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J Clin Orthop Trauma. 2019 Oct; 10(Suppl 1): S156–S162. PMCID: PMC6823784
Published online 2019 Jan 14. doi: 10.1016/j.jcot.2019.01.008 PMID: 31695275

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): A review of

indications, technique, results and complications
Bhavuk Garg and Nishank Mehta∗

Abstract

Minimal access surgery has revolutionized most surgical disciplines and spine surgery is no ex‐
ception. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) was devised to
reduce the approach-related morbidity of open TLIF and has flourished in the last decade.
With expanding indications, standardization of technique and equipment, publication of more
studies on its results and complications being brought to light – an update of the existing
knowledge on MI-TLIF is imminent. We provide a review of the indications, technique, results
and complications of MI-TLIF while also highlighting its variations and utility in special
situations.

1. Introduction

Degenerative lumbar spine disease is one of the most rampantly prevalent healthcare prob‐
lems in the world, with chronic low back pain being the second leading cause of adult disability
in the United States.1 The symptoms can broadly be divided into low back pain and radicular
symptoms in the lower extremities leading in some cases, to neurogenic claudication. Whereas
radicular symptoms may be relieved by decompression, discectomy or laminectomy at the ap‐
propriate location – these techniques have limited potential in relieving low back pain. Low
back pain in such patients usually has a structural origin – from the degenerated disc, facet
joints, spinal instability or sagittal malalignment – and necessitates spinal fusion of the indicted
segment.

Lumbar spine fusion procedures have come a long way since the first description of the same
by Albee2 and Hibbs3 in independent reports in 1911. The evolution of these spinal fusion pro‐
cedures has seen some remarkable developments in the last century which include: descrip‐
tion of ALIF (Anterior Lumbar Inter-body Fusion) by Burns(1933),4 PLIF (Posterior Lumbar
Inter-Body Fusion) by Cloward(1943),5 pedicle screws by Roy-Camille(1970)6 and TLIF
(Trans-foraminal Lumbar Inter-body Fusion) by Harms and Rolinger(1982).7 Along with de‐
velopment of carbon fibre cages and orthobiologics in the 1990s, each of these developments
has contributed in achieving better fusion rates and clinical outcomes for lumbar spine fusion
procedures. TLIF currently enjoys the pride of place in the armamentarium of spine surgeons
dealing with lumbar degenerative disease. The more lateral exposure to the interspace in TLIF
as compared to PLIF gives it three distinct advantages over the latter – i) minimal neural re‐
traction, ii) thorough interspace preparation through a unilateral approach owing to its lateral-
to-medial trajectory and iii) avoidance of the midline scar in revision cases (like recurrent disc
herniations).8

The evolution of MAST (Minimal Access Spine Technique) in the last two decades has been
nothing less than spectacular. Taking cue from the dramatic success of laparoscopic and endo‐
scopic techniques in other surgical disciplines, spine surgeons have also focussed on ‘minimal‐
ist’ techniques. While excellent results were obtained with open TLIF, there was significant
morbidity seen due to iatrogenic soft tissue and muscle injury that occurs with subperiosteal
paraspinal muscle stripping and prolonged retractor application.9, 10, 11, 12 The unique set of
symptoms attributed to the deleterious effects of surgical exposure in posterior spinal fusion
procedures came to be known as the ‘fusion disease’8 – and manifested as post-operative back
pain, delayed recovery and ambulation, decreased trunk muscle strength and poorer long-
term outcomes. With an aim of achieving similar if not better outcomes with a smaller ‘surgical
footprint’, MI-TLIF was described by Foley.13 By employing smaller incisions and accessing the
spine through paraspinal muscle-splitting surgical corridors, MI-TLIF causes significantly less
soft-tissue and muscle disruption. Technological advances, better magnification and illumina‐
tion, modern tubular retractors and percutaneous screw systems and more frequent exposure
of surgeons to minimally access surgery in their residency training has greatly contributed to
the global success of MI-TLIF. This review seeks to take the reader through the various nu‐
ances of MI-TLIF – its indications, operative technique, comparative results with open TLIF,
technical challenges, complications and its utility in certain special situations.

2. Indications

The goals of all lumbar fusion surgeries – whether open or minimally-invasive - remain the
same: i) Adequate neural decompression, ii) Restoring spinal alignment and iii) Preventing ab‐
normal motion with fusion. Broadly, the indications for minimally invasive TLIF are the same as
that of open TLIF – however, in special conditions, one of these techniques might be preferred
over the other. Needless to say, a surgeon must be proficient in both open TLIF and in more
straightforward minimally invasive procedures like microdiscectomy before performing regu‐
lar MI-TLIF surgeries.

