Minimally Invasive Spine Surgery: Advanced Techniques, Instrumentation, and Patient Outcomes

Úvod

The evolution of spine surgery has witnessed a paradigm shift over the past few decades, transitioning from traditional open approaches to minimally invasive spine surgery (MISS) techniques. This transformation has been driven by the fundamental goal of achieving equivalent or superior clinical outcomes while minimizing tissue trauma, reducing perioperative morbidity, and accelerating patient recovery. Minimally invasive spine surgery encompasses a spectrum of techniques and technologies designed to address various spinal pathologies through smaller incisions and reduced tissue disruption compared to conventional open procedures.

The development of specialized instrumentation, enhanced visualization systems, and refined surgical approaches has expanded the applications of MISS across degenerative, traumatic, oncologic, and deformity conditions affecting the spine. This comprehensive review examines contemporary minimally invasive spine surgery approaches, including tubular access systems, percutaneous fixation techniques, and the growing body of evidence supporting their clinical utility and outcomes.

Historical Perspective and Evolution

Early Developments

The concept of minimally invasive surgery emerged in the late 20th century across various surgical disciplines, with laparoscopic cholecystectomy often cited as a pivotal development that demonstrated the feasibility and benefits of minimally invasive approaches. In spine surgery, the journey toward minimally invasive techniques began with several key innovations:

1. Microsurgical Techniques (1970s-1980s): The introduction of the operating microscope and microsurgical instruments allowed for more precise tissue manipulation and smaller incisions for procedures such as lumbar discectomy.

2. Percutaneous Discectomy (1980s): Hijikata and colleagues developed techniques for percutaneous nucleotomy, representing early attempts at addressing disc pathology through minimal access approaches.

3. Endoscopic Techniques (1990s): The adaptation of endoscopic technology to spine surgery enabled visualization through smaller portals, further reducing the need for extensive tissue exposure.

4. Tubular Retractor Systems (Late 1990s): The development of tubular retractors by Foley and Smith marked a significant advancement, providing a systematic approach to minimally invasive access for various spinal procedures.

These early developments laid the foundation for the subsequent rapid expansion of minimally invasive spine surgery techniques and applications.

Technological Enablers

Several technological advancements have been instrumental in the evolution and widespread adoption of MISS:

1. Advanced Imaging: Intraoperative fluoroscopy, navigation systems, and 3D imaging have enhanced the surgeon’s ability to visualize anatomy and implant placement without direct exposure.

2. Specialized Instrumentation: The development of low-profile implants, long-handled instruments, and specialized insertion devices has facilitated surgery through smaller corridors.

3. Biologické přídatné látky: Advances in biologics, including bone graft substitutes and growth factors, have improved fusion outcomes despite the reduced surface area available for fusion in minimally invasive approaches.

4. Optical Systems: Enhanced endoscopes, exoscopes, and microscopes with improved illumination and visualization capabilities have overcome many of the early limitations of working through restricted surgical corridors.

The convergence of these technologies has transformed MISS from a limited set of procedures for specific indications to a comprehensive approach applicable to a wide range of spinal pathologies.

Access Systems and Approaches

Tubular Retractor Systems

Tubular retractor systems represent one of the most significant technological advancements enabling minimally invasive spine surgery:

1. Design and Evolution:
2. First-generation systems featured fixed-diameter tubes
3. Second-generation expandable retractors allowed for customizable working channels
4. Contemporary systems incorporate multiple blades with adjustable angles and depths

5. Integration with light sources, navigation arrays, and specialized attachments

6. Technical Considerations:

7. Sequential dilation technique minimizes muscle trauma
8. Docking strategies vary by spinal region and pathology
9. Working distance and angle considerations affect instrument selection

10. Retractor positioning significantly impacts visualization and access

11. Aplikace:

12. Lumbar discectomy and decompression
13. Transforaminal and direct lateral interbody fusion
14. Posterior cervical foraminotomy
15. Intradural tumor resection
16. Minimally invasive deformity correction

The evolution of tubular systems has progressively addressed early limitations related to working area, illumination, and instrument maneuverability, expanding their utility across a broader range of procedures.

