Neurosurg Rev

DOI 10.1007/s10143-014-0565-3

REVIEW

Minimally invasive spine surgery: systematic review

Péter Banczerowski & Gábor Czigléczki & Zoltán Papp &
Róbert Veres & Harry Zvi Rappaport & János Vajda

Received: 20 May 2013 / Revised: 10 April 2014 / Accepted: 18 May 2014

# Springer-Verlag Berlin Heidelberg 2014

Abstract Minimally invasive procedures in spine surgery Abbreviations

have undergone significant development in recent times. ALIF Anterior lumbar interbody fusion
These procedures have the common aim of avoiding biome- BLBD Bilateral laminotomy for bilateral decompression
chanical complications associated with some traditional de- DLIF Direct lateral interbody fusion
structive methods and improving efficacy. These new tech- MED Microendoscopic discectomy
niques prevent damage to crucial posterior stabilizers and miPLIF Minimally invasive posterior lumbar interbody
preserve the structural integrity and stability of the spine. fusion
The wide variety of reported minimally invasive methods MISST Minimally invasive spine surgery technique
for different pathologies necessitates a systematic classifica- miTLIF Minimally invasive transforaminal lumbar
tion. In the present review, authors first provide a classification interbody fusion
system of minimally invasive techniques based on the location PED Percutaneous endoscopic discectomy
of the pathologic lesion to be treated, to help the surgeon in PEEK Poly-Ether-Ether-Ketone
selecting the appropriate procedure. Minimally invasive tech- PLDD Percutaneous laser disc decompression
niques are then described in detail, including technical fea- PLIF Posterior lumbar interbody fusion
tures, advantages, complications, and clinical outcomes, based TLIF Transforaminal lumbar interbody fusion
on available literature. ULBD Unilateral laminotomy for bilateral decompression
XLIF Extreme lateral interbody fusion
Keywords Minimally invasive . Spine surgery . Surgical
approach . Endoscopic procedure . Percutaneous technique .
Interspinous device . Interbody fusion Introduction

Various minimally invasive spine surgery techniques

P. Banczerowski (*) : Z. Papp : R. Veres : J. Vajda
National Institute of Neurosurgery, Amerikai út 57, Budapest 1145,
Hungary
e-mail: bancpet@gmail.com
P. Banczerowski
e-mail: banczerowski.peter@med.semmelweis-univ.hu
P. Banczerowski : G. Czigléczki
Department of Neurosurgery, Faculty of Medicine,
Semmelweis University, Budapest, Hungary
H. Z. Rappaport
Department of Neurosurgery, Rabin Medical Centre,
Tel Aviv University, Petah Tiqva, Israel
(MISSTs) have been developed recently with the aim of
improving clinical outcomes as opposed to traditional proce-
dures. MISSTs have no universally accepted definition, but all
of these techniques aim to reduce iatrogenic complications
and postoperative pain, promote faster recovery, and allow
patients an earlier return to their normal daily activities.
Further benefits include reduction of operative blood loss,
shortening of hospital stay, reduced need for analgesics, small-
er incisions, and preservation of posterior motion segments
and paraspinal muscles. Several MISSTs have been intro-
duced recently.
The purpose of this article is to provide an overview of
MISSTs, including technical aspects, advantages, complications,
and clinical outcomes. The review is divided into two parts.