Table 1 details the indications of MI-TLIF14,15:

 Table 1

Indications of MI-TLIF

Indications where MI-TLIF and open TLIF are equally preferable

Severe degenerative disc disease (DDD)

Low-grade spondylolisthesis (Grade 1 and 2)

Post-laminectomy instability

Pseudarthrosis

Trauma requiring interbody fusion

Indications where MI-TLIF is preferred over open TLIF

Recurrent disc herniation

Obese patient16

Indications where open TLIF is preferred over MI-TLIF

Multiple level surgery (spondylolisthesis, DDD, lumbar canal stenosis)

High-grade spondylolisthesis (Grade 3 and 4)

Distorted anatomy

The benefits accrued by MI-TLIF over open TLIF in recurrent disc herniations are largely as a
result of avoiding the post-operative scar tissue in the midline. In obese patients, open tech‐
nique requires a larger exposure for adequate retraction to visualize the pedicle screw inser‐
tion landmarks making percutaneous screw insertion more appealing. The usual association of
comorbidities like diabetes mellitus in this group of patients also places them at a greater risk
of post-operative infection, which makes a minimally-invasive technique preferable. Most sur‐
geons prefer open TLIF for high-grade spondylolisthesis. Multiple-level surgery is also more
often treated by open TLIF to evade longer operative times and increased radiation exposures
associated with the former.

3. Operative Technique17

1) Positioning: Patients are positioned prone on a radiolucent table after induction with
general anaesthesia. Prior to painting and draping, we ensure that the abdomen is hanging
free to avoid engorgement of epidural venous plexuses. Some surgeons also perform
‘Awake’ MI-TLIF under conscious sedation or spinal anaesthesia.18,19 Optimal sagittal
balance or lumbar lordosis on the operating table is obtained by either using a standard
table with bolsters or an open Jackson frame table (Fig. 1). The patient is then prepared and
draped.
 Fig. 1

Patient positioned on an open Jackson frame table.

2) Incision and localization: The first and practically the most essential step at this stage is
appropriate C-arm positioning. The C-arm should be positioned in such a manner that: i)
the spinous process is precisely in midline, ii) the superior and inferior end plates of the
vertebra to be instrumented are parallel in both AP and lateral views, iii) there is no
rotation in the vertebra (Fig. 2). Small 2–3 cm paramedian skin incisions are given under C-
arm guidance, just lateral to the lateral border of the pedicles – typically ∼5 cm from the
midline. The incision is carried further down through the subcutaneous tissue and the
underlying fascia. Using blunt dissection with a finger, the planes are split further to create a
‘surgical corridor’ for percutaneous screw insertion.
 Fig. 2

The ideal AP fluoroscopy view before starting percutaneous screw insertion. Note that both endplates are
parallel, spinous process is in the centre and both pedicles are symmetrical ovals (no rotation).

3) Percutaneous pedicle screw and rod placement: Jamshidi needles (#11) are inserted
through these ‘corridors’ and parked at the junction of the transverse process and superior
facet. Fine adjustments of the needle position are made under AP fluoroscopy guidance.
The pedicle entry site will be at the 10‘o clock position of the pedicle for left sided pedicles
and at 2‘o clock position for right sided pedicles. Each needle is then advanced roughly
2 cm, taking care not to pass beyond the medial border of the pedicle projection on AP
fluoroscopy (Fig. 3A). Upon insertion to such a depth, the needle tip should lie in the
posterior third of the vertebral body on lateral fluoroscopy (Fig. 3B). A high incidence of
cranial facet violation following percutaneous pedicle screw insertion has been reported20
and it would be prudent to start more lateral and inferior on the pedicle to ensure that the
screw head does not impinge on the cranial facet joint – something that could potentially
lead to future adjacent segment degeneration (ASD). Following this, the trocar from the
Jamshidi needle is taken out and a guide-wire is inserted through the needle. The Jamshidi
needle is removed while holding the guide-wire in place. Sequential dilators follow the
guide-wire and finally the percutaneous pedicle screw, loaded with long, radiolucent soft
tissue retractors is inserted over the guide-wire with or without prior tapping (Fig. 4A, B,
4C, 4D). Next, a pre-contoured rod of appropriate size in inserted, typically on the side
opposite to that of patient's radicular symptoms. Using a special insertion handle, the rod is
inserted underneath the fascia from the end where the pedicle head is closer to the skin
(usually the cranial end). Set screws (innies) are then placed through the sleeves to put the
rod in place.
 Fig. 3

Showing Jamshidi needle insertion under fluoroscopy guidance. Note that when the needle reaches the
medial wall of the pedicle in AP view (Fig. 3A), the needle is in the posterior third of the vertebral body in
lateral view (Fig. 3B).

