A synopsis of current practices in minimally invasive surgery for adult spinal deformity


  • Aniruddh V. Agrawal Topiwala National Medical College, Lilavati Hospital, Mumbai, Maharashtra
  • Vinod A. Agrawal Consultant Orthopaedic Surgeon, Lilavati Hospital, Mumbai, Maharashtra
  • Adit A. Singhal Geisinger Commonwealth School of Medicine, Scranton, PA,
  • Adit Maniar Dr. Vasantrao Pawar Hospital and Research Centre, Nashik, Maharashtra




Adult deformity, Minimally invasive surgery, Review, TLIF, LLIF, ALIF


To provide a comprehensive summary of the status, indications and developments in the use of minimally invasive surgery in the field of adult spinal deformity. This study was performed by expert review of literature which has been published and is indexed on PubMed. The most appropriate and recent articles were selected to obtain a consolidation of information and knowledge on use and benefits of minimally invasive surgery in adult spinal deformity. Various MIS techniques have been developed to perform the complex ASD surgeries. These include the transforaminal lateral interbody fusion (TLIF), percutaneous segmental fixation as well as the lateral body interbody fusion (LLIF). It is important for a surgeon to obtain a holistic view of current literature and recommended guidelines on the procedures available for ASD surgeries. Overall, minimally invasive spine surgery has resulted in less use of pain medicine, less blood loss, lower infection rates, less requirement for intensive care, less hospitalization, reduction in physiologic stress, reduction in complication rates, reduction in muscle atrophy and preservation of normal motion with fusion rates being as high as 80-95%. More articles consolidating the vast literature on minimally invasive spine surgery need to be published to allow a surgeon to effectively weight the benefits and drawbacks of it. More research needs to be performed to compare the efficacy of sub-types of minimally invasive spine surgery.

Author Biography

Vinod A. Agrawal, Consultant Orthopaedic Surgeon, Lilavati Hospital, Mumbai, Maharashtra

Consultant Orthopedic Surgeon, Lillavati Hospital


Akinbo OC, Tu T-H, Ziewacz JE, Mummaneni PV. Classification Schema for Scoliosis. In: Wang YM, Lu Y, Anderson GD, Mummaneni VP, eds. Minimally Invasive Spinal Deformity Surgery: An Evolution of Modern Techniques. Vienna: Springer Vienna; 2014: 11-20.

Bridwell KH, Glassman S, Horton W, Shaffrey C, Schwab F, Zebala LP, et al. Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine. 2009;34(20):2171-8.

Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine. 2005;30(18):2024-9.

Lafage V, Bharucha NJ, Schwab F, Hart RA, Burton D, Boachie-Adjei O, et al. Multicenter validation of a formula predicting postoperative spinopelvic alignment. J Neurosurg Spine. 2012;16(1):15-21.

Lafage V, Schwab F, Patel A, Hawkinson N, Farcy JP. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine. 2009;34(17):599-606.

Mac-Thiong JM, Berthonnaud E, Dimar JR, 2nd, Betz RR, Labelle H. Sagittal alignment of the spine and pelvis during growth. Spine. 2004;29:1642-7.

Schwab F, Lafage V, Patel A, Farcy JP. Sagittal plane considerations and the pelvis in the adult patient Sagittal alignment of spine and pelvis regulated by pelvic incidence: standard values and prediction of lordosis. Spine. 2009;34:1828-33.

Boulay C, Tardieu C, Hecquet J, Benaim C, Mouilleseaux B, Marty C, et al. Sagittal alignment of spine and pelvis regulated by pelvic incidence: standard values and prediction of lordosis. Eur Spine J. 2006;15(4):415-22.

Skalli W, Zeller RD, Miladi L, Bourcereau G, Savidan M, Lavaste F, et al. Importance of pelvic compensation in posture and motion after posterior spinal fusion using CD instrumentation for idiopathic scoliosis. Spine. 2006;31:359-66.

Schwab F, Patel A, Ungar B, Farcy JP, Lafage V. Adult spinal deformity-postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery Importance of pelvic compensation in posture and motion after posterior spinal fusion using CD instrumentation for idiopathic scoliosis. Spine. 2010;35:2224-31.

Ames CP, Smith JS, Scheer JK, Bess S, Bederman SS, Deviren V, et al. Impact of spinopelvic alignment on decision making in deformity surgery in adults: A review. J Neurosurg Spine. 2012;16(6):547-64.

