Enhancing precision in robotic navigated minimally invasive transforaminal lumbar interbody fusion using a streamlined surgical workflow: a technical note

Abstract

Introduction

Minimally invasive spine surgery has evolved through the integration of advanced imaging, navigation, and robotics. However, standardized workflows combining these technologies with intraoperative neuromonitoring remain limited.

Research question

This technical note presents a stepwise approach for robot-assisted, navigated, and neuromonitored minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

Material and methods

We describe a complete workflow using intraoperative cone beam computed tomography (CBCT) for anatomical registration, robotic arm alignment for pedicle screw trajectory guidance, and real-time triggered electromyography (tEMG) to verify screw path safety. A drill-based technique is adopted for screw placement, followed by posterior decompression and navigated interbody cage placement. An illustrative case of L4–L5 spondylolisthesis is presented to demonstrate the feasibility of this method.

Results

This workflow enables navigation-based, intraoperative imaging-guided pedicle screw placement and optimized interbody cage positioning under direct neuromonitoring feedback. In the illustrative case, all screws were placed within pedicle boundaries without breaching, and optimal cage insertion was confirmed with intraoperative CBCT. The integration of robotic guidance and real-time tEMG guaranteed both surgical accuracy and intraoperative confidence.

Discussion and conclusion

The described technique demonstrates how combining robotics, navigation, and neuromonitoring can streamline MIS-TLIF procedures. This approach may offer a high level of precision, promote reproducibility across surgical teams, and serve as an educational platform for the next generation of spine surgeons.

Highlights

• •This technical note presents a stepwise approach for robot-assisted, navigated, and neuro-monitored minimally invasive transforaminal lumbar interbody fusion.
• •In the illustrative case, all screws were placed without breaching, and cage insertion was confirmed with intraoperative cone beam computed tomography.
• •This approach offers a high level of precision, promotes reproducibility , and may serve as an educational platform for spine surgeons in training.

1. Introduction

Lumbar spine fusion is one of the most common surgical procedures worldwide, with an ever-increasing number of cases performed globally (O'Lynnger et al., 2015). In the USA, a 62% increase in case volume was reported from 2004 to 2015, primarily driven by degenerative spondylolisthesis and scoliosis in patients over 65 years of age (Martin et al., 2019).

Minimally invasive spine surgery (MISS) has significantly advanced over the past two decades, offering reduced soft tissue disruption, blood loss, and postoperative recovery time compared to traditional open procedures (Papalia et al., 2024). These benefits are particularly valuable in transforaminal lumbar interbody fusion (TLIF), where the preservation of posterior musculature can improve postoperative outcomes. However, the technical demands of MISS, including limited visualization, reliance on indirect anatomical landmarks, and a narrow working corridor, pose challenges for consistent reproducibility and surgeon adoption (Ghaednia et al., 2021).

To address these limitations, the integration of advanced intraoperative imaging, navigation, and robotic assistance has emerged as a transformative paradigm. Navigation and robotic guidance enables high-precision screw placement with reduced intraoperative radiation exposure and ergonomic benefits (Lieberman et al., 2020). When combined with intraoperative cone beam computed tomography (CBCT) and real-time navigation, it allows for accurate trajectory planning and execution (Vadalà et al., 2020). Furthermore, intraoperative neuromonitoring adds an essential safety layer by detecting proximity to neural structures during instrumentation (Montenegro et al., 2022; Lall et al., 2012).

Despite these technological advancements, there remains a lack of standardized workflows that integrate these tools into a cohesive and reproducible technique. In addition, while the benefits of robotic and navigated approaches are increasingly documented, detailed procedural descriptions that emphasize safety steps and training value are still underrepresented in the literature.

This technical note presents a comprehensive, stepwise workflow for robot-assisted, navigated, and neuro-monitored minimally invasive TLIF (MIS-TLIF). The proposed protocol incorporates CBCT-based registration, robotic alignment, a drill-based screw placement technique, real-time triggered electromyography (tEMG), and navigated interbody cage implantation.

2. Technical note

2.1. Operating room setup

A well-structured operating room (OR) setup is essential to ensure a smooth and reproducible workflow when performing minimally invasive lumbar fusion with robotic navigation and intraoperative imaging (Fig. 1A). The patient is positioned prone on a radiolucent carbon fiber surgical table equipped with a floating tabletop and a Wilson frame. The use of radiolucent materials minimizes imaging artifacts and allows unimpeded longitudinal movement of the mobile CBCT gantry along the spine. Before sterile draping, the robotic arm (Cirq®, Brainlab) is secured to the side rail of the operating table, adjacent to the primary surgeon. A stabilizing support arm extends beneath the table and anchors to the contralateral rail, increasing construct rigidity and minimizing the risk of displacement during use. This configuration provides a stable platform for instrument guidance without interfering with patient positioning or CBCT acquisition. The CBCT imaging system (LoopX®, Brainlab) is placed at the distal end of the table, aligned with the patient's longitudinal axis to facilitate scan acquisition. Adequate clearance must be ensured to allow the mobile gantry to pass over the target spinal levels without interference. The wireless console permits remote operation, allowing the surgical team to step outside the OR during imaging acquisition and thereby reducing radiation exposure. To maintain full mobility of the imaging system, the surgical table must remain free of obstructions along its entire length. The navigation system console (Curve®, Brainlab) is positioned at distal end of the table to provide surgeons with optimal visibility during intraoperative navigation. The optical tracking camera is placed at the foot of the table, centered on the surgical field. Continuous, unobstructed line of sight to both the patient reference array and the reflective markers on navigated instruments is essential to ensure accurate real-time tracking. Preoperative imaging data, including standard lumbar X-rays (standing anteroposterior, lateral, and dynamic views) and magnetic resonance imaging (MRI), are uploaded to the navigation platform. These datasets are used to guide intraoperative CBCT-MRI image fusion, screw planning, and navigation.