Percutaneous Access Techniques

Percutaneous approaches have revolutionized spinal instrumentation placement:

1. Pedicle Screw Systems:
2. Jamshidi needle-based targeting techniques
3. Guidewire-directed cannulated screw systems
4. Specialized screw extenders and reduction towers

5. Integration with navigation and robotics for enhanced accuracy

6. Interbody Access:

7. Transforaminal approaches through Kambin’s triangle
8. Direct lateral access through the psoas
9. Oblique lateral corridors anterior to the psoas

10. Anterior minimally invasive approaches

11. Specialized Applications:

12. Percutaneous iliac screw placement
13. Minimally invasive S2-alar-iliac (S2AI) fixation
14. Cortical bone trajectory techniques
15. Facet screw and transfacet fixation methods

These percutaneous techniques have dramatically reduced the soft tissue morbidity associated with spinal instrumentation while maintaining or improving accuracy rates compared to open techniques.

Endoscopic Spine Surgery

Endoscopic spine surgery represents the least invasive end of the MISS spectrum:

1. Technical Approaches:
2. Interlaminar endoscopic discectomy
3. Transforaminal endoscopic spine surgery (TESS)
4. Full-endoscopic anterior cervical discectomy

5. Endoscopic lumbar decompression

6. Technological Considerations:

7. Working channel endoscopes (typically 4.0-7.0mm diameter)
8. Specialized irrigation systems for visualization
9. High-definition camera systems

10. Purpose-designed microinstruments

11. Výhody a omezení:

12. Minimal tissue disruption and potential for local anesthesia
13. Steep learning curve and limited working channel
14. Excellent visualization of neural structures
15. Challenging management of certain complications

Endoscopic techniques continue to evolve, with expanding indications and improved technology addressing many of the early limitations of these ultra-minimally invasive approaches.

Specific Minimally Invasive Techniques

Minimally Invasive Lumbar Decompression

Lumbar decompression procedures were among the first to be adapted to minimally invasive techniques:

1. Tubular Microdiscectomy:
2. 16-22mm tubular retractors for access
3. Microscopic or endoscopic visualization
4. Preservation of midline structures

5. Reduced muscle denervation compared to open approaches

6. Minimally Invasive Laminectomy/Laminotomy:

7. Unilateral or bilateral tubular approaches
8. Over-the-top technique for contralateral decompression
9. Preservation of facet integrity

10. Reduced risk of iatrogenic instability

11. Interspinous Process Devices:

12. Indirect decompression through distraction
13. Minimally invasive insertion techniques
14. Limited indications based on pathoanatomy

15. Variable long-term outcomes in the literature

16. Percutaneous Image-Guided Lumbar Decompression (PILD):

17. Specialized instruments for ligamentum flavum debulking
18. Fluoroscopic or endoscopic guidance
19. Primarily for lumbar spinal stenosis
20. Limited evidence base compared to other techniques

These techniques have demonstrated equivalent outcomes to open decompression with reduced blood loss, shorter hospital stays, and faster return to activities in appropriately selected patients.

Minimally Invasive Lumbar Fusion

Minimally invasive fusion techniques have evolved to address the full spectrum of degenerative lumbar pathologies:

1. Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF):
2. Unilateral tubular approach (18-26mm)
3. Facetectomy and discectomy through tube
4. Expandable or articulated cage options

5. Percutaneous pedicle screw fixation

6. Direct Lateral Interbody Fusion (DLIF/XLIF):

7. Lateral retroperitoneal transpsoas approach
8. Specialized retractor systems with integrated neuromonitoring
9. Large footprint interbody devices

10. Supplemental fixation options (lateral plates, percutaneous screws)

11. Oblique Lateral Interbody Fusion (OLIF):

12. Anterior to psoas approach
13. Reduced risk of lumbar plexus injury
14. Access to L2-S1 levels

15. Similar cage options to DLIF/XLIF

16. Minimally Invasive Anterior Lumbar Interbody Fusion (MI-ALIF):

17. Mini-open retroperitoneal approach
18. Specialized retractor systems
19. Preservation of posterior tension band
20. Standalone or supplemental fixation options

These techniques have demonstrated fusion rates comparable to open procedures with reduced perioperative morbidity, though each has specific advantages, limitations, and learning curves that influence patient selection and outcomes.