In the first part, a classification of the different surgical
methods is presented with the aim of helping the surgeon in
selecting the appropriate minimally invasive procedure based
on the location topography of the pathology in the spinal
canal. This classification system can be applied in the daily
routine of spine surgery.
In the second part, individual MISSTs are defined and
described, focusing on the main elements and the instrumen-
tation of the procedures. Furthermore, clinical efficacy is
analysed based on available literature.
Part 1: classification of surgical techniques
A classification system [10] was introduced, which pairs
various intraspinal pathologic lesions, taking into account
their location topography relative to the spinal cord, with the
appropriate MISST. Lesions within the spinal canal may be
segmental or longitudinal to the spinal levels and axial or
lateral relative to the spinal cord. Four types of lesion locations
are defined in the classification system (Fig. 1): segmental-
lateral (e.g. meningioma or neurinoma), segmental-axial (e.g.
intramedullary cavernous haemangiomas), longitudinal-axial
(e.g. intramedullary astrocytoma or ependymoma), and
longitudinal-lateral (e.g. metastatic epidural tumour). Table 1
summarizes these lesion location categories paired with the
most appropriate surgical procedures.
Surgical techniques for lesions with segmental-lateral location
Hemi-semi laminectomy (partial hemilaminectomy)
The technique of hemi-semi laminectomy (partial
hemilaminectomy) (Fig. 2a) was developed for the removal
of space-occupying lesions within the spinal canal, while
preserving dorsal bone structures and the bone-muscle-
ligament complex. The preservation of spinal integrity pre-
vents the development of instability of the spinal column.
Hemilaminectomy and hemi-semi laminectomy are mainly
used to remove unilateral, intradural (e.g. meningioma,
neurinoma), or extradural (e.g. epidural haematoma, abscess)
pathologic lesions.
Technical features [7, 130] Patients are placed in the prone
position. After the determination of the spinal level with an
image intensifier, a midline or paramidline incision is made
according to the location of the lesion. Paraspinal muscles are
dissected and retracted. The upper and lower arches of the
laminae are drilled off partially. If the laminae remain intact,
the method is known as hemi-semi laminectomy. If the lam-
inae are transsected, it is known as hemilaminectomy. When
needed, the hemi-semi laminectomy approach can and should
be extended to a hemilaminectomy. For a wider surgical view,
Neurosurg Rev
the base of the spinous process and the medial parts of the
articular process may be removed or the intraspinal space can
be exposed by performing further adjacent fenestrations. The
interspinous ligaments are left intact. In case of intradural
lesions, the dura is longitudinally incised. After the removal
of all pathologic tissue, the dura, fascia, and skin are closed in
standard fashion.
Although hemilaminectomy is considered to be a safe and
effective procedure [108], hemi-semi laminectomy (partial
hemilaminectomy) offers further advantages [7, 65, 130]:
superior preservation of spinal integrity and fewer negative
consequences in the event the level is misjudged. It is also
more advantageous if re-operation becomes necessary [7]. If a
segmental lesion is not explored at the right level, secondary
hemi-semi laminectomies are considerably less invasive than
secondary hemilaminectomies. If the need for re-
exploration emerges, it is considerably easier and safer
to find the dural surface if part of the bony lamina
remains in place. The method is suitable for the opera-
tive treatment of intra- or extradural lesions at any seg-
ment of the spine [7, 71, 95, 130], even in pregnant
patients [42]. Clinical outcomes were excellent with re-
gard to the preservation of posterior spinal structures,
prevention of postoperative spinal instability or deformi-
ty, shorter hospital stay, and reduced operative blood loss
[7, 130, 132].
Modifications of hemi-semi laminectomy In case of patholo-
gies with intraforaminal components, supraforaminal burr
hole modification [9] (Fig. 2b) may be performed by making
an additional burr hole across the medial part of the facet joint
with an average diameter of 5–7 mm. This allows complete
removal of the lesion with the sparing of as much of the facet
as possible.
“Open-tunnel” modification [11] (Fig. 2c) may be used
to remove tumours with intra- and extraforaminal compo-
nents by exposing intraforaminal components from the
inside of the spinal canal with hemi-semi laminectomy
and from the outside with the partial removal of the lateral
part of the facet joint. The outlet of the neuroforamen is
opened, and tumour removal becomes possible from both
ends of the opened “tunnel” while sparing most of the
facet joint.
Unilateral and bilateral laminotomy for bilateral
decompression (ULBD or “over the top” decompression,
BLBD) of lumbar spinal stenosis
The standard surgical procedures used in the treatment of
degenerative thoracic and lumbar spinal stenosis often result-
ed in the destruction or dysfunction of facet joints, disruption
of the interspinous/supraspinous ligament complex, and strip-
ping of paraspinal muscles, leading to segment instability.
Neurosurg Rev

Fig. 1 Various pathologies

classified according to location
(see also Table 1)

ULBD (Fig. 3) and BLBD are MISSTs, which maintain the decompression of neural structures located in the spinal canal
integrity and stability of the spine, provide sufficient and may be used in the lumbar and thoracic regions.

Table 1 Classification system

based on lesion location Lateral Axial

Segmental • Hemi-semi laminectomy • Hemi-semi laminectomy

• Supraforaminal burr hole technique • [Split laminotomy]
• “Open-tunnel” technique • Unilateral and bilateral laminotomy
• Unilateral and bilateral laminotomy for for bilateral decompression
bilateral decompression
• Posterior foraminotomy with tubular retractor
assistance
• Transuncal and transcorporeal anterior
microforaminotomy
Longitudinal • Multilevel hemi-semi laminectomy • Split laminotomy (+ “archbone” technique)
• Para-split laminotomy
 Neurosurg Rev

Fig. 2 Pathologies with

segmental-lateral location
(and foraminal or extraforaminal
spreading) and appropriate
surgical approaches. A Hemi-
semi laminectomy (partial
hemilaminectomy, interlaminar
fenestration). B Supraforaminal
burr hole approach. C “Open-
tunnel” (partial lateral
facetectomy) approach

Technical features [6, 115, 116] Patients are placed in the
prone position. Unilateral approach is used from the side with
the more pronounced stenosis. Decompression is achieved by
the partial medial resection of adjacent facets and of the small
medial portion of the base of the spinous process, the partial
resection of the upper and lower part of the laminar arch, and
the complete removal of the ligamentum flavum. The contra-
lateral ligamentum flavum and the medial portion of the
contralateral facet are also removed for contralateral decom-
pression. This process allows visualization of the contralateral
nerve root and foramen. If necessary, discectomy and
foraminotomy may also be performed. Bilateral approach
can be used in case of a complicated anatomical situation or
if bilateral decompression cannot be achieved via a unilateral
approach. The surgical steps are similar to those described
above, with the exception of the bilateral approach [34].

