Awake Robotic Minimally Invasive L4-5 Transforaminal Lumbar Interbody Fusion

This video describes an awake robotic minimally invasive transforaminal lumbar interbody fusion (TLIF). Minimally invasive spine surgery leads to reduced perioperative morbidity while accelerating recovery by limiting soft tissue damage, blood loss, and postoperative pain. Robotic guidance systems have recently emerged to increase accuracy of instrumentation placement, reduce radiation burden, and enhance surgical ergonomics. The benefits of awake spine surgery, under spinal anesthesia, include decreased operative time, less postoperative opioid usage, decreased time to reemergence compared to general anesthesia, and also better patient satisfaction. In this video we present a case of a 78-year-old female with intractable lower back and right leg pain. Lumbar magnetic resonance imaging revealed a grade I anterolisthesis of L4 on L5 with severe spinal canal stenosis. Given that the patient failed conservative measures, and considering that she had severe nausea and delirium after general anesthesia, she was offered an awake L4-5 robotic TLIF using the Mazor X robotic guidance system (Medtronic, Minneapolis, Minnesota, USA) (Video 1). We document the first awake robotic TLIF in the literature. This video describes how to efficiently insert robotic techniques into the awake spine workflow.^1,2.