Minimally Invasive Thoracic Procedures

Thoracic spine procedures present unique challenges for minimally invasive approaches:

1. Thoracoscopic Anterior Release and Fusion:
2. Video-assisted thoracoscopic surgery (VATS)
3. Multiple portal placements
4. Specialized long instruments

5. Applications in deformity, trauma, and tumor

6. Mini-Open Thoracic Approaches:

7. Limited muscle-splitting exposures
8. Specialized retractor systems
9. Integration with navigation for instrumentation

10. Reduced pulmonary morbidity compared to thoracotomy

11. Percutaneous Thoracic Instrumentation:

12. Similar principles to lumbar percutaneous fixation
13. Increased technical demands due to anatomy
14. Critical importance of imaging guidance

15. Applications in trauma, tumor, and deformity

16. Minimally Invasive Thoracic Decompression:

17. Tubular approaches for disc herniation
18. Transpedicular approaches for central pathology
19. Endoscopic options for select indications
20. Limited applications compared to lumbar region

The adoption of minimally invasive thoracic techniques has been slower than in the lumbar spine due to anatomical constraints, but continued refinement of approaches and instrumentation has expanded their applications.

Minimally Invasive Cervical Techniques

Cervical spine procedures have also benefited from minimally invasive adaptations:

1. Posterior Cervical Foraminotomy:
2. Tubular approaches (14-18mm)
3. Microscopic or endoscopic visualization
4. Preservation of midline structures and stability

5. Outpatient procedure potential

6. Anterior Cervical Procedures:

7. Omezené techniky řezu
8. Specialized retractor systems
9. Endoscopic assistance options

10. Similar exposure with reduced soft tissue trauma

11. Percutaneous Posterior Cervical Instrumentation:

12. Specialized navigation techniques
13. Modified entry points for percutaneous access
14. Limited but growing applications

15. Technical challenges due to anatomy

16. Endoscopic Anterior Cervical Discectomy:

17. Ultra-minimally invasive approach
18. Limited fusion options
19. Specializované přístrojové vybavení
20. Emerging evidence base

While anterior cervical procedures were already relatively minimally invasive, further refinements in technique and instrumentation have reduced soft tissue trauma and improved cosmetic outcomes.

Specialized Instrumentation and Technology

Navigation and Robotics

Image guidance technologies have dramatically enhanced the safety and accuracy of minimally invasive spine procedures:

1. Intraoperative Navigation Systems:
2. CT-based navigation with intraoperative 3D imaging
3. Fluoroscopy-based navigation systems
4. Reference frame considerations in minimally invasive approaches

5. Real-time instrument tracking and trajectory planning

6. Robotická asistence:

7. Trajectory guidance systems
8. Drill guide positioning
9. Integration with navigation platforms

10. Potential for reduced radiation exposure

11. Augmented Reality Applications:

12. Heads-up display technologies
13. Overlay of critical structures
14. Integration with microscopes and endoscopes

15. Emerging applications in complex deformity

16. Machine Learning Integration:

17. Automated segmentation of anatomy
18. Predictive algorithms for optimal implant placement
19. Intraoperative decision support
20. Quality control applications

These technologies have been particularly valuable in minimally invasive spine surgery, where direct visualization of anatomical landmarks is often limited compared to open approaches.

Specialized Implant Systems

Implant design has evolved specifically to address the challenges of minimally invasive delivery:

1. Percutaneous Pedicle Screw Systems:
2. Cannulated designs for guidewire-based insertion
3. Extended tabs and reduction capabilities
4. Low-profile tulip designs

5. Specialized rod insertion and reduction instruments

6. Expandable Interbody Devices:

7. In-situ expansion capabilities
8. Reduced insertion profile
9. Various expansion mechanisms (mechanical, hydraulic)

10. Lordotic correction options

11. Articulated and Steerable Implants:

12. Curved insertion paths
13. Post-insertion manipulation capabilities
14. Reduced need for neural retraction

15. Applications in complex anatomy

16. 3D-Printed Patient-Specific Implants:

17. Customized to patient anatomy
18. Optimized endplate contact
19. Integrated fusion windows
20. Potential for reduced subsidence

These specialized implant systems have overcome many of the early limitations of minimally invasive spine surgery, expanding the range of pathologies that can be effectively addressed through restricted surgical corridors.