Fig. 3 Postoperative three-

dimensional reconstruction and
axial CT scans showing unilateral
laminotomy for bilateral
decompression of lumbar spinal
stenosis
Neurosurg Rev
ULBD is a safe technique with long-term effectiveness
for the treatment of spinal stenosis [24, 88], even in high-
risk patients with multilevel stenosis [93]. Complications
are few and include dural tear, nerve root injury, and the
necessity of re-operation [27]. This approach demonstrates
the extent of navigation possible within the spinal canal; it
is even adaptable to the resection of extramedullary-
intradural spinal tumours [40]. To fulfil the requirements
of a MISST, bilateral decompression via unilateral approach
exists in a full-endoscopic setup as well, which offers
benefits in terms of complications, traumatization, and re-
habilitation [67].
When comparing ULBD to BLBD, operative time was
significantly shorter and operative blood loss and the rate of
postoperative radiographic instability were lower [44]. On the
other hand, some studies revealed the advantage of BLBD
over ULBD in outcome parameters [120]. Other clinical and
radiologic findings showed no difference between the two
surgical procedures, and neither approach was associated with
an increased dynamic slip during flexion-extension motion
[87]. However, an increase in the risk of slippage was ob-
served in patients who demonstrated sagittal motion associat-
ed with spondylolisthesis and who were treated via the uni-
lateral approach [50]. Despite these controversies, both tech-
niques led to the marked improvement of symptoms and
quality of life [27, 120].
Posterior foraminotomy with tubular retractor assistance
Posterior foraminotomy is an alternative surgical approach for
the treatment of lateral disc herniation, spinal stenosis, and
radiculopathy [49, 63, 127]. MISST with tubular retractor
assistance preserves spinal stability and may avoid the need
of prosthesis implantation [127]. It is used mainly in the
cervical region, but it may also be applied for thoracic and
lumbar surgery. Posterior approach prevents complications
associated with anterior procedures, such as vessel injury,
nerve root injury, oesophageal penetration, and adjacent seg-
ment disease [25, 63, 127].
Technical features [29, 63, 84, 127] Patients are placed in
the prone position, and a midline or paramidline inci-
sion is made after determination of spinal level.
Paraspinal muscles and tissues are carefully dilated to
allow for the placement of tubular dilators. The tubular
retractor is placed over the dilators and may be fixed (if
required) over the lamina-facet junction with a table-
mounted flexible arm. After removing the dilators, the
lateral mass of the lamina and the medial facet joint are
drilled off to create a surgical route for the removal of
the pathologic lesion with the aid of a surgical micro-
scope. The extent of resection depends on the size of
pathology. In case of spinal stenosis or disc herniation,
bony decompression or discectomy may be performed
through the foramen. Closure is made in standard
fashion.
The most common reported complications are dural tear,
cerebrospinal fluid leak, and postoperative neck discomfort
with painful muscular spasms [54, 127]. The complications of
tubular-assisted foraminotomy originate from the inability to
obtain adequate visualization, which may lead to inadequate
decompression or nerve injury [84]. Precise lesion location
can be determined and complications can be avoided with
three-dimensional visualization under the microscope [43].
Compared to traditional open procedures, no statistically
significant difference was found in intervention time or com-
plications, but analgesic need, hospital stay, blood loss, skin
incision size, and muscle injury were reduced as opposed to
standard procedures [63, 127]. Long-term outcomes showed
complete recovery and no instability in the operated cervical
segment [49, 129]. The keyhole approach offers an effective
treatment option and improves quality of life [49, 128, 129].
Transuncal and transcorporeal anterior microforaminotomy
Transuncal foraminotomy was developed as a new
MISST for the treatment of cervical radiculopathies.
To relieve a compressed nerve root by removing the
disc fragment, a hole is drilled through the base of the
uncinate process without disturbing most of the disc
tissue in the intervertebral space. The functional anato-
my of the motion segment remains preserved, and the
adjacent level disease followed by interbody fusion is
prevented [51, 73].
As a modification, the transcorporeal foraminotomy is
performed by drilling a hole through the inferolateral part of
the upper vertebral body to the lateral direction and down-
wards ending at the foraminal level of the disc below [52]. The
method may be suitable to preserve the lower end plate and
the medial wall of the transverse foramen [20]. The short-term
and long-term outcomes are also favourable, and there were
no major complications during the follow-up periods [19, 20].
Comparing the preserved disc height, spinal stability,
length of hospital stay, and patient satisfaction revealed that
the transcorporeal approach is more effective than the
transuncal approach [45].
Surgical techniques for lesions with an axial-longitudinal
location
Split laminotomy and the “archbone” technique
The multilevel spinous process splitting and distracting
laminotomy (Fig. 4) for the surgery of multilevel lesions
located in the spinal canal was developed for adults to explore
primarily intramedullary spinal pathologies with the aim of