Berthonnaud E, Dimnet J, Roussouly P, Labelle H. Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spinal Disord Tech. 2005;18(1):40-7.

Roussouly P, Gollogly S, Berthonnaud E, Dimnet J. Classification of the normal variation in the sagittal alignment of the human lumbar spine and pelvis in the standing position. Spine. 2005;30(3):346-53.

Neal CJ, McClendon J, Halpin R, Acosta FL, Koski T, Ondra SL. Predicting ideal spinopelvic balance in adult spinal deformity. J Neurosurg Spine. 2011;15(1):82-91.

Cheng JS, Forbes J, Wong C, Perry E. The Epidemiology of Adult Spinal Deformity and the Aging Population. In: Wang YM, Lu Y, Anderson GD, Mummaneni VP, eds. Minimally Invasive Spinal Deformity Surgery: An Evolution of Modern Techniques. Vienna: Springer Vienna; 2014: 3-10.

Deyo RA, Mirza SK, Martin BI. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2011;306(10):1088.

EC B, WF L, AJ B, SA K. Anatomy of nerve root compression, nerve root tethering, and spinal instability spine surgery: techniques, complication avoidance, and management. 2nd Edition. Philadephia: Saunders elsevier; 2005.

Williams RW. Microcervical foraminotomy. A surgical alternative for intractable radicular pain. Spine. 1983;8(7):708-16.

de Loubresse CG, Bon T, Deburge A, Lassale B, Benoit M. Posterolateral fusion for radicular pain in isthmic spondylolisthesis. Clin Orthop Relat Res. 1996;323:194-201.

Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980;66(8):271-3.

Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613-9.

Schwab FJ, Bess S, Blondel B, Hostin R, Shaffrey CI, Smith JS, et al. Combined Assessment of Pelvic Tilt, Pelvic Incidence/Lumbar Lordosis Mismatch and Sagittal Vertical Axis Predicts Disability in Adult Spinal Deformity: A Prospective Analysis. Spine J Meeting Abstracts. 2011: 65.

Horton WC, Brown CW, Bridwell KH, Glassman SD, Suk SI, Cha CW. Is there an optimal patient stance for obtaining a lateral 36" radiograph? A critical comparison of three techniques. Spine. 2005;30:427-33.

Yadla S, Maltenfort MG, Ratliff JK, Harrop JS. Adult scoliosis surgery outcomes: a systematic review. Neurosurg Focus. 2010;28(3):3.

Schwab FJ, Hawkinson N, Lafage V, Smith JS, Hart R, Mundis G, et al. Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J. 2012;21(12):2603-10.

Mummaneni PV, Wang MY, Silva FE, et al. The MiSLAT Algorithm: Minimally Invasive Evaluation and Treatment for Adult Degenerative Deformity. In: Wang YM, Lu Y, Anderson GD, Mummaneni VP, eds. Minimally Invasive Spinal Deformity Surgery: An Evolution of Modern Techniques. Vienna: Springer Vienna; 2014: 67-74.

Park P, Wang MY, Lafage V, Nguyen S, Ziewacz J, Okonkwo DO, et al. Comparison of two minimally invasive surgery strategies to treat adult spinal deformity. J Neurosurg Spine. 2015;22(4):374-80.

Mundis G, Uribe JS, Mummaneni PV, Anand N. 172 A Critical Analysis of Sagittal Plane Deformity Correction With Minimally Invasive Surgery: A 2-Year Follow-up Study of Deformity Patients Categorized by the SRS-Schwab Classification. Neurosurgery. 2015;62:222-3.

Mummaneni PV, Shaffrey CI, Lenke LG, Park P, Wang MY, La Marca F, et al. The minimally invasive spinal deformity surgery algorithm: a reproducible rational framework for decision making in minimally invasive spinal deformity surgery. Neurosurg Focus. 2014;36(5):6.

Blume HG. Unilateral posterior lumbar interbody fusion: simplified dowel technique. Clin Orthop Relat Res. 1985;193:75-84.

Harms JG, Jeszenszky D. Die posteriore, lumbale, interkorporelle Fusion in unilateraler transforaminaler Technik. Oper Orthop Traumatol. 1998;10(2):90-102.

Kambin P. Arthroscopic microdiskectomy. Mt Sinai J Med. 1991;58(2):159-64.