Fig. 4

Steps of pedicle screw insertion. 4A: Guide wire inserted through Jamshidi needle, 4B: Sequential dilators
passed over guide wire, 4C: Pedicle screw inserted over guide wire, 4D: Exposure with retraction sleeves
to aid rod placement.

4) Bony Decompression: Before proceeding to resection of bone, temporary distraction is

done over the contralateral rod. Next, a guide pin is inserted – most appropriately on the
ipsilateral facet joint and tubular dilators are passed sequentially until a final expandable
dilator is in place (Fig. 5). After coagulating the soft tissue and vasculature, the pars
interarticularis is identified and exposed. The resection of bone essentially involves
ipsilateral hemilaminectomy and near complete facetectomy (whole of inferior facet and
upper part of superior facet). This is carried out by a combination of sharp osteotomes and
Kerrison rongeurs/upcutters. Burrs are best avoided if one plans on using locally harvested
bone as autograft. After developing an appropriate sublaminar plane with a probe/Penfield
dissector, the ligamentum flavum is carefully excised to expose the underlying thecal sac. An
almost pedicle-to-pedicle exposure is obtained at this stage – the disc space and the
 traversing nerve root will lie in the lower half of this space, whereas the exiting nerve root
will lie in the upper half of this space. Dissection and exposure of the exiting nerve root is
not mandatory unless one intends to reduce a Grade 3 or 4 anterolisthesis or the patient
has relevant symptoms which can be attributed to exiting nerve root compression.

Fig. 5

Decompression and TLIF done through space created by a tubular dilator.

5) Disc Space Preparation and Interbody Fusion: Once the traversing nerve root is
identified and adequately mobilized, it is retracted medially using a probe or a dura
protector. The annulus is incised using a long-handled scalpel and a thorough discectomy is
performed using a combination of shavers, pituitary forceps and curretes. The instruments
are angled lateral-to-medial to reach the contralateral part of the disc space as well. The
cartilaginous end-plates must be denuded completely with curretes and rasps to provide a
broad area of cancellous bone for solid bony fusion. A complete and meticulous disc space
preparation, including removal of disc material and cartilaginous end plates, is the key to a
successful interbody fusion and this step should be done patiently and industriously.
Typically, 60–80% of the disc space can be effectively prepared for fusion via a MI-TLIF
unilateral approach.17 Using a funnel, the disc space is then partially packed with
morcellized locally harvested bone graft meant to lodge in the anterior disc space. A cage
(Polyetheretherketone – PEEK/titanium) of an appropriate size is then chosen. While some
surgeons prefer to use trial implants to estimate the size of the cage to be used, a sound
estimate can also be made from the ‘tight feel’ of the largest shaver inserted previously. The
cage is packed with bone graft and after insertion, is positioned in the disc space using a
combination of impactors so that it lies in the centre-anterior portion of the disc space and
rests on the stronger anterior ring apophysis rather than just the soft central cancellous
portion, to prevent delayed cage subsidence.17 Some surgeons prefer sealing the
annulotomy with a fibrin sealant such as Tisseel (Baxter Biosurgery, Deerfield, IL) and a
gelfoam to prevent subsequent leakage from the disc space which can potentially cause
chemical radiculitis or seroma formation. Our use of such materials is restricted to cases
where there is an inadvertent dural tear. A pre-contoured rod is inserted on the opposite
side to complete the surgical procedure. The previously applied temporary distraction is
 released so that the cage gets impacted well on both superior and inferior vertebral
surfaces. Further compression is done over the rod bilaterally. Usually, the combination of
facet release, cage insertion, foraminal height restoration and initial rod distraction and
later rod compression helps in achieving the twin goals of reducing a low-grade
spondylolisthesis and restoring the local sagittal balance. For reduction of high-grade
spondylolisthesis, one might be required to use threaded reduction screws.
6) Wound closure: After thorough wash and achievement of hemostasis, remaining bone graft
is packed in the posterolateral gutters. Fascia is closed with continuous absorbable sutures,
subcutaneous tissue with absorbable interrupted sutures and skin with conventional
staples or a surgical closure system like Zip® Surgical Skin Closure (Zipline Medical, CA).