Visualization Systems

Enhanced visualization has been critical to the advancement of minimally invasive spine techniques:

1. Surgical Microscopes:
2. High magnification capabilities
3. Improved illumination in deep corridors
4. Integration with navigation systems

5. Recording and teaching capabilities

6. Endoscopic Systems:

7. High-definition camera technology
8. Angled lens options
9. Integrated working channels

10. Specialized irrigation systems

11. Exoscopes:

12. Extracorporeal visualization platforms
13. 3D visualization capabilities
14. Ergonomic advantages for surgeon

15. Integration with navigation and augmented reality

16. Intraoperative Imaging:

17. Mobile C-arms with 3D capabilities
18. Intraoperative CT
19. O-arm technology
20. Reduced radiation techniques

These visualization technologies have collectively addressed one of the primary challenges of minimally invasive spine surgery: maintaining excellent visualization while working through restricted surgical corridors.

Clinical Applications and Outcomes

Degenerative Spine Conditions

The majority of minimally invasive spine surgery is performed for degenerative pathologies:

1. Lumbar Disc Herniation:
2. Multiple randomized trials supporting MIS approaches
3. Equivalent or superior short-term outcomes compared to open
4. Reduced tissue trauma and blood loss

5. Similar long-term recurrence rates

6. Lumbar Spinal Stenosis:

7. Comparable decompression efficacy to open techniques
8. Reduced blood loss and length of stay
9. Preservation of midline structures

10. Potential for reduced adjacent segment degeneration

11. Degenerative Spondylolisthesis:

12. Multiple techniques for minimally invasive fusion
13. Similar fusion rates to open procedures
14. Reduced perioperative morbidity

15. Equivalent long-term clinical outcomes

16. Adult Degenerative Scoliosis:

17. Expanding applications for minimally invasive techniques
18. Hybrid approaches for complex deformity
19. Reduced morbidity particularly beneficial in elderly population
20. Careful patient selection remains critical

The evidence base for minimally invasive approaches to degenerative conditions is robust, with multiple high-quality studies demonstrating at least equivalence to open techniques with reduced perioperative morbidity.

Trauma Applications

Minimally invasive techniques have found increasing applications in spinal trauma:

1. Thoracolumbar Fractures:
2. Percutaneous fixation for unstable fractures
3. Minimally invasive corpectomy techniques
4. Reduced approach-related morbidity

5. Particular benefits in polytrauma patients

6. Cervical Trauma:

7. Percutaneous posterior fixation options
8. Minimally invasive anterior approaches
9. Navigation-guided techniques

10. Limited but growing applications

11. Sacral Fractures:

12. Percutaneous iliosacral screw fixation
13. Minimally invasive lumbopelvic fixation
14. Reduced wound complications in high-risk patients

15. Improved visualization with navigation

16. Osteoporotic Fractures:

17. Vertebral augmentation techniques
18. Minimally invasive posterior fixation with cement augmentation
19. Reduced morbidity particularly beneficial in elderly population
20. Hybrid techniques for complex cases

The reduced physiological impact of minimally invasive approaches is particularly beneficial in trauma patients, who often have multiple injuries and limited physiological reserve.

Oncologic Applications

Minimally invasive techniques have expanded options for spinal tumor management:

1. Vertebral Body Metastases:
2. Minimally invasive separation surgery
3. Percutaneous stabilization
4. Reduced wound complications in immunocompromised patients

5. Faster return to adjuvant therapy

6. Intradural Tumors:

7. Tubular approaches for well-localized lesions
8. Minimized muscle and bone disruption
9. Enhanced visualization with microscopes

10. Reduced postoperative pain

11. Vertebral Augmentation for Pathologic Fractures:

12. Kyphoplasty and vertebroplasty techniques
13. Radiofrequency ablation integration
14. Cement augmentation of instrumentation

15. Palliative applications

16. Minimally Invasive Corpectomy:

17. Lateral and mini-open anterior approaches
18. Expandable cage technology
19. Reduced approach-related morbidity
20. Integration with percutaneous fixation

The reduced physiological impact and wound complications associated with minimally invasive approaches are particularly valuable in oncologic patients, who often have limited reserves and compromised immune function.

