Ten-step technique for navigated tubular transforaminal and extraforaminal lumbar interbody fusion

Minimally invasive transforaminal lumbar interbody fusion (mTLIF) is an effective technique for treating degenerative lumbar spinal disorders that have failed nonoperative interventions and require fusion with or without decompression. mTLIF is technically challenging and requires significant experience with percutaneous instrumentation and microsurgical decompression techniques, which contributes to variability among surgeons and a challenging learning curve. Based on our extensive experience, we present a ten-step technique for performing mTLIF that integrates advanced technologies to enhance safety, efficiency, and reproducibility, and describe minimally invasive extraforaminal lumbar interbody fusion (mELIF), an intertransverse approach that serves as a valuable alternative-particularly in revision surgeries or cases with significant foraminal pathology-by minimizing dural exposure and reducing incidental tears. The objective is to present our experience and provide recommendations through detailed ten-step workflows for performing a total three-dimensional (3D) navigated tubular mTLIF and mELIF using expandable interbody cages and single-step navigated pedicle screws. We retrospectively reviewed our experience with mTLIF and mELIF procedures, based on a total of 350 cases, to develop step-by-step surgical techniques and workflows. These techniques were supplemented by illustrations and operative videos demonstrating the key steps. Our overview documents the key technical details for the reliable and reproducible performance of mTLIF and mELIF. Across 350 patients, complications occurred exclusively in the mTLIF cohort (2.1%), including cerebrospinal fluid (CSF) leak, wound infection, and hardware complications, with no neurological complications reported. Median hospital stay was shorter for mELIF (24 hours) compared to mTLIF (48 hours). Median follow-up time was 2.0 years. We present a comprehensive ten-step workflow for navigated mTLIF and mELIF. This workflow integrates three key features: (I) total 3D navigation, eliminating radiation exposure for the surgical team while minimizing radiation to the patient; (II) the use of expandable cages to enhance segmental lordosis; and (III) single-step navigated pedicle screws designed to streamline the surgical workflow. By providing clear and standardized workflows, we aim to support the education and training of surgeons, enabling consistent and safe outcomes.