4. Search methodology

Our search methodology involved a Medline search with the Medical subject Heading(MeSH)
term ‘Intervertebral Disc Degeneration’ and the subheadings ‘surgery’ and ‘therapy’. Search
keywords included a combination of ‘minimally invasive’, ‘MI-TLIF’, ‘TLIF’, ‘transforaminal lum‐
bar interbody fusion’ or ‘minimally invasive spine surgery’. We set the following criteria for a
study to be included in our review: i) Published after 2009, ii) full text available, iii) Pubished in
English language, iv) comparative study design (MI-TLIF v/s open TLIF, v) at least 10 patients
in both groups (MI-TLIF v/s open TLIF), vi) at least 24 months follow-up, vii) patients suffering
single-level degenerative disc disease or isthmic spondylolisthesis, viii) atleast two or more
clinical outcomes reported. Both the authors independently screened the titles, abstracts and
full texts to ensure fulfilment of the inclusion criteria – any difference in opinion was settled by
discussion until a consensus was reached. The arbitrary limit of last 10 years set for the inclu‐
sion of studies was done to ensure a uniformity in instrumentation, technique and other oper‐
ative parameters across studies and also to include only those studies where the operative set‐
ting will most closely resemble the present scenario. However, we recognize that this repre‐
sents a potential bias and hence, remains a limitation of our search methodology.

5. Discussion

5.1. Comparative studies with open TLIF

Several studies have been published, more so in the last decade, comparing open TLIF and MI-
TLIF. Even though MI-TLIF is established worldwide as a surgical procedure, there is a lack of
adequately powered, clinically robust, multi-centre randomized controlled trials which directly
compare open TLIF with MI-TLIF. Existing systematic reviews and meta-analysis suffer from
limitations – reliance on retrospective and prospective cohorts, publication bias for a newer
technique, lack of standardization of MI-TLIF procedure at different centres, differing surgical
experience and skills of various surgeons and lack of standardized reporting or outcome
scores. Using our search methodology, we narrowed down to 11 studies which fulfilled our in‐
clusion criteria. Thus, the current evidence is based on various prospective and retrospective
studies – the findings of which are summarized in Table 2.
Table 2

Comparison of minimally invasive and open TLIF.

Study Year Design Patients Follow-up Comments/Significant findings

(MI:Open) (MI/Open)

Schizas et al.21 2009 PC 18:18 22.0/24.0 MI-TLIF: lesser EBL, shorter LOS
(statistically significant difference),
Steeper learning curve
ODI, VAS scores – difference
statistically insignificant

Peng et al.22 2009 PC 29:29 24.0/24.0 MI-TLIF: higher fluoroscopy and

operating time, lesser EBL, shorter
LOS (all statistically significant)
ODI, VAS scores, fusion rates –
difference statistically insignificant

Villavicencio 2010 RC 76:63 37.5/37.5 MI-TLIF: lesser EBL, shorter LOS

23
et al. (both statistically significant)
Higher rates of neurological deficit
with MI-TLIF

Wang et al.24 2010 PC 42:43 26/26 MI-TLIF: lesser EBL, shorter LOS,
lower post-operative VAS at 3rd day
after surgery (all statistically
significant)
More radiation exposure with MI-
TLIF
VAS and ODI at final follow-up same
between both groups

Lee et al.25 2012 PC 72:72 24.0/24.0 MI-TLIF: 3 times more fluoroscopy

time, 88% decrease in EBL, shorter
LOS (all statistically significant)
ODI, VAS scores, fusion rates –
difference statistically insignificant

Rodriguez-Vela 2013 PC 21:20 45.0/45.0 Clinical outcome scores (ODI, VAS,

26
et al. NASS score, SF-36) – all better with
MI-TLIF but difference not
statistically significant

Brodano 2013 RC 30:34 23.0/25.0 MI-TLIF: shorter LOS, lesser EBL,

27
et al. higher operating time (all
statistically significant)
Better early post-operative pain
(VAS d 3 f
[PC = Prospective cohort, RC = Retrospective cohort, EBL = estimated blood loss, LOS = length of (hospital)
stay, ODI = Oswestry disability index, VAS = visual analog scale, NASS = North American Spine Society, SF-
36 = Short Form 36 Health Survey].
To summarize, existing studies differ greatly in terms of study design, measured outcome vari‐
ables and most importantly, the precise surgical technique used for performing MI-TLIF.
However, most studies agree that MI-TLIF leads to lesser intra-operative blood loss and
shorter hospital stay compared to open TLIF. Some studies report longer operating times with
MI-TLIF whereas the other report no significant difference – the disparity can be due to the
differing experience of the operating surgeons/team with the minimally invasive technique.
Clinical patient-reported outcome scores do not differ between the two groups in long-term
follow-up with MI-TLIF faring slightly better in short-term follow-up.