Deformity Correction

Initially considered a contraindication, deformity surgery has seen growing applications of minimally invasive techniques:

1. Adult Degenerative Scoliosis:
2. Lateral interbody fusion for anterior column realignment
3. Percutaneous fixation across multiple levels
4. Minimally invasive decompression of symptomatic levels

5. Hybrid techniques for complex cases

6. Sagittal Plane Deformity:

7. Minimally invasive anterior column realignment
8. Specialized reduction techniques
9. Expandable and lordotic interbody devices

10. Integration with posterior osteotomies when necessary

11. Adolescent Idiopathic Scoliosis:

12. Limited but growing applications
13. Anterior endoscopic release techniques
14. Navigation-guided instrumentation

15. Emerging evidence base

16. Limitations and Considerations:

17. Restricted ability to perform three-column osteotomies
18. Challenges in rod contouring and insertion
19. Limited fusion surface area
20. Careful patient selection remains critical

While not applicable to all deformity cases, minimally invasive and hybrid techniques have expanded options for patients who might not tolerate traditional open deformity correction.

Comparative Effectiveness and Outcomes

Perioperative Outcomes

Multiple studies have demonstrated perioperative advantages of minimally invasive approaches:

1. Blood Loss:
2. Consistently reduced across procedure types
3. Particularly significant in multilevel procedures
4. Reduced transfusion requirements

5. Potential for reduced surgical site infections

6. Length of Stay:

7. Shorter hospitalization compared to open equivalents
8. Increased outpatient procedure potential
9. Earlier mobilization and rehabilitation

10. Reduced resource utilization

11. Pain and Narcotic Use:

12. Reduced early postoperative pain scores
13. Decreased narcotic requirements
14. Earlier transition to oral pain management

15. Potential for enhanced recovery protocols

16. Complication Profiles:

17. Reduced wound complications
18. Decreased infection rates
19. Lower incidence of approach-related morbidity
20. Potential for unique complications specific to MIS techniques

These perioperative advantages have been consistently demonstrated across multiple studies and represent the most well-established benefits of minimally invasive spine surgery.

Long-Term Clinical Outcomes

The evidence regarding long-term outcomes continues to evolve:

1. Funkční výsledky:
2. Generally equivalent to open procedures at 2+ years
3. Some studies suggest faster early recovery
4. Similar improvements in quality of life measures

5. Comparable return to work rates

6. Radiographic Outcomes:

7. Similar fusion rates with modern techniques
8. Equivalent correction of focal deformity
9. Comparable maintenance of correction

10. Some techniques may have unique subsidence profiles

11. Adjacent Segment Effects:

12. Theoretical advantages for reduced adjacent segment degeneration
13. Limited long-term comparative data
14. Potential benefits from reduced muscle denervation

15. Preservation of posterior tension band in some techniques

16. Reoperation Rates:

17. Generally comparable to open procedures
18. Technique-specific considerations for certain pathologies
19. Learning curve effects in early studies
20. Improved with modern techniques and technology

While early studies of minimally invasive techniques sometimes showed inferior results compared to open procedures, contemporary techniques with modern instrumentation have generally demonstrated equivalence in long-term outcomes.

Ekonomické aspekty

The economic impact of minimally invasive spine surgery is complex:

1. Initial Procedure Costs:
2. Often higher implant and technology costs
3. Potentially longer operative times, especially during learning curve
4. Požadavky na specializované vybavení

5. Higher capital investment for facilities

6. Hospitalization Costs:

7. Reduced length of stay
8. Decreased ICU utilization
9. Lower complication-related costs

10. Increased outpatient procedure potential

11. Societal Costs:

12. Earlier return to work and activities
13. Reduced lost productivity
14. Decreased caregiver burden

15. Potential for reduced disability claims

16. Value-Based Considerations:

17. Improved cost-effectiveness with experience
18. Potential for enhanced recovery protocols
19. Bundled payment implications
20. Quality-adjusted life year analyses

The overall economic impact varies by procedure type, patient population, and healthcare system, with increasing evidence supporting the cost-effectiveness of minimally invasive approaches when considering the total episode of care.

Challenges and Future Directions

Úvahy o křivce učení

The learning curve represents a significant challenge in minimally invasive spine surgery:

1. Procedure-Specific Learning Curves:
2. Varies by technique (20-50+ cases for proficiency)
3. Steeper for more complex procedures
4. Impact on complication rates and outcomes

5. Ethical considerations for implementation

6. Přístupy k odborné přípravě:

7. Cadaver and simulation-based training
8. Mentorship and proctoring models
9. Case selection progression

10. Institutional volume considerations

11. Technology Adoption:

12. Navigation and robotics may flatten some learning curves
13. New technologies introduce their own learning requirements
14. Balancing innovation with patient safety

15. Institutional support requirements

16. Mitigation Strategies:

17. Structured training pathways
18. Careful patient selection during early experience
19. Conversion criteria and bailout strategies
20. Outcomes monitoring and quality improvement

Addressing learning curve challenges through structured training and appropriate technology adoption is critical for the safe implementation and continued advancement of minimally invasive spine techniques.