Kambin P, Sampson S. Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res. 1986;207:37-43.

Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006;6(4):435-43.

Sharma AK, Kepler CK, Girardi FP, Cammisa FP, Huang RC, Sama AA. Lateral lumbar interbody fusion: clinical and radiographic outcomes at 1 year: a preliminary report. J Spinal Disord Tech. 2011;24(4):242-50.

Wang MY. Improvement of sagittal balance and lumbar lordosis following less invasive adult spinal deformity surgery with expandable cages and percutaneous instrumentation. J Neurosurg Spine. 2013;18(1):4-12.

Jagannathan J, Sansur CA, Oskouian RJ, Fu KM, Shaffrey CI. Radiographic restoration of lumbar alignment after transforaminal lumbar interbody fusion. Neurosurgery. 2009;64(5):955-63.

Yson SC, Santos ER, Sembrano JN, Polly DW. Segmental lumbar sagittal correction after bilateral transforaminal lumbar interbody fusion. J Neurosurg Spine. 2012;17(1):37-42.

Anand N, Hamilton JF, Perri B, Miraliakbar H, Goldstein T. Cantilever TLIF with structural allograft and RhBMP2 for correction and maintenance of segmental sagittal lordosis: long-term clinical, radiographic, and functional outcome. Spine. 2006;31(20):748-53.

Hioki A, Miyamoto K, Hosoe H, Sugiyama S, Suzuki N, Shimizu K. Cantilever transforaminal lumbar interbody fusion for upper lumbar degenerative diseases (minimum 2 years follow up). Yonsei Med J. 2011;52(2):314-21.

Ahmadian A, Bach K, Bolinger B, Malham GM, Okonkwo DO, Kanter AS, et al. Stand-alone minimally invasive lateral lumbar interbody fusion: multicenter clinical outcomes. J Clin Neurosci. 2015;22(4):740-6.

Eck JC, Hodges S, Humphreys SC. Minimally invasive lumbar spinal fusion. J Am Acad Orthop Surg. 2007;15(6):321-9.

Acosta FL, Liu J, Slimack N, Moller D, Fessler R, Koski T. Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. J Neurosurg Spine. 2011;15(1):92-6.

Karikari IO, Nimjee SM, Hardin CA, Hughes BD, Hodges TR, Mehta AI, et al. Extreme lateral interbody fusion approach for isolated thoracic and thoracolumbar spine diseases: initial clinical experience and early outcomes. J Spinal Disord Tech. 2011;24(6):368-75.

Akbarnia BA, Mundis GM, Moazzaz P, Kabirian N, Bagheri R, Eastlack RK, et al. Anterior column realignment (ACR) for focal kyphotic spinal deformity using a lateral transpsoas approach and ALL release. J Spinal Disord Tech. 2014;27(1):29-39.

Deukmedjian AR, Dakwar E, Ahmadian A, Smith DA, Uribe JS. Early outcomes of minimally invasive anterior longitudinal ligament release for correction of sagittal imbalance in patients with adult spinal deformity. Scientific World J. 2012;2012:789698.

Deukmedjian AR, Le TV, Baaj AA, Dakwar E, Smith DA, Uribe JS. Anterior longitudinal ligament release using the minimally invasive lateral retroperitoneal transpsoas approach: a cadaveric feasibility study and report of 4 clinical cases. J Neurosurg Spine. 2012;17(6):530-9.

Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg. 2002;97(1):7-12.

Anderson DG, Samartzis D, Shen FH, Tannoury C. Percutaneous instrumentation of the thoracic and lumbar spine. Orthop Clin North Am. 2007;38(3):401-8.

Anand N, Baron EM, Thaiyananthan G, Khalsa K, Goldstein TB. Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study. J Spinal Disord Tech. 2008;21(7):459-467.

Mobbs RJ, Sivabalan P, Li J. Technique, challenges and indications for percutaneous pedicle screw fixation. J Clin Neurosci. 2011;18(6):741-9.

Wang MY, Mummaneni PV, Fu KM, Williams S, Mummaneni PV, Sherman JD. Less invasive surgery for treating adult spinal deformities: ceiling effects for deformity correction with 3 different techniques. Neurosurg Focus. 2014;36(5):12.

Lowe T, Berven SH, Schwab FJ, Bridwell KH. The SRS classification for adult spinal deformity: building on the King/Moe and Lenke classification systems. Spine. 2006;31(19):119-25.

