Minimally invasive spine surgery with endoscopy, navigation, robotics, and artificial intelligence: Clinical evidence and future directions

Abstract

In recent years, minimally invasive spine surgery (MISS) has advanced rapidly in both technological capability and clinical adoption. By leveraging endoscopic visualization, minimally invasive working corridors, image-guided navigation, and robot-assisted instrumentation, MISS aims to achieve adequate decompression and stabilization while minimizing iatrogenic soft-tissue disruption and enhancing intraoperative accuracy and safety. This systematic critical review synthesizes contemporary innovations in MISS, including high-definition and three-dimensional endoscopy, intraoperative computed tomography/three-dimensional fluoroscopy-based navigation, and intelligent surgical instruments, and rigorously appraises clinical evidence across common spinal disorders (degenerative disc disease, spinal stenosis, deformity) and complex pathologies (tumors, infections). A structured literature search (2013-2023) adhering to PRISMA guidelines was conducted to identify randomized controlled trials, cohort studies, and systematic reviews/meta-analyses. Available data generally support meaningful perioperative advantages over conventional open surgery, including reduced blood loss, less postoperative pain, shorter hospitalization, faster functional recovery, and lower complication rates in appropriately selected patients, with expanding indications as techniques mature. However, these benefits are contextual, heterogeneity in surgeon experience, case complexity, and technology readiness influence outcomes. Key limitations include a steep learning curve, imaging-related radiation exposure, cost considerations, and ongoing debates regarding long-term effectiveness in multilevel disease or deformity correction. Future progress will depend on artificial intelligence-assisted planning/navigation, augmented visualization, personalized implants, and emerging biomaterials, alongside standardized training and high-quality prospective studies to define value, safety, and durable outcomes. Critical appraisal of evidence strength (GRADE system) and risk of bias (Cochrane Tool, Newcastle-Ottawa Scale) highlights where data remain inconclusive, emphasizing the need for targeted pragmatic randomized controlled trials and standardized outcome reporting.