Fig. 4 Intraoperative photograph
and illustrations showing the
appropriate approaches for
pathologies with longitudinal-
axial location. A Split laminotomy
approach. B “Para-split”
laminotomy approach, as a rescue
technique for split laminotomy
preservation of posterior structures and spine stability. The
technique is a slight modification of the multilevel split
laminotomy developed for children [13]. This method leaves
the muscle attachment intact and reduces postoperative com-
plications. It may be applied in the cervical region and in the
thoracic and lumbar regions as well. Furthermore, it may be
used in patients of all ages and the number of vertebral
segments involved in this surgical process is theoretically
unlimited.
Technical features [5, 8, 13] Patients are placed in the prone
position. In midline posterior approach, the skin, fascia, and
interspinous ligaments are incised. The interspinous ligaments
are dissected longitudinally, then the ligamentum flavum is
removed at the middle part to expose the midline epidural
space. The spinous processes are split in the midline with an
oscillating saw or craniotome and are then separated and
distracted with Cloward-type retractors. The retractors are
positioned precisely to the inner cortex of the vertebral arch
above the dura in the epidural space. It is important to use
gentle force when opening the retractor in order to prevent
fracture of the spinous process. After gradual distraction of the
bones, the dura space is exposed and intramedullary space-
occupying lesions located mainly in the midline can be re-
moved. The dura is sutured directly or, if necessary, duraplasty
is carried out with a liodural patch and fibrin glue. After
removal of the retractors, the spinous processes are also su-
tured directly to each other. If total resection of an
intramedullary tumour is not possible because of the lack of
recognizable cleavage (i.e. diffusely infiltrative tumours),
intraspinal space occupation can only be alleviated
Neurosurg Rev
temporarily. In this case, with the aim of moderate enlarge-
ment of the spinal canal, bony decompression is achieved by
placing a tricortical iliac bone graft between the bony parts
facing each other. Data in the literature indicate that tricortical
iliac grafts may lead to complications such as pain at the donor
site and infections. To reduce complications and surgery time
(graft removal), PEEK (Poly-Ether-Ether-Ketone, Solis
Cervical Cage, Stryker Spine SAS, Z.I. de Marticot, 33610,
Cestas, France) cages can also be applied (Fig. 5). In all cases,
precise insertion and continuous visual control are important
to avoid penetration of the grafts into the spinal canal. The
technique is similar to the placement of an “archstone” into the
arch of a vault in architecture, and thus, it was borrowed and
changed to “archbone” in surgery.
Banczerowski et al. [8] used the multilevel spinous process
splitting and distracting laminotomy technique with or without
complementary bone grafting in 19 adult patients with various
pathologies located in the spinal canal. The approach used did
not affect the extent of resection or neurological outcome. No
sign of spinal instability or deformation was observed during
follow-up. Papp et al. [94] also operated on 38 patients (in-
cluding the previous cohort of patients) with this method. The
incidence of postoperative local pain was lower and early
mobilization was possible resulting in shorter hospital stay.
Spinal instability was not observed in the follow-up period.
Para-split laminotomy [92] (Fig. 4b) is a modification of
split laminotomy, where the opening of the spinal canal is in
the parasagittal plane. It is used in complicated anatomical
situations (thin, immature, or osteoporotic spinous process-
es), where midline splitting and opening of spinal canal is
not feasible.
Neurosurg Rev
Fig. 5 Intraoperative photograph
and illustration showing the
“archbone” technique. Distracted
spinous process and
complementary PEEK cage
between the facing bony parts
resulting in moderate enlargement
of the spinal canal
Kota Watanabe et al. [125] described a variation of the
spinous process splitting laminotomy technique for the treat-
ment of lumbar canal stenosis where the L4 spinous process is
split longitudinally in the midline and then divided from the
L4 posterior arch, leaving the paraspinal muscles attached to
the bony elements. A randomized controlled study showed
that acute postoperative wound pain was decreased and post-
operative muscle atrophy was prevented by this procedure
compared with conventional laminectomy [126]. Kim K.
et al. [62] examined the effect of spinous process splitting
methods on postoperative paraspinal muscle damage and
found it less invasive compared to the technique of bilateral
decompression via hemilaminectomy.
As another variation of the spinous process splitting
laminotomy technique, the “Marmot operation” was intro-
duced for the treatment of degenerative lumbar spinal ste-
nosis. With this procedure, muscular trauma is also mini-
mized, spinal stability is preserved, and hospital stay is
shortened [18].
Surgical techniques for lesions with a segmental-axial location
Hemi-semi laminectomy (partial hemilaminectomy) can be
recommended when the intramedullar pathology is positioned
in one segment and close to the interlaminar fenestration (e.g.
intramedullary cavernous haemangioma). Surgical explora-
tion allows visualization of the dorsal and dorsolateral parts
of the spinal cord and easy removal of the pathologic lesion.
Spinous process splitting laminotomy, the Watanabe and
Marmot technique in degenerative cases, and unilateral and
bilateral laminotomy for bilateral decompression (ULBD,
BLBD) may also be appropriate MISSTs for the treatment of
lesions with a segmental-axial location. The spinous process
splitting laminotomy for non-degenerative pathologies of the
segmental-axial location is more complicated and time-con-
suming. Surgical steps of these methods are described above
in detail.
Surgical techniques for lesions with a lateral-longitudinal
location
If the pathologic lesion is located in lateral-longitudinal or
dorsolateral-longitudinal positions with expansion involving
several segments, multiple hemi-semi laminectomy (partial
hemilaminectomy) may be the appropriate technique (Figs. 2
and 6). It provides better visualization of the lateral space of
the spinal canal, but the technique requires more surgical
routine. Surgical steps are described above in detail.
Part 2: minimally invasive instrumented techniques
Endoscopic techniques
Microendoscopic discectomy (MED) and METRx system As
an early endoscopic technique, MED (Fig. 7) was intro-
duced in 1997 [38, 98] as a MISST. Although this
method was successfully used for the treatment of disc
herniation, there were limitations such as a non-reusable
endoscope, inconsistent image quality, and limited work-
ing space. To address these limitations, the METRx
system (Medtronic Sofamor Danek, Memphis, TN,
USA) was developed, with the benefits of three-
dimensional visualization, improvement of image quality,
smaller endoscopic diameter, and larger surgical space
[90]. The method is adaptable to perform discectomy or

