Minimally invasive spine surgery with endoscopy, navigation, robotics, and artificial intelligence: Clinical evidence and future directions

Figure 1 Innovation and clinical efficacy of minimally invasive spine surgery. The central illustration shows the human spine, surrounded by five key domains related to minimally invasive spine surgery (MISS): (1) Technological innovations: The development of spinal endoscopy, image-guided navigation, intraoperative computed tomography/three-dimensional fluoroscopy, robotics, and artificial-intelligence-assisted planning enables more precise and less invasive spinal procedures; (2) Procedures: Representative MISS techniques include percutaneous endoscopic discectomy, endoscopic decompression for spinal canal stenosis, minimally invasive transforaminal lumbar interbody fusion, lateral and extreme lateral interbody fusion, and percutaneous tumor ablation combined with vertebral cement augmentation; (3) Clinical indications: Common indications comprise degenerative disc disease, lumbar spinal stenosis, spinal deformity, and spinal tumors or infections; (4) Clinical outcomes: Compared with conventional open surgery, MISS is associated with reductions in pain visual analogue scale, disability (Oswestry Disability Index), intraoperative blood loss, length of hospital stays, and procedure-related complications, together with improved quality of life; and (5) Challenges and future directions: Current limitations include a steep learning curve, radiation exposure, indication selection, and high costs, whereas future development is expected to rely on artificial-intelligence-based navigation, augmented/virtual-reality and telesurgery platforms, personalized three-dimensional-printed implants, and biomaterials- and tissue-engineering-based strategies. CT: Computed tomography; 3D: Three-dimensional; AI: Artificial intelligence; PED: Percutaneous endoscopic discectomy; MIS-TLIF: Minimally invasive surgery-transforaminal lumbar interbody fusion; LLIF/XLIF: Lateral and extreme lateral interbody fusion; DDD: Degenerative disc disease; VAS: Visual analogue scale; ODI: Oswestry Disability Index; QoL: Quality of life; AR/VR: Augmented/virtual-reality.

Figure 2 Comparison between traditional open spine surgery and minimally invasive spine surgery. The left panel illustrates a traditional open posterior lumbar approach with a long midline incision, extensive paraspinal muscle stripping, and wide laminectomy exposure. These features are associated with increased muscle damage, higher intraoperative blood loss, more severe postoperative pain, longer hospital stay, and a higher risk of complications, leading to slow functional recovery, especially in elderly patients. The right panel depicts a minimally invasive spine surgery approach using a paramedian skin incision, tubular retractors, and percutaneous pedicle screw, assisted by endoscopy, image-guided navigation, intraoperative computed tomography/three-dimensional fluoroscopy, robotics, and artificial intelligence-based planning. Compared with open surgery, minimally invasive spine surgery enables small incisions, less soft-tissue trauma, and precise decompression, resulting in reduced pain (visual analogue scale), decreased blood loss and complication rates, faster postoperative mobilization, and improved quality of life, particularly for elderly and comorbid patients. CT: Computed tomography; AI: Artificial intelligence; VAS: Visual analogue scale; QoL: Quality of life.

Figure 3 From current minimally invasive spine surgery to future intelligent, regenerative, and personalized minimally invasive spine surgery platforms. The left panel depicts a representative current minimally invasive spine (MISS) surgery procedure using endoscopic visualization and fluoroscopy-based navigation. From this baseline, a forward arrow illustrates key future directions. In the upper middle, artificial intelligence- and data-driven surgery integrates multimodal preoperative and intraoperative imaging into machine-learning algorithms to assist surgical planning, predict risk, and provide decision support, including suggested pedicle screw trajectories and optimized fusion levels or alignment corrections. On the upper right, augmented/virtual-reality and remote surgery enable augmented reality-guided navigation, immersive virtual-reality training, and telerobotic MISS via high-speed 5G communication. The lower middle highlights personalized and precision implants, such as three-dimensional-printed cages, patient-specific implants, and instrumentation designed for individualized spinal alignment and segmental stability. The lower right illustrates biomaterials and regenerative medicine approaches, including disc regeneration, bone graft substitutes, bioactive scaffolds, stem cell- and exosome-based therapies, and tissue-engineering strategies. Together, these innovations aim to deliver safer MISS with more individualized treatment, better long-term biomechanical stability, and lower complication rates. MISS: Minimally invasive spine; AI: Artificial intelligence; AR/VR: Augmented/virtual-reality.