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Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) Using O-Arm 3D Imaging, Navigation, and Robotic Guidance: A Step-by-Step Surgical Technique Paper

Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) Using O-Arm 3D Imaging, Navigation, and Robotic Guidance: A Step-by-Step Surgical Technique Paper

Dr Mirant Dave, Dr Bharat Dave, Dr Ajay Krishnan, Dr Shivanand Mayi, Dr Raviranjan Rai

Authors: Mirant Dave, Bharat Dave, Ajay Krishnan, Shivanand Mayi, Raviranjan Rai

Keywords:
MIS-TLIF; Minimally invasive spine surgery; Transforaminal lumbar interbody fusion; O-arm; Navigation; Robotic spine surgery; Pedicle screw fixation; StealthStation; Mazor

Abstract (Structured)

Background

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a widely accepted procedure for lumbar degenerative pathology requiring decompression and stabilization. The integration of intraoperative 3D imaging, navigation, and robotic guidance aims to improve accuracy, reduce radiation exposure, and enhance reproducibility.

Objective

To describe a standardized step-by-step technique of MIS-TLIF performed using O-arm 3D imaging, navigation (StealthStation), and robotic assistance (Mazor) with emphasis on operative workflow, technical pearls, and complication avoidance.

Technique Description

The technique includes patient positioning, robotic registration, navigated tubular docking, unilateral facetectomy and decompression, navigated discectomy and endplate preparation, navigated cage placement, and robotic-assisted pedicle screw insertion. Reduction maneuvers, rod delivery, compression, and closure are described.

Conclusion

MIS-TLIF performed with O-arm, navigation, and robotics is a safe and reproducible technique. It enables precise screw placement, reliable decompression, and optimized cage positioning while minimizing tissue trauma. Standardized workflow and disciplined execution remain critical to achieving consistent outcomes.

1. Introduction

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is an established technique for lumbar degenerative conditions such as spondylolisthesis, foraminal stenosis, recurrent disc herniation with instability, and degenerative disc disease. Compared to open TLIF, MIS-TLIF reduces paraspinal muscle injury, blood loss, and postoperative pain while maintaining comparable fusion and clinical outcomes.

Despite these advantages, MIS-TLIF is technically demanding due to limited working corridors, dependence on fluoroscopy, and steep learning curves for screw accuracy and cage placement. The adoption of intraoperative 3D imaging (O-arm), navigation systems, and robotic guidance has significantly improved surgical precision and workflow consistency.

This paper presents a step-by-step MIS-TLIF technique using O-arm, navigation (StealthStation), and robotic guidance (Mazor), focusing on operative setup, sequence, intraoperative decision points, and pearls/pitfalls.

2. Indications and Patient Selection

2.1 Indications

MIS-TLIF with navigated/robotic instrumentation is indicated for:

  • Grade I degenerative spondylolisthesis
  • Selected Grade II degenerative or isthmic spondylolisthesis
  • Foraminal stenosis with segmental instability
  • Lumbar canal stenosis with back pain and instability
  • Degenerative disc disease with mechanical pain refractory to conservative treatment
  • Recurrent disc herniation with instability
  • Adjacent segment degeneration requiring fusion

2.2 Contraindications (Relative)

  • High-grade spondylolisthesis (Grade III–IV)
  • Severe coronal/sagittal deformity requiring extensive correction
  • Infection or tumor requiring wide exposure
  • Severe osteoporosis with high risk of fixation failure
  • Inability to tolerate prone positioning

3. Preoperative Evaluation and Planning

All patients undergo:

  • Standing AP and lateral radiographs
  • Flexion-extension radiographs (instability assessment)
  • MRI to assess neural compression
  • CT scan in revision cases or when pars defects/pedicle anatomy are uncertain

Planning focuses on:

  • Operative level confirmation
  • Side of approach (usually symptomatic side)
  • Cage selection (banana vs bullet vs expandable)
  • Screw diameter/length and rod contour
  • Anticipation of reduction maneuvers