Fig. 6 Intraoperative photograph
and illustration showing the
appropriate approaches for
pathologies with longitudinal-
lateral location: multilevel hemi-
semi laminectomy (partial
hemilaminectomy, interlaminar
fenestration)
decompression in the cervical [57], thoracic [113], and
lumbar regions [98] of the spine.
Technical features [38, 90, 98] Patients are placed in the
prone position with flexed spine. Incision length is matched
to the diameter of the respective tubular retractor. The guide
wire is gently docked onto the bone under fluoroscopic guid-
ance to avoid inadequate positioning. The initial dilators are
placed on the lamina under fluoroscopy to dilate the
paraspinal musculature. The working channel is placed over
the final dilator and is fixed with a table-mounted flexible arm.
Fig. 7 Microendoscopic discectomy (MED) technique
Neurosurg Rev
The endoscope is inserted into the working channel. After
achieving appropriate visualization on the video monitor,
microdiscectomy or bony decompression can be performed.
Closure is made in standard fashion.
The advantages [35, 98] of endoscopic procedures
over open techniques include reduced tissue trauma, op-
erative time, recovery time, and risk of complications.
Furthermore, these methods allow better, direct visuali-
zation of the lesion, which is an element of successful
treatment; however, these procedures have a learning
curve [98, 107]. Long-term clinical outcomes are satis-
factory and significantly better than those achieved with
traditional methods [15, 124]. Reported complications
are rare [38, 98, 107] and include dural tear, neurological
damage, infection, and instrument malfunction. Several
MISSTs have a full-endoscopic variant [106, 122].
PED (percutaneous endoscopic discectomy) technique As a
full-endoscopic variant, percutaneous endoscopic discectomy
is considered to be a minimally invasive technique for the
treatment of disc herniation, especially in the lumbar spine
[82]. The procedure may be performed via transforaminal,
extraforaminal, and interlaminar approaches [21, 22, 75] and
under local or general anaesthesia. Its advantages over open
methods are similar to those mentioned before [35, 98].
Reported complications [1, 118] include dural tear, postoper-
ative dysaesthesia, haematoma, and visceral and S1 nerve
injury.
Neurosurg Rev
To avoid S1 nerve root injury, a new technique known
as sMED (small-incision microendoscopic discectomy)
was introduced. It mimics microendoscopic discectomy
and is a variation of PED. The S1 nerve root is safely
retracted medially and caudally, which allows treatment
of disc herniation without nerve root complication [31,
66].
If the herniated nucleus pulposus has migrated into the
hidden zone, traditional PED approaches cannot be used. In
these cases, PETA (percutaneous endoscopic translaminar
approach) can be applied, which is also a variation of PED.
In PETA, a bone hole is made above the hidden zone with a
high-speed drill and through this hole the pathologic disc can
be removed [30].
PLDD (percutaneous laser disc decompression) The proce-
dure is a treatment option for patients with different stage of
disc degeneration. Although it may be applied for all regions
of the spine, it is primarily used for the treatment of lumbar
lesions.
Technical features [23, 24, 39] Patients are placed in the
prone position with semiflexed spine under local anaes-
thesia. The entry point and the correct pathway are
determined with CT or fluoroscopy. After creating a
satisfactory pathway with a needle, an optical fibre is
inserted into the disc under fluoroscopic or CT guidance.
Discectomy is performed with laser energy to vaporize
the disc area. Due to heat generation or hyperpressure
caused by gas accumulation in the disc, pain may occur
during the procedure, so patients have to be able to
communicate and respond to pain [39]. Reducing pres-
sure with aspiration or increasing the interval between
pulses may alleviate the pain. At the end of the proce-
dure, closure is made in standard fashion.
The most common complications [39, 99] of PLDD in-
clude infection, postoperative back pain, or necessity of re-
operation, but these occur rarely. Its advantages [23, 24, 39]
are similar to those mentioned with other endoscopic proce-
dures. The percutaneous approach, instrumented guidance,
and performance under local anaesthesia contribute to the
safety and long-term efficacy of this technique [24]. A sys-
tematic review is available from Singh et al., which evaluates
the clinical effectiveness of percutaneous laser discectomies
[112].
Percutaneous pedicle screw fixation and the Sextant
technique
The long-lasting procedures and forceful retraction of
paraspinal muscles often resulted in ischemic necrosis, which
may have contributed to chronic back pain in
postlaminectomy syndrome [90]. Minimally invasive
percutaneous pedicle screw instrumentation methods were
developed to minimize muscle damage and to provide suffi-
cient fixation. These methods include, but are not limited to,
the Luxor, Mantis (Stryker Medical), and Sextant techniques.
In the present review, the arc-based system called Sextant
(Medtronic Sofamor Danek, Memphis, TN) is discussed in
detail [36] (Fig. 8).
Technical features of the Sextant technique [36, 90] Patients
are placed in the prone position, and small incisions are
made to place guiding wires and tubular retractors.
After the placement of screws, screw towers are coupled
and an arc system with a measuring device is connected
to them. The distal end of the arc system with a
perforating tip is used to make the subcutaneous path-
way. The required rod size is measured and then passed
through the pathway made previously to finish fixation.
Closure is performed in standard fashion. Other percu-
taneous pedicle screw stabilization methods follow more
or less the similar surgical steps as the Sextant tech-
nique by using standard instruments.
Advantages [37, 86, 103] of percutaneous pedicle screw
fixation techniques include reduced operation time, muscular
trauma and blood loss, quick recovery, favourable aesthetic
outcome with small incisions, and sparing of posterior ele-
ments with effective posterior stabilization of the thoracic and
lumbar spine. However, the use of these equipments has a
learning curve [86]. The Sextant technique is also a safe
procedure for posterior fixation, shares the same advantages
mentioned above, and fulfils the requirements of MISSTs [36,
37].
Interspinous devices and X-STOP technique
Although a discussion on interspinous devices should be
included in a review of MISSTs, their use remains controver-
sial. The most common indication of interspinous devices is
Fig. 8 Percutaneous pedicle screw fixation and Sextant technique