5.2. Variations of MI-TLIF and their outcomes

Some authors have reported technical modifications in the MI-TLIF procedure. Mummaneni31
described a mini-open TLIF procedure where an expandable tube retractor was placed using a
muscle-splitting Wiltse approach. Screws were inserted and decompression with interbody fu‐
sion was done through the space afforded by this expandable retractor. The author proposed
that the learning curve for this procedure was less than that for MI-TLIF. Dhall32 compared
their results of mini-open TLIF and open TLIF and reported that while the mean blood loss
and length of hospital stay was lower with mini-open TLIF without affecting the outcomes, the
incidence of hardware-associated complications was also higher with the mini-open TLIF.

In an attempt to further reduce approach-related morbidity, unilateral pedicle screw fixation

with MI-TLIF has been proposed. Deutsch et al.33 reported on a prospective cohort of 20 pa‐
tients who underwent MI-TLIF with unilateral pedicle screw fixation. There was significant im‐
provement in mean ODI and VAS scores, and 13/20 patients showed evidence of fusion in CT
scans done at 6 months. However, a more recent study by Choi et al.34 with a longer follow-up
(mean = 28.2 months, minimum 2 years) showed that while the operating time and blood loss
were significantly less with unilateral screw fixation with similar clinical outcomes, the fusion
rates at 2 years were less than that with bilateral screw fixation (unilateral 82.6%, bilateral
95.7%). In a pilot study, Jang and Lee35 used ipsilateral pedicle screw and contralateral facet
screw fixation via a MI-TLIF approach. At a mean follow-up of 19 months, they reported signifi‐
cant improvements in mean numerical rating scale and ODI.

Reinshagen et al.36 have recently described a novel minimally invasive technique for decom‐
pression and interbody fusion known as hybrid lumbar interbody fusion (HLIF). The tech‐
nique combines the advantages of PLIF and TLIF. Using a standard posterior midline approach
unilaterally, decompression and partial facetectomy are carried out, allowing for the implanta‐
tion of a specially designed cage. Ipsilateral screws are inserted in a dorsoventral fashion, with
a vertical vector using neuronavigation. Contralateral pedicle screws are inserted in a percuta‐
neous fashion through small stab incisions under fluoroscopy guidance. Awake MI-TLIF has
been performed by some surgeons to achieve a rapid and painless recovery and essentially
make it a day-care surgery. Wang et al.18 described their experience with this technique in
which they utilized conscious sedation using an infusion of propofol and ketamine and injec‐
tion of the percutaneous pedicle screw tracts with liposomal bupivacaine. Nine out of 10 pa‐
tients in their cohort could be discharged on the 1st post-operative day.

5.3. Complications and technical challenges

In a recent meta-analysis, although MI-TLIF was reported to have a lower complication rate
than open TLIF, the difference was not statistically significant.37 Wang38 in 2014 and Wong39 in
2015 reported on two of the largest series of perioperative complications when doing MI-TLIF.
In a retrospective cohort study on 204 patients who underwent MI-TLIF, Wang reported a
complication incidence of 31.37%.38 Only 7 were persistent complications, with the rest being
transient. Of note, there were 24 patients with leg sensory disturbance after surgery. Ten small
dural tears during decompression were managed with tight closure of the overlying fascia – no
additional exposure and repair was done. Wong et al.39 performed a retrospective analysis of
513 patients which included both single-level and multi-level fusions using MI-TLIF. Of the 80
patients (15.4%) who had a perioperative complication – 53 had a surgical complication and
37 had a medical complication. Durotomy (5.1%) was the most common complication followed
by instrumentation failure (2.1%). Performing a multi-level TLIF significantly increased the
chances of complication as compared to single-level TLIF.