4. Operating Room Setup

4.1 Equipment

  • Radiolucent spine table (Jackson or equivalent)
  • O-arm intraoperative 3D imaging system
  • Navigation platform (StealthStation)
  • Robotic guidance system (Mazor)
  • Tubular retractor system (fixed or expandable)
  • High-speed burr and Kerrison punches
  • Navigated instruments (pointer, tap, awl, pedicle probe)
  • Percutaneous pedicle screw system compatible with navigation/robotics

4.2 Team Positioning

  • Surgeon and assistant stand on the working side
  • Scrub nurse positioned for easy access to navigated and tubular instruments
  • C-arm is generally not required except as backup
  • O-arm positioned for unobstructed spin and sterile draping

5. Surgical Technique (Step-by-Step)

5.1 Anesthesia and Positioning

  • General anesthesia with endotracheal intubation
  • Prone positioning on a radiolucent table
  • Abdomen free to reduce epidural venous pressure
  • Hips extended mildly to restore lumbar lordosis
  • Ensure symmetric positioning to avoid registration errors in navigation

Pearl: Final alignment is achieved before registration; repositioning after O-arm spin can reduce navigation accuracy.

5.2 Reference Frame Placement

A navigation reference frame is fixed:

  • Most commonly to the posterior superior iliac spine (PSIS) using a stab incision
  • Alternatively to a spinous process clamp in short-segment cases

Pearl: PSIS reference is stable and avoids interference with tubular docking.

5.3 O-Arm 3D Scan and Registration

  • The O-arm is brought in and a 3D spin is performed across the operative segment.
  • Navigation registration is confirmed using:
    • Spinous process
    • Lamina edge
    • Facet joint surface

Pearl: Accuracy is confirmed before any drilling or decompression begins.

5.4 Robotic Planning and Screw Trajectory Design

Using the robotic platform:

  • Pedicle screw trajectories are planned bilaterally
  • Screw size (diameter and length) is selected
  • Entry points and angulation are finalized

Pearl: Planning should account for reduction goals and rod delivery, not only screw accuracy.

5.5 Robotic-Assisted Percutaneous Pedicle Screw Placement

Screws may be placed either:

  • Before decompression/cage placement (stabilizes segment early), or
  • After interbody work (preferred by many surgeons for decompression access)

Technique:

  • Robotic arm positions at planned entry point.
  • Skin incision made at the robotic cannula.
  • Navigated drill/awl used to breach cortex.
  • Navigated pedicle probe advances through pedicle.
  • Tap and screw insertion performed under navigation.

Pearl: Navigation allows real-time depth control, reducing risk of anterior breach.

5.6 Tubular Docking (Navigated)

  • A paramedian incision is made typically 3–4 cm off midline.
  • The tubular system is docked on:
    • The facet joint complex
    • The junction of inferior articular process and superior articular process

Navigation is used to:

  • Confirm correct level
  • Confirm precise docking point
  • Maintain orientation during dilation

Pearl: Navigation reduces wrong-level risk and prevents medial drift.

5.7 Unilateral Facetectomy

Under microscope or loupe magnification:

  • Soft tissue is cleared from the facet capsule
  • Inferior articular process is drilled
  • Superior articular process is removed to expose foraminal region

A complete facetectomy provides:

  • Decompression
  • Disc space access
  • Graft source (local autograft)

5.8 Decompression

  • Ligamentum flavum is removed
  • Traversing nerve root is identified
  • Lateral recess decompression performed
  • Foraminal decompression performed, ensuring exiting root is free

Pitfall: Exiting root injury risk is higher in MIS-TLIF. Retraction must be minimal, intermittent, and performed with blunt nerve retractors.

5.9 Discectomy and Endplate Preparation

  • The annulus is incised and disc material removed.
  • Endplate preparation is performed using:
    • Curettes
    • Disc shavers
    • Pituitary rongeurs

Navigation can assist in:

  • Confirming disc orientation
  • Maintaining midline direction
  • Preventing overly aggressive endplate violation

Pearl: Complete cartilaginous removal with bony endplate preservation is essential for fusion and to reduce subsidence.

