Advancements in Minimally Invasive Lumbar Spine Surgery: Techniques and Outcomes

Minimally invasive techniques in lumbar spine surgery are at the forefront of driving better patient outcomes, though approach selection remains indication- and expertise-dependent, and open surgery is appropriate in select scenarios. Surgeons face challenging clinical decisions as endoscopic methods steadily gain ground against traditional microdiscectomy, and innovative stabilization techniques emerge, showcasing their potential to redefine surgical standards. We explore how decompression choices intersect with stabilization strategies and implant advances to shape outcomes.

Advances in endoscopic tools improve visualization and, alongside reduced tissue disruption and optimized perioperative protocols, are associated with shorter recovery. Comparative studies suggest endoscopic approaches are non-inferior for short-term pain relief, with similar ODI and VAS outcomes at 6–12 months. Recent studies report comparable outcomes between endoscopic and traditional microdiscectomy in certain domains, with similar ODI and VAS measures at 6–12 months in many analyses.

Reduced paraspinal muscle detachment and smaller laminotomy/less facet disruption can simplify procedures and support recovery, with potential implications for long-term outcomes. Biportal approaches offer enhanced visualization but are associated with a steeper learning curve and longer operative times during early adoption. These methods offer improved visualization and may increase calculated hidden blood loss, though this often does not affect transfusion rates, contrasting with less invasive uniportal techniques. Comparative research provides insight into their use, aiding surgeons in making informed choices based on patient needs and surgical goals.

Evidence from recent comparative studies points to less invasive options that maximize patient recovery while minimizing risk. Spinal osteotomies have been augmented through advanced pedicle subtraction osteotomies, particularly when addressing PI–LL mismatch and sagittal imbalance per established deformity criteria. The integration of these techniques with advanced fixation methods can improve construct stability in select complex cases—e.g., osteoporotic bone or multilevel constructs. Emerging reports on these procedures suggest potential to strengthen spinal stabilization, with signals in alignment correction and fusion durability described in early series. Innovative applications of these procedures are being explored, informing how surgeons refine stabilization strategies.

This evidence is transforming how surgeons approach lumbar spine interventions, including earlier mobilization/day-case pathways and reduced fluoroscopy through navigation. Key advancements in osseointegrative implants are associated with improved fusion rates and lower subsidence or revision risk in some studies, enhancing mechanical stability in appropriate contexts. The enhanced biological fixation of these implants is associated with higher fusion rates and lower subsidence versus some PEEK comparators in select studies, contributing to incremental improvements in care. Benefits vary by indication and learning curve, underscoring the importance of careful selection.

For patients enduring severe post-surgical pain, the move toward minimally invasive decompression and biologically integrative stabilization strategies can indicate a profound change in recovery and quality of life. The application of osseointegrative implants is pivotal, offering better fusion rates and durability, especially in complex spinal deformities. Such advances may yield meaningful improvements in the management of lumbar spine conditions when matched to patient phenotype, pathology, and surgeon expertise. Despite these advancements, achieving universal application of these methods remains a barrier due to learning curves, equipment needs, and perioperative pathway changes, pointing to the need for ongoing research and adaptation.

The diversity of patient conditions necessitates a personalized surgical strategy to ensure optimal outcomes, including selection between uniportal versus biportal endoscopy, thresholds for osteotomy, and implant surface technology.

Key Takeaways:

• Endoscopic techniques demonstrate non-inferior outcomes versus microdiscectomy with faster early recovery in some studies.
• Surgeons should weigh patient-specific factors when selecting between uniportal and biportal techniques, including visualization needs, potential differences in hidden blood loss, and learning curve or operative-time trade-offs.
• In cases such as fixed sagittal imbalance requiring multi-level fusion, advanced osteotomy techniques and osseointegrative implants can facilitate alignment correction and promote fusion.
• Ongoing adaptation will likely remain essential to maximize patient outcomes and integrate innovative approaches into standard practice.