back pain and neurogenic claudication caused by foraminal
stenosis. X-STOP, StenoFix (DePuy Synthes), DIAM and
APERIUS (Medtronic Sofamor Danek) and Coflex
(Paradigm Spine) are some of the known interspinous devices.
T h e X - STO P te ch n i q u e ( S t . F r a n ce s Me d i ca l
Technologies, Inc.) was approved for the treatment of the
lumbar region in elderly patients who are not candidates for
traditional surgical treatment due to comorbidities. Patient
selection is performed according to a criterion system [17,
68, 69, 90]. Advantages of the X-STOP technique include
shorter operation time, improved sagittal balance of the spine
[109], increased foraminal diameter [102, 111], and the pos-
sibility of implant removal in the event of complications [90].
The most common reported complications are device dis-
lodgement and spinous process fracture [14, 58, 90], which
occur mainly in patients with spondylolisthesis or osteoporo-
sis [58]. With optimal patient selection, the X-STOP technique
may constitute a clinically effective and radiologically viable
method and can improve quality of life [17, 48, 68].
On the other hand, Epstein [32] reviewed the literature of
interspinous devices and found high rates of complications
and reoperations, poor outcomes, and high costs in patients
over the age of 50 years. Based on these data, the author
questioned the safety and effectiveness of interspinous devices
and recommended a re-evaluation of their use.
Interbody fusion techniques
Laparoscopic anterior lumbar interbody fusion (laparoscopic
ALIF) Minimally invasive laparoscopic ALIF is an appro-
priate option for the treatment of degenerative diseases
[80, 96, 134]. The technique is performed via a
transperitoneal approach while maintaining pneumoperi-
toneum and using an endoscope to enable adequate visu-
alization [80, 134]. Several types of cages are available to
create fusions, stabilize motion segments, and reconstruct
the anatomy of operated areas [133]. Reported complica-
tions include vascular, nerve, retroperitoneal, and perito-
neal injury; chyloperitoneum; ileus; pseudoarthrosis; and
adjacent segment disease [80, 96, 119, 134]. Long-term
clinical outcomes are satisfactory; however, low incidence
of adjacent segment disease has been reported [59]. After
a long learning curve, complications are reduced and
laparoscopic ALIF becomes a useful surgical alternative
even for the treatment of elderly patients, particularly if
additional percutaneous fixation is used [59, 80, 96, 134].
When comparing transforaminal lumbar interbody fusion
(TLIF) with ALIF, TLIF shows biomechanical advantages
over ALIF; on the other hand, blood loss, operative time,
and costs are less with ALIF [47, 53, 61]. Comparing ALIF
to posterior lumbar interbody fusion (PLIF), clinical outcomes
are similar, but ALIF may be preferable in the prevention of
adjacent segment disease [85] (Fig. 9).
Neurosurg Rev
Minimally invasive posterior lumbar interbody fusion
(miPLIF) The main indications [16, 56, 77] of the
miPLIF procedure include degenerative disc diseases
and spondylolisthesis. In this procedure [26, 56], the
lateral extent of the disc space is exposed using a
tubular retractor system (described at the METRx sys-
tem). Decompression, discectomy, and interbody fusion
with cages are carried out through the working channel.
Finally, a percutaneous pedicle screw system (described
at the Sextant technique) can be placed to stabilize the
segments. Advantages [16, 26, 56, 77] of this technique
include biomechanical advantages, shorter hospital stay,
and faster recovery rate. The most common complica-
tions [16, 26, 56, 89] are nerve injury, instability,
pseudoarthrosis, and adjacent segment disease. Long-
term outcomes are maintained and comparable with
open PLIF procedures; thus, miPLIF is considered to
be an effective alternative surgical option [16] (Fig. 9).
Minimally invasive transforaminal lumbar interbody fusion
(miTLIF) The miTLIF was introduced with the goal of
reducing complications of other interbody fusion tech-
niques and may be also adaptable for the treatment of
lumbar pathologies [70, 110]. The surgical procedure
[26, 70, 110] is similar to miPLIF, but with this method,
the lateral aspect of the spinous process, the lamina, and
the facet joint are exposed. In addition to biomechanical
advantages, reduced operative blood loss, shorter hospital
stay, faster rehabilitation, and cost-effectiveness have