5.10 Grafting and Interbody Cage Insertion (Navigated)

  • Local bone from facetectomy is morselized and combined with:
    • Allograft or DBM (as per institutional preference)

Cage insertion:

  • Performed under navigation and/or O-arm guidance
  • Positioned in anterior-third of disc space
  • Cage ideally crosses midline

Pearl: Navigation improves confidence in cage placement without repeated fluoroscopy shots.

5.11 Rod Placement and Final Construct

  • Rods are delivered percutaneously
  • Set screws are applied
  • Compression is applied to restore lordosis
  • Final tightening performed

Reduction of spondylolisthesis is achieved via:

  • Sequential rod reduction
  • Compression across pedicle screws
  • Interbody cage acting as anterior column support

5.12 Confirmatory Imaging

  • A second O-arm spin is performed to confirm:
    • Screw position
    • Cage placement
    • Alignment
    • Absence of breach

This provides immediate opportunity for correction if required.

5.13 Closure

  • Tubular retractor removed slowly with hemostasis
  • Fascial closure performed
  • Subcutaneous closure
  • Skin closure with staples or subcuticular sutures
  • Drain is typically avoided unless significant oozing is noted

6. Postoperative Care

  • Early mobilization within 6–12 hours
  • Multimodal analgesia
  • DVT prophylaxis as per protocol
  • Discharge commonly within 24–48 hours
  • Follow-up radiographs at 6 weeks, 3 months, 6 months, and 1 year

7. Pearls and Pitfalls

Pearls:

  • Ensure final patient alignment before O-arm registration
  • Use PSIS reference for stable navigation
  • Confirm navigation accuracy before drilling
  • Dock on facet precisely to avoid medial drift
  • Perform complete facetectomy for safe cage corridor
  • Keep cage anterior to prevent migration
  • Use confirmatory O-arm scan before closure

Pitfalls:

  • Navigation drift if reference frame loosens
  • Wrong-level surgery if registration is inaccurate
  • Exiting nerve root injury due to retraction
  • Endplate violation leading to subsidence
  • Posterior cage placement causing radicular pain
  • Screw breach due to poor robotic arm stability or soft tissue pressure

8. Discussion

The use of O-arm 3D imaging, navigation, and robotic guidance has improved precision and reproducibility in MIS-TLIF. Robotic-assisted screw placement demonstrates high accuracy in multiple studies, reducing malposition rates compared to freehand and fluoroscopy-based methods. Navigation also reduces cumulative radiation exposure to the surgical team, as the need for continuous fluoroscopy is reduced.

From a workflow standpoint, robotics assists in planning and executing screw trajectories with minimal variability. Navigation improves confidence in tubular docking and cage placement, which are critical to preventing wrong-level surgery and cage malposition. Additionally, confirmatory O-arm imaging before closure enables immediate revision if a breach is detected, preventing postoperative neurological complications.

Despite technological assistance, MIS-TLIF remains technique-sensitive. Complications such as dural tears, exiting root injury, cage migration, and subsidence can still occur if surgical steps are rushed or if endplate preparation and cage placement are suboptimal.

9. Conclusion

MIS-TLIF using O-arm, navigation, and robotic guidance is a modern, accurate, and reproducible technique for lumbar degenerative disorders requiring fusion. It combines the advantages of minimally invasive muscle-splitting access with high-precision instrumentation. With disciplined workflow and adherence to technique principles, this approach offers excellent outcomes with reduced soft tissue trauma and improved intraoperative accuracy.

10. Ethics Statement

This manuscript describes a surgical technique. No patient-identifiable data is included. Institutional ethical approval is not required for technique description alone; however, ethical guidelines should be followed if clinical outcome data are added.

11. Conflict of Interest Statement

The authors declare no conflict of interest related to this manuscript.

12. Funding

No external funding was received for this work.

References

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  • Fan Y, et al. Robotic-assisted pedicle screw accuracy.
  • Lieberman IH, et al. Navigation and O-arm in spine surgery.
  • Hyun SJ, et al. Robotics in minimally invasive lumbar fusion.