Some complications are unique to MI-TLIF though with a meticulous technique, they have been
scarcely reported. Changing the direction of the screw over the guide-wire can lead to break‐
age of the guide-wire within the vertebral body or pedicle which can be difficult to retrieve.
Percutaneous technique can be challenging at the L5/S1 level due to the pedicle angulations of
L5 and S1.40 The long retraction sleeves can impinge on each other at the skin level. To deal
with this, one can either place the S1 pedicle screw in a more inferior starting position, or use
flexible retraction sleeves which can be deflected at skin level.40 Cannulation of small and scle‐
rotic pedicles can be another potential problem. Sometimes, if one is not careful, guide wires
can migrate anteriorly and can injure viscera or vascular structures.

Two important misgivings remain in most surgeons' minds regarding MI-TLIF: the steep learn‐
ing curve and the increased amount of radiation exposure. Lee et al.41 analyzed their results
on the first 90 single level MI-TLIF performed by a single surgeon in a prospective cohort
study and noted that technical proficiency for MI-TLIF was achieved after 44 surgeries and the
patients operated after this achieved a better clinical outcome and had shorter LOS and opera‐
tive time. Another study which plotted the operative times of MI-TLIF cases against experience
noted that a 50% learning milestone was achieved at case 12 and a 90% learning milestone
was achieved at case 39. MI-TLIF invariably places the surgeon to additional radiation expo‐
sure when compared to open TLIF. Bindal et al.42 recorded the mean fluoroscopy time in 24
consecutive patients (33 MI-TLIFs). The mean fluoroscopy time was 1.69 min/case, and mean
radiation exposure to dominant unprotected hand, waist under lead, and unprotected thyroid
were 76, 27, and 32 mrem/case, respectively. A surgeon would thus exceed OELs (occupational
exposure limit), in 194 cases for torso, 664 for hand, and 166 cases for unprotected thyroid
annually. Use of navigation for screw insertion, protective gear, collimation, ‘spot’ radiographs
and pulsed fluoroscopy have been recommended as some of the measures to deal with this
problem.43

6. Conclusion

• MI-TLIF is a versatile technique with its spectrum of indications rivaling that of its open
counterpart.
• Meticulous operative technique is the key to a good outcome in MI-TLIF
• MI-TLIF offers several advantages over open TLIF while giving similar clinical and
radiological outcomes. The advantages include lesser blood loss, shorter hospital stay, faster
rehabilitation and decreased need for analgesia and blood transfusions. These advantages
are offset by a steeper learning curve, longer operating time and increased radiation
exposure with MI-TLIF.
• High-powered, well-designed randomized controlled trials are needed to further validate
MI-TLIF.

Conflicts of interest

The authors declare that there is no conflict of interest regarding the publication of this paper.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commer‐
cial, or not-for-profit sectors.

References

1. Gooch C.L., Pracht E., Borenstein A.R. The burden of neurological disease in the United States: a summary report and
call to action. Ann Neurol. 2017;81(4):479–484. [PubMed] [Google Scholar]

2. Albee F.H. Transplantation of a portion of the tibia into the spine for Pott's disease: a preliminary report. J Am Med
Assoc. 1911;57(11):885–886. [Google Scholar]

3. Hibbs R.A. An operation for progressive spinal deformities. A preliminary report of three cases from the service of
the Orthopaedic Hospital. NY Med J. 1911;93:1013–1016. [PubMed] [Google Scholar]

4. Burns B.H. An operation for spondylolisthesis. Lancet. 1933;221(5728):1233. [Google Scholar]

5. Cloward R.B. Posterior lumbar interbody fusion. Clin Orthop. 1945;193:16. [PubMed] [Google Scholar]

6. Roy-Camille R., Roy-Camille M., Demeulenaere C. Osteosynthesis of dorsal, lumbar, and lumbosacral spine with
metallic plates screwed into vertebral pedicles and articular apophyses. Presse Med. 1970;78(32):1447. [PubMed]
[Google Scholar]

7. Harms J., Rolinger H. A one-stager procedure in operative treatment of spondylolistheses: dorsal traction-reposition
and anterior fusion (author's transl) Z Orthop Ihre Grenzgeb. 1982;120(3):343–347. [PubMed] [Google Scholar]

8. Schwender J.D., Holly L.T., Rouben D.P., Foley K.T. Minimally invasive transforaminal lumbar interbody fusion
(TLIF): technical feasibility and initial results. Clin Spine Surg. 2005;18 S1–S6. [PubMed] [Google Scholar]

9. Sihvonen T., Herno A., Paljärvi L., Airaksinen O., Partanen J., Tapaninaho A. Local denervation atrophy of paraspinal
muscles in postoperative failed back syndrome. Spine. 1993;18(5):575–581. [PubMed] [Google Scholar]