been described [26, 41, 97, 123]. Main complications
are durotomy and infection, but no increased risk was
observed in elderly patients [70, 74, 110]. With respect
to long-term clinical outcomes [60, 105], miTLIF may
become a treatment option as effective as open ap-
proaches, but the technique has a learning curve [72].
The comparison [4, 26] of TLIF and PLIF techniques
shows similar effectiveness of the two surgical alterna-
tives. However, posterior integrity is better preserved
and radiological results are superior with the TLIF pro-
cedure (Fig. 9).
Lateral transpsoas approach: direct lateral interbody fusion
(DLIF) or extreme lateral interbody fusion
(XLIF) Spondylolisthesis, degenerative disc diseases,
and foraminal stenosis are considered to be the main
indications of the lateral transpsoas approach [2, 78, 81,
83, 91]. Lumbarized sacrum is a relative contraindication
of this method [114]. In lateral patient positioning, the
procedure is performed through the retroperitoneum and
psoas muscle under fluoroscopy guidance, using tubular
retractors [2, 78, 81, 83]. Neural monitoring is required
during surgery to prevent lumbosacral plexus injury,
which is the main complication of this method [46, 55].
Neurosurg Rev
Fig. 9 Axial view of lumbar
interbody fusion techniques and
directions of approaches
Additional reported complications are postoperative
radiculopathy, vessel injury, and pseudoarthrosis [2,
104]. A “safe corridor” was defined to avoid iatrogenic
injuries [101], and this improved the safety of this tech-
nique. The lateral transpsoas approach shares the same
advantages as other interbody fusion techniques [2, 78,
81, 83, 131] (Fig. 9). Long-term clinical and radiological
outcomes and fusion rates are satisfactory [131] and
render interbody fusion via a lateral transpsoas approach
an effective and popular surgical option [2, 78, 81, 83].
The axial or presacral approach, axiaLIF system The
axiaLIF system (TranS1, Inc.) is an alternative surgical
option in cases where traditional approaches are contra-
indicated [3, 28, 100]. The procedure may be applied for
the treatment of degenerative disc diseases, scoliosis,
spinal stenosis, and spondylolisthesis at the L4–S1 level
[12, 28, 100]. After a small perianal incision, the dissec-
tor and the tubular retractor are docked to the base of the
sacrum through the avascular presacral space, which is
followed by the surgery of pathology and screw inser-
tion. Additional posterior fixation can be applied with
pedicle or facet screws to stabilize the L4–S1 segments
[28, 100]. Biomechanical and anatomical advantages in-
clude sparing of neurovascular and posterior structures
[33, 100]. The main complications are pseudoarthrosis
and superficial infection [76, 100], but satisfactory mid-
term clinical outcomes prove the effectiveness of the
axiaLIF system [79, 121].
Discussion
Laminectomy remains the most common procedure for re-
moving spinal pathologic lesions [64, 117]. Multilevel
laminectomies that cause destruction of dorsal bony elements,
joints, and posterior ligaments may lead to spinal instability,
deformation, and other complications. The derangement of
normal anatomy and biomechanical structure and the damage
to paraspinal muscle attachments may both contribute to the
development of instability of posterior motion segments. In
order to prevent biomechanical and surgical complications,
the need for less invasive surgical techniques emerged world-
wide. These techniques aim to minimize derangement of the
normal spinal structure and to preserve as much bony ele-
ments and bone-muscle units as possible. The development of
minimally invasive procedures has accelerated during the last
two decades, characterized by technical advances in illumina-
tion, magnification, and instrumentation. Due to varying sur-
gical results and differences in reported methods, it is difficult
to define the exact place of each procedure and to state
whether a given technique is suitable for use in daily routine.
The purpose of this review was to provide a summary of
minimally invasive procedures within the framework of a
classification system and to describe individual techniques,
including detailed technical aspects.
In part 1, surgical methods are presented within the frame-
work of a classification system based on the location of
pathologic lesions (Table 1, Fig. 1). Hemi-semi laminectomy
(partial hemilaminectomy) and its variants are appropriate