Smith JS, Klineberg E, Schwab F, Shaffrey CI, Moal B, Ames CP, et al. Change in classification grade by the SRS-Schwab Adult Spinal Deformity Classification predicts impact on health-related quality of life measures: prospective analysis of operative and nonoperative treatment. Spine. 2013;38(19):1663-71.

Uribe JS, Deukmedjian AR, Mummaneni PV, Fu KM, Mundis GM Jr, Okonkwo DO, et al. Complications in adult spinal deformity surgery: an analysis of minimally invasive, hybrid, and open surgical techniques. Neurosurg Focus. 2014;36(5):15.

Haque RM, Mundis GM, Ahmed Y, El Ahmadieh TY, Wang MY, Mummaneni PV, et al. Comparison of radiographic results after minimally invasive, hybrid, and open surgery for adult spinal deformity: a multicenter study of 184 patients. Neurosurg Focus. 2014;36(5):13.

Park P, La Marca F. Combined "hybrid" open and minimally invasive surgical correction of adult thoracolumbar scoliosis: a retrospective cohort study. Neurosurgery. 2013;72(2):151-9.

Wang MY, Mummaneni PV. Minimally invasive surgery for thoracolumbar spinal deformity: initial clinical experience with clinical and radiographic outcomes. Neurosurg Focus. 2010;28(3):9.

Wang J, Zhou Y, Feng Zhang Z, Qing Li C, Jie Zheng W, Liu J. Comparison of the clinical outcome in overweight or obese patients after minimally invasive versus open transforaminal lumbar interbody fusion. J Spinal Disord Tech. 2014;27(4):202-6.

Fessler RG, Khoo LT. Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience. Neurosurgery. 2002;51(5):37-45.

O'Toole JE, Sheikh H, Eichholz KM, Fessler RG, Perez-Cruet MJ. Endoscopic posterior cervical foraminotomy and discectomy. Neurosurg Clin N Am. 2006;17(4):411-22.

Khoo LT, Palmer S, Laich DT, Fessler RG. Minimally invasive percutaneous posterior lumbar interbody fusion. Neurosurgery. 2002;51(5):166-81.

Peng CW, Yue WM, Poh SY, Yeo W, Tan SB. Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion. Spine. 2009;34(13):1385-9.

O'Toole JE, Eichholz KM, Fessler RG. Surgical site infection rates after minimally invasive spinal surgery. J Neurosurg Spine. 2009;11(4):471-6.

Eichholz KM, O'Toole JE, Fessler RG. Thoracic microendoscopic discectomy. Neurosurg Clin N Am. 2006;17(4):441-6.

Huang TJ, Hsu RW, Li YY, Cheng CC. Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orthop Res. 2005;23(2):406-11.

Rosen DS, O'Toole JE, Eichholz KM, et al. Minimally invasive lumbar spinal decompression in the elderly: outcomes of 50 patients aged 75 years and older. Neurosurgery. 2007;60(3):503-10.

Bresnahan L, Fessler RG, Natarajan RN. Evaluation of change in muscle activity as a result of posterior lumbar spine surgery using a dynamic modeling system. Spine. 2010;35(16):761-7.

Bresnahan L, Ogden AT, Natarajan RN, Fessler RG. A biomechanical evaluation of graded posterior element removal for treatment of lumbar stenosis: comparison of a minimally invasive approach with two standard laminectomy techniques. Spine. 2009;34(1):17-23.

Lauber S, Schulte TL, Liljenqvist U, Halm H, Hackenberg L. Clinical and radiologic 2-4-year results of transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Spine. 2006;31(15):1693-8.

Goldstein CL, Rampersaud YR. Clinical Research in MIS Surgery: Current State and Future Challenges. In: Wang YM, Lu Y, Anderson GD, Mummaneni VP, eds. Minimally Invasive Spinal Deformity Surgery: An Evolution of Modern Techniques. Vienna: Springer Vienna; 2014: 371-385.

Kim CW, Lee YP, Taylor W, Oygar A, Kim WK. Use of navigation-assisted fluoroscopy to decrease radiation exposure during minimally invasive spine surgery. Spine J. 2008;8(4):584-90.

Gebhard FT, Kraus MD, Schneider E, Liener UC, Kinzl L, Arand M. Does computer-assisted spine surgery reduce intraoperative radiation doses? Spine. 2006;31(17):2024-8.






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