10. Styf J.R., Willén J. The effects of external compression by three different retractors on pressure in the erector spine
muscles during and after posterior lumbar spine surgery in humans. Spine. 1998;23(3):354–358. [PubMed] [Google
Scholar]

11. Gejo R., Matsui H., Kawaguchi Y., Ishihara H., Tsuji H. Serial changes in trunk muscle performance after posterior
lumbar surgery. Spine. 1999;24(10):1023–1028. [PubMed] [Google Scholar]
12. Cawley D.T., Alexander M., Morris S. Multifidus innervation and muscle assessment post-spinal surgery. Eur Spine J.
2014;23(2):320–327. [PMC free article] [PubMed] [Google Scholar]

13. Foley K.T., Holly L.T., Schwender J.D. Minimally invasive lumbar fusion. Spine. 2003;28(15S):S26–S35. [PubMed]
[Google Scholar]

14. Holly L.T., Schwender J.D., Rouben D.P., Foley K.T. Minimally invasive transforaminal lumbar interbody fusion:
indications, technique, and complications. Neurosurg Focus. 2006;20(3):1–5. [PubMed] [Google Scholar]

15. Karikari I.O., Isaacs R.E. Minimally invasive transforaminal lumbar interbody fusion: a review of techniques and
outcomes. Spine. 2010;35(26S):S294–S301. [PubMed] [Google Scholar]

16. Lau D., Khan A., Terman S.W., Yee T., La Marca F., Park P. Comparison of perioperative outcomes following open
versus minimally invasive transforaminal lumbar interbody fusion in obese patients. Neurosurg Focus. 2013;35(2):E10.
[PubMed] [Google Scholar]

17. Wong A.P., Smith Z.A., Stadler J.A. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) Neurosurg
Clin. 2014;25(2):279–304. [PubMed] [Google Scholar]

18. Wang M.Y., Grossman J. Endoscopic minimally invasive transforaminal interbody fusion without general
anesthesia: initial clinical experience with 1-year follow-up. Neurosurg Focus. 2016;40(2):E13. [PubMed] [Google
Scholar]

19. Chang H.-K., Kolcun J.P.G., Wang M.Y. Modern Thoraco-Lumbar Implants for Spinal Fusion. Springer; Cham: 2018. New
techniques and MIS: the awake TLIF; pp. 101–112. [Google Scholar]

20. Park Y., Ha J.W., Lee Y.T., Sung N.Y. Cranial facet joint violations by percutaneously placed pedicle screws adjacent to
a minimally invasive lumbar spinal fusion. Spine J. 2011;11(4):295–302. [PubMed] [Google Scholar]

21. Schizas C., Tzinieris N., Tsiridis E., Kosmopoulos V. Minimally invasive versus open transforaminal lumbar
interbody fusion: evaluating initial experience. Int Orthop. 2009;33(6):1683–1688. [PMC free article] [PubMed] [Google
Scholar]

22. Peng C.W.B., Yue W.M., Poh S.Y., Yeo W., Tan S.B. Clinical and radiological outcomes of minimally invasive versus
open transforaminal lumbar interbody fusion. Spine. 2009;34(13):1385–1389. [PubMed] [Google Scholar]

23. Villavicencio A.T., Burneikiene S., Roeca C.M., Nelson E.L., Mason A. Minimally invasive versus open
transforaminal lumbar interbody fusion. Surg Neurol Int. 2010;1 [PMC free article] [PubMed] [Google Scholar]

24. Wang J., Zhou Y., Zhang Z.F., Li C.Q., Zheng W.J., Liu J. Comparison of one-level minimally invasive and open
transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2. Eur Spine J.
2010;19(10):1780–1784. [PMC free article] [PubMed] [Google Scholar]

25. Lee K.H., Yue W.M., Yeo W., Soeharno H., Tan S.B. Clinical and radiological outcomes of open versus minimally
invasive transforaminal lumbar interbody fusion. Eur Spine J. 2012;21(11):2265–2270. [PMC free article] [PubMed]
[Google Scholar]

26. Rodríguez-Vela J., Lobo-Escolar A., Joven E., Muñ oz-Marín J., Herrera A., Velilla J. Clinical outcomes of minimally
invasive versus open approach for one-level transforaminal lumbar interbody fusion at the 3-to 4-year follow-up. Eur
Spine J. 2013;22(12):2857–2863. [PMC free article] [PubMed] [Google Scholar]

