewed the manuscript for important intellectual content, and secured financial support for the project; Li D and Tang XD contributed equally to this work as co-first authors; Zhang CJ and Wang RB jointly supervised the study and are recognized as co-corresponding authors. All authors approved the final version to publish.
AI contribution statement: AI-assisted tools were used only for language polishing, grammar correction, and improvement of readability during the preparation of this manuscript. No portion of the main scientific content, including the abstract, introduction, materials and methods, results, discussion, and conclusion, was generated by AI. AI tools did not participate in the design of the study, data collection, data analysis, interpretation of results, or formulation of conclusions. All data, analyses, interpretations, textual content, figures, and scientific statements were generated, verified, and approved by the authors. The authors take full responsibility for the accuracy, integrity, originality, and reliability of the manuscript. All figures and images in this manuscript are original and were prepared by the authors; no AI tool was used to generate any image or figure.
Supported by Henan Provincial Key Research and Development Program, No. 231111311000; Henan Provincial Higher Education Institutions Key Research Project, No. 26A320038; Henan Provincial Medical Science and Technology Key Project, No. LHGJ20250403, No. LHGJ20220566, and No. LHGJ20240365; and Henan Provincial Medical Education Research Project, No. WJLX2023079.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Rui-Bo Wang, MD, Associate Chief Physician, Professor, Second Department of Orthopedics, The Fifth Affiliated Hospital of Zhengzhou University, No. 3 Kangfu Qian Street, Erqi District, Zhengzhou 450052, Henan Province, China.
18336397518@163.com
Received: January 20, 2026
Revised: February 8, 2026
Accepted: March 2, 2026
Published online: June 18, 2026
Processing time: 148 Days and 22.1 Hours
In recent years, minimally invasive spine surgery (MISS) has advanced rapidly in both technological capability and clinical adoption. By leveraging endoscopic visualization, minimally invasive working corridors, image-guided navigation, and robot-assisted instrumentation, MISS aims to achieve adequate decompression and stabilization while minimizing iatrogenic soft-tissue disruption and enhancing intraoperative accuracy and safety. This systematic critical review synthesizes contemporary innovations in MISS, including high-definition and three-dimensional endoscopy, intraoperative computed tomography/three-dimensional fluoroscopy-based navigation, and intelligent surgical instruments, and rigorously appraises clinical evidence across common spinal disorders (degenerative disc disease, spinal stenosis, deformity) and complex pathologies (tumors, infections). A structured literature search (2013-2023) adhering to PRISMA guidelines was conducted to identify randomized controlled trials, cohort studies, and systematic reviews/meta-analyses. Available data generally support meaningful perioperative advantages over conventional open surgery, including reduced blood loss, less postoperative pain, shorter hospitalization, faster functional recovery, and lower complication rates in appropriately selected patients, with expanding indications as techniques mature. However, these benefits are contextual, heterogeneity in surgeon experience, case complexity, and technology readiness influence outcomes. Key limitations include a steep learning curve, imaging-related radiation exposure, cost considerations, and ongoing debates regarding long-term effectiveness in multilevel disease or deformity correction. Future progress will depend on artificial intelligence-assisted planning/navigation, augmented visualization, personalized implants, and emerging biomaterials, alongside standardized training and high-quality prospective studies to define value, safety, and durable outcomes. Critical appraisal of evidence strength (GRADE system) and risk of bias (Cochrane Tool, Newcastle-Ottawa Scale) highlights where data remain inconclusive, emphasizing the need for targeted pragmatic randomized controlled trials and standardized outcome reporting.
Core Tip: Minimally invasive spine surgery uses navigation, endoscopy, and robotics to minimize soft-tissue damage, enhance precision, and improve safety, achieving clear benefits in degenerative disc disease, spinal stenosis, deformity, and related disorders. Compared with open surgery, minimally invasive spine surgery offers less trauma, quicker recovery, and particular advantages for older or comorbid patients. Yet its broader adoption is limited by a steep learning curve, radiation exposure, and evolving indications. Future priorities include artificial intelligence, individualized medicine, novel biomaterials, and strengthened training and standardized clinical research.