Technological Frontiers

Several emerging technologies promise to further advance minimally invasive spine surgery:

1. Advanced Robotics:
2. Active rather than passive systems
3. Haptic feedback integration
4. Automated trajectory correction

5. Reduced radiation exposure

6. Augmented Reality:

7. Real-time anatomical overlays
8. Integration with navigation systems
9. Heads-up display technologies

10. Enhanced visualization of critical structures

11. Artificial Intelligence Applications:

12. Automated surgical planning
13. Intraoperative decision support
14. Predictive analytics for outcomes

15. Quality control and standardization

16. Novel Biologics and Materials:

17. Enhanced fusion technologies
18. Surface-modified implants
19. Biodegradable and bioactive materials
20. Přístupy tkáňového inženýrství

These technological frontiers have the potential to address many of the remaining limitations of current minimally invasive spine techniques.

Expanding Indications

The scope of minimally invasive spine surgery continues to expand:

1. Complex Deformity:
2. Hybrid techniques for severe deformity
3. Minimally invasive three-column osteotomies
4. Circumferential minimally invasive approaches

5. Integration with navigation and robotics

6. Pediatrické aplikace:

7. Growing rod technologies
8. Minimally invasive scoliosis correction
9. Reduced approach-related morbidity

10. Preservation of growth potential

11. Revision Surgery:

12. Specialized techniques for previously operated spines
13. Minimally invasive approaches to pseudarthrosis
14. Management of adjacent segment disease

15. Implant removal and replacement strategies

16. Osteoporotic Spine:

17. Augmented fixation techniques
18. Expandable implant technologies
19. Reduced approach-related morbidity
20. Integration with vertebral augmentation

Continued refinement of techniques and technology will likely further expand the indications for minimally invasive approaches across the spectrum of spinal pathologies.

Evidence Development

The evidence base for minimally invasive spine surgery continues to evolve:

1. Randomized Controlled Trials:
2. Increasing number of high-quality studies
3. Longer-term follow-up data
4. Procedure-specific outcome measures

5. Patient-reported outcome emphasis

6. Registry Data:

7. Large-scale, multicenter registries
8. Real-world effectiveness data
9. Identification of rare complications

10. Subgroup analyses for optimized patient selection

11. Srovnávací výzkum účinnosti:

12. Srovnání technik Head-to-head
13. Analýzy nákladové efektivity
14. Kvalita života a funkční výsledky

15. Return to work and productivity measures

16. Patient Selection Refinement:

17. Predictive models for optimal outcomes
18. Nástroje pro stratifikaci rizika
19. Shared decision-making approaches
20. Personalized medicine applications

Continued development of high-quality evidence will be essential for defining the optimal applications of various minimally invasive techniques across different patient populations and pathologies.

Závěr

Minimally invasive spine surgery has evolved from a limited set of procedures for specific indications to a comprehensive approach applicable to a wide range of spinal pathologies. The development of specialized instrumentation, enhanced visualization systems, and refined surgical approaches has expanded the applications of MISS across degenerative, traumatic, oncologic, and increasingly, deformity conditions affecting the spine.

The evidence base supporting minimally invasive techniques continues to grow, with multiple studies demonstrating reduced perioperative morbidity while maintaining equivalent long-term outcomes compared to traditional open approaches. Challenges remain, particularly related to learning curves, technology adoption, and the need for continued refinement of techniques for complex pathologies.

As technology continues to advance and surgical experience grows, the field of minimally invasive spine surgery is likely to further expand, potentially becoming the standard approach for many spinal conditions. The integration of robotics, navigation, augmented reality, and artificial intelligence promises to address many of the current limitations while further enhancing the precision and consistency of these techniques.

The ultimate goal remains unchanged: to achieve optimal clinical outcomes while minimizing collateral tissue trauma and accelerating patient recovery. Minimally invasive spine surgery represents a significant step toward this goal, offering patients effective treatment options with reduced perioperative morbidity across an expanding range of spinal pathologies.