methods for the removal of various types of segmental-lateral-
located pathologies with preservation of dorsal spinal stability.
Both unilateral and bilateral laminotomy for bilateral decom-
pression can be used for the treatment of spinal stenosis, with
good clinical outcomes. Foraminotomies with or without
modifications are alternative surgical approaches for the treat-
ment of disc herniations and tumours and for bony decom-
pression. Split laminotomy and its variant, para-split
laminotomy are mainly recommended for the removal of
longitudinal-axial located intraspinal lesions. Its “archbone”
modification enables the moderate enlargement of the spinal
canal.
In part 2, MISSTs involving different instruments are
discussed. Providing improved visualization and sufficient
surgical space, endoscopic techniques are appropriate
methods to perform discectomy or decompression at any level
of the spine. Percutaneous pedicle screw fixation (e.g.
Sextant) techniques minimize muscle damage and enable
sufficient stabilization of the spine. The use of interspinous
devices still remains controversial. Various minimally inva-
sive interbody fusion methods are commonly used in the
treatment of degenerative diseases. None of them is proved
to be superior to each other; however, some of them results in
better outcomes in some aspects. In general, benefits of in-
strumented methods are reduction of tissue trauma, recovery
time, and blood loss. Further benefits include low rate of
complications, favourable aesthetic outcome with small inci-
sions, and sparing of posterior elements with effective poste-
rior stabilization of the spine.
In summary, sufficient evidence is available for each
MISST to be used as a clinically effective treatment option.
In addition, MISSTs fulfil the basic principle of surgery:
“leaving the smallest footprint”.
Acknowledgments The authors are indebted to Zsófia Perjés M.D. for
the excellent illustrations.
Conflict of interest The authors report no conflict of interest
concerning the materials or methods used in this study or the findings
specified in this paper.
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Comments
Tamas Doczi, Pecs, Hungary
The goals of minimally invasive spine surgery are (1) to avoid
biomechanical complications inherent in traditional destructive tech-
niques and (2) to improve the efficacy of surgical management of various
spinal diseases. The purpose is aimed to be achieved by avoiding struc-
tural damage to crucial posterior stabilizing elements and by preserving
both anatomical integrity and stability of the spine. The aim of this
manuscript is to formulate a systematic classification of various minimal-
ly invasive methods previously reported that were applied for different
pathologies. The authors also claim that the manuscript shall help spinal
surgeons in the selection of the appropriate approach or procedure. To
achieve these goals, minimally invasive techniques have been described
in details including technical features, advantages, complications, and
clinical outcomes based on personal experience and available literature.
As an overview, it is not an original study in terms of setting first a
Neurosurg Rev
hypothesis then trying to prove or disprove the concept with facts and
figures that are based on either own data or on those collected from
literature search. It is a description of available surgical tech-
niques and creation of a system according to the authors’ personal
view. It is rather questionable whether the manuscript can really
help spinal surgeons in the selection of the appropriate procedure in an
individual case. As a trial of setting a nomenclature for spinal surgeons in
the field of minimally invasive surgery, this manuscript well deserves
publication.
Sandro M. Krieg, Bernhard Meyer, Munich, Germany
Nowadays, spine surgeons have a large armamentarium of procedures
and treatment options at hand, which also include various minimally
invasive procedures. It is therefore highly welcomed that the present
review offers not only an overview but also the recommendation for a
classification system of minimally invasive techniques. The targets of this
article are two different types of surgeons: experienced spine surgeons
who might get another view on some of their own surgical approaches
and junior surgeons who need a structured overview for daily decision-
making processes.
However, a very wide variety of approaches is presented and some
quantification concerning the frequency of use or applicability as well as
actual percentages of treatment success or complications seem desirable.
Moreover, the characterization and choice of references concerning en-
doscopic techniques are highly biased and do not mirror daily routine or
the current state of evidence. This accords also to laser techniques. More
critical statements from an evidence-based point of view would increase
the value of this article. Moreover, in the age of increasing use of posterior
dynamic stabilization by screw-rod systems, this option deserves at least
some notice in a systematic overview.