27. Brodano G.B., Martikos K., Lolli F. Transforaminal lumbar interbody fusion in degenerative disk disease and
spondylolisthesis grade I: minimally invasive versus open surgery. Clin Spine Surg. 2015;28(10):E559–E564. [PubMed]
[Google Scholar]
28. Parker S.L., Mendenhall S.K., Shau D.N. Minimally invasive versus open transforaminal lumbar interbody fusion for
degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis. World Neurosurg. 2014;82(1):230–
238. [PubMed] [Google Scholar]

29. Saetia K., Phankhongsab A., Kuansongtham V., Paiboonsirijit S. Comparison between minimally invasive and open
transforaminal lumbar interbody fusion. J Med Assoc Thail Chotmaihet Thangphaet. 2013;96(1):41–46. [PubMed]
[Google Scholar]

30. Sulaiman W.A.R., Singh M. Minimally invasive versus open transforaminal lumbar interbody fusion for
degenerative spondylolisthesis grades 1-2: patient-reported clinical outcomes and cost-utility analysis. Ochsner J.
2014;14(1):32–37. [PMC free article] [PubMed] [Google Scholar]

31. Mummaneni P.V., Rodts G.E., Jr. The mini-open transforaminal lumbar interbody fusion. Oper Neurosurg.
2005;57(suppl l_4) ONS–256. [Google Scholar]

32. Dhall S.S., Wang M.Y., Mummaneni P.V. Clinical and radiographic comparison of mini–open transforaminal lumbar
interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up.
J Neurosurg Spine. 2008;9(6):560–565. [PubMed] [Google Scholar]

33. Deutsch H., Musacchio M.J. Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle
screw fixation. Neurosurg Focus. 2006;20(3):1–5. [PubMed] [Google Scholar]

34. Choi U.Y., Park J.Y., Kim K.H. Unilateral versus bilateral percutaneous pedicle screw fixation in minimally invasive
transforaminal lumbar interbody fusion. Neurosurg Focus. 2013;35(2):E11. [PubMed] [Google Scholar]

35. Jang J.-S., Lee S.-H. Minimally invasive transforaminal lumbar interbody fusion with ipsilateral pedicle screw and
contralateral facet screw fixation. J Neurosurg Spine. 2005;3(3):218–223. [PubMed] [Google Scholar]

36. Reinshagen C., Ruess D., Walcott B.P., Molcanyi M., Goldbrunner R., Rieger B. A novel minimally invasive technique
for lumbar decompression, realignment, and navigated interbody fusion. J Clin Neurosci. 2015;22(9):1484–1490.
[PubMed] [Google Scholar]

37. Xie L., Wu W.-J., Liang Y. Comparison between minimally invasive transforaminal lumbar interbody fusion and
conventional open transforaminal lumbar interbody fusion: an updated meta-analysis. Chin Med J (Engl).
2016;129(16):1969. [PMC free article] [PubMed] [Google Scholar]

38. Wang J., Zhou Y. Perioperative complications related to minimally invasive transforaminal lumbar fusion:
evaluation of 204 operations on lumbar instability at single center. Spine J. 2014;14(9):2078–2084. [PubMed] [Google
Scholar]

39. Wong A.P., Smith Z.A., Nixon A.T. Intraoperative and perioperative complications in minimally invasive
transforaminal lumbar interbody fusion: a review of 513 patients. J Neurosurg Spine. 2015;22(5):487–495. [PubMed]
[Google Scholar]

40. Mobbs R.J., Sivabalan P., Li J. Technique, challenges and indications for percutaneous pedicle screw fixation. J Clin
Neurosci. 2011;18(6):741–749. [PubMed] [Google Scholar]

41. Lee K.H., Yeo W., Soeharno H., Yue W.M. Learning curve of a complex surgical technique: minimally invasive
transforaminal lumbar interbody fusion (MIS TLIF) Clin Spine Surg. 2014;27(7):E234. [PubMed] [Google Scholar]

42. Bindal R.K., Glaze S., Ognoskie M., Tunner V., Malone R., Ghosh S. Surgeon and patient radiation exposure in
minimally invasive transforaminal lumbar interbody fusion. J Neurosurg Spine. 2008;9(6):570–573. [PubMed] [Google
Scholar]

43. Srinivasan D., Than K.D., Wang A.C. Radiation safety and spine surgery: systematic review of exposure limits and
methods to minimize radiation exposure. World Neurosurg. 2014;82(6):1337–1343. [PubMed] [Google Scholar]