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

Table 1 Summary of advantages and disadvantages of minimally invasive spine-related technologies

Technology	Advantages	Disadvantages	Typical clinical scenarios
Intraoperative CT navigation	Accurate localization of bony structures; enhances surgical safety; reduces intraoperative errors	Increases operative cost and radiation exposure; requires high operator proficiency	Spinal fixation; pedicle screw placement; complex fracture reconstruction
Endoscopic systems (HD/4K)	High-definition visualization; reduces soft-tissue trauma; improves clarity of the operative field	Limited field of view; narrow working space; technically demanding	Discectomy; spinal decompression; laminectomy
Robotic systems	High accuracy; shorter operative time; reduces intraoperative surgeon fatigue	High equipment cost; system complexity; requires dedicated training	Spinal deformity correction; complex multilevel procedures
Sequential muscle dilators	Decrease muscle retraction; reduce postoperative pain; shorten recovery time	Applicable only to specific approaches; cannot fully replace conventional open procedures	Lumbar fusion surgery; disc procedures
Fluorescence imaging (e.g., ICG)	Improves intraoperative identification of vascular and neural structures; reduces iatrogenic injury	Requires additional equipment and contrast agents; increases procedural complexity	Complex spinal surgery in vascular-rich regions

CT: Computed tomography; HD: High definition; 4K: 4K ultra–high definition; ICG: Indocyanine green.

Table 2 Comparison of surgical techniques and indications

Technique	Indications	Advantages	Disadvantages
Endoscope-assisted decompression	DDD; spinal canal stenosis	Minimal tissue trauma, rapid recovery, and reduced intraoperative blood loss; high-resolution imaging improves surgical visualization	Limited indications; steep learning curve; high operative complexity
Percutaneous endoscopic discectomy	Mild to moderate disc herniation	Small incision, less postoperative pain, shorter hospital stay; reduced soft-tissue disruption	Restricted endoscopic field of view and relatively narrow indications; requires high technical precision
Robot-assisted surgery	Spinal deformity correction; multilevel spinal fixation	High surgical accuracy and reduced human error; improves pedicle screw placement accuracy and lowers complication rates	High equipment cost and demanding training requirements; complex system maintenance
3D fluoroscopy and real-time navigation	Spinal fixation procedures; pedicle screw placement	High accuracy; lowers the risk of screw misplacement; real-time imaging shortens operative time and reduces radiation exposure	Requires substantial radiation exposure; depends on expensive imaging equipment

DDD: Degenerative disc disease; 3D: Three-dimensional.

Table 3 Summary of minimally invasive treatment modalities for spinal disorders

Disease type	Minimally invasive method	Specific procedure	Outcome evaluation
Degenerative disc disease	Percutaneous endoscopic discectomy	Small skin incision; herniated disc tissue is removed under direct endoscopic visualization to relieve neural compression	Pain relief in > 85% of patients; rapid postoperative recovery; short length of hospital stay
Spinal canal stenosis	Endoscope-assisted decompression	Resection of hypertrophic bone and ligament via an endoscopic approach to enlarge the spinal canal	Improved walking capacity; reduced pain; relatively short postoperative recovery period
Spinal scoliosis	Robot-assisted surgery	Robot-guided precise pedicle screw placement combined with corrective maneuvers to restore normal spinal alignment	Significant deformity correction; low postoperative complication rate; high patient satisfaction
Spinal tumors	Percutaneous biopsy, radiofrequency ablation, and cement augmentation	CT- or MRI-guided biopsy followed by radiofrequency ablation of the tumor and subsequent cement injection to stabilize the spine	Marked pain relief; short recovery period; applicable to benign and selected malignant lesions

CT: Computed tomography; MRI: Magnetic resonance imaging.

Table 4 Comparison between minimally invasive spine surgery and traditional open surgery

Parameter	MISS	Traditional open surgery
Intraoperative blood loss	< 50-100 mL; minimal soft-tissue disruption	200-500 mL; requires extensive soft-tissue dissection
Length of hospital stay	Average 2-4 days	Average 7-10 days
Pain relief (VAS)	VAS score reduced by 50%-60% at 1 week postoperatively; further improvement by 2 weeks	Pain relief typically observed around 4 weeks postoperatively; recovery is comparatively slower
Complication rate	Overall complication rate < 5%; mainly minor infections and mild transient neurological deficits	Complication rate 10%-20%; includes bleeding, infection, and neurological injury
Functional recovery (ODI)	ODI improved by 30%-40% at 3 months; marked improvement by 6 months	ODI gradually improves, reaching approximately 30%-35% improvement at 6 months

MISS: Minimally invasive spine surgery; VAS: Visual analogue scale; ODI: Oswestry Disability Index.

Table 5 Future directions and research priorities

Research area	Objectives	Potential clinical impact	Technological applications
AI	Optimize preoperative planning, real-time intraoperative navigation, and postoperative complication prediction	Improve surgical precision and safety; reduce postoperative complications	AI-based imaging analysis; intelligent intraoperative monitoring systems
Personalized medicine	Develop individualized treatment strategies based on patient-specific genetic and anatomical characteristics	Increase surgical success rates; reduce risks associated with inter-individual variability	Genomic profiling; 3D-printed patient-specific implants
Novel biomaterials	Promote spinal tissue regeneration and enhance implant biocompatibility	Accelerate postoperative healing; reduce inflammation and procedure-related complications	Nanofiber scaffolds; bioactive glass; hydrogels and other regenerative materials
Tele-surgery and virtual reality	Enable remote surgical guidance and real-time training; shorten the learning curve	Improve healthcare quality in underserved regions; reduce training time and cost	Remote robotic surgery; virtual surgical simulation; augmented-reality-based navigation systems

AI: Artificial intelligence; 3D: Three-dimensional.