Fig. 1.

Operating room setup. Room preparation before (A) and after (B) robotic arm installation and patient positioning, with sterile draping subsequently applied (C). Panel D shows a schematic representation of the overall operating room setup.

2.2. Patient positioning and sterile draping

Following the induction of general anesthesia and placement of neuromonitoring adhesive surface electrodes on relevant myotomes, the patient is carefully positioned prone on the radiolucent table with the Wilson frame. Mild flexion of the hips and knees is maintained to increase the interlaminar space, reduce nerve root tension, and decrease intra-abdominal pressure, thereby limiting epidural venous congestion and intraoperative bleeding while maintaining physiological spinal alignment. All pressure points are meticulously padded to prevent skin injury and peripheral nerve compression. The arms are gently abducted, supported, and padded, avoiding excessive traction to minimize the risk of brachial plexus or ulnar nerve injury. The head is maintained in a neutral position on a soft headrest to preserve cervical alignment and reduce the risk of ocular complications associated with prone positioning (Fig. 1B). Sterile draping is performed to fully expose the posterior thoracolumbar region, including the posterior superior iliac spines (PSIS) and iliac crests. This allows flexibility in selecting the site for reference frame placement, typically the posterior iliac crest. Drapes must be securely fixed along the operative field and imaging corridor, ensuring that no material overhangs or contacts the mobile imaging system, as this may activate collision-avoidance sensors and interrupt CBCT acquisition. Proper positioning and draping are critical for maintaining optimal surgical exposure, ensuring neuromonitoring reliability, and enabling seamless integration with navigation and robotic systems. After mounting, the robotic arm is incorporated into the sterile field using a dedicated sterile drape applied during standard preparation. The system remains in standby mode until intraoperative imaging and trajectory planning are completed (Fig. 1C). A schematic representation of the complete operating room setup is shown in Fig. 1D.

2.3. Reference frame positioning

According to the manufacturer's instructions, the reference frame can be secure either to a spinous process or the posterior aspect of the iliac crest. At our institution, we preferentially attach it to the latter as positioning the frame away from the operative field reduces the risk of intraoperative collision or inadvertent displacement that could compromise navigation accuracy (Fig. 2). Two Schanz pins are percutaneously drilled into the PSIS, and the reference frame is mounted onto the pins. Alternatively, the reference frame may be clamped to a spinous process following surgical exposure of the spine. The orientation of the reference frame is then adjusted to optimize optical tracking and ensure smooth navigation. Before image acquisition, proper frame detection is confirmed on the Curve® Navigation display. Malpositioning of the frame or obstruction of the optical pathway between the camera and reflective markers will prevent successful registration and scanning. If detection fails, the reflective markers should be cleaned with a moist swab, dried thoroughly, and reassessed. After successful registration, extreme care must be taken to avoid accidental displacement. This might result in a loss of navigation accuracy, potentially leading to incorrect anatomical localization, suboptimal implant positioning, and related complications.

Fig. 2.

Reference frame attached to the posterior aspect of the iliac crest.

2.4. CBCT imaging and intraoperative navigation

Following completion of the initial setup, intraoperative imaging is performed. All OR personnel exit the room, and the CBCT system is operated remotely via the wireless console (Fig. 3). Preliminary two-dimensional anteroposterior and lateral radiographs are obtained to define the appropriate scan range, which is confirmed directly on the console display. Subsequently, in coordination with the anesthesiologist, the patient is placed in temporary apnea while maintaining continuous positive airway pressure of at least 5 cm H₂O to minimize motion artifacts. The CBCT scan is then acquired. After image acquisition, the gantry is carefully returned to the distal end of the table, avoiding any contact with the sterile drapes. The data are then transferred to the navigation system for three-dimensional reconstruction. The CBCT images can be reviewed in axial, coronal, and sagittal planes, and a 3D volumetric model is generated to facilitate surgical planning. Navigated instruments, including the pointer and drill guide, are subsequently calibrated using the dedicated calibration device to ensure accurate real-time tracking.

Fig. 3.

Cone beam computed tomography imaging acquisition.

2.5. Preoperative planning

Once intraoperative CBCT acquisition is completed, preoperative planning is performed using the dedicated spine navigation software. The system automatically segments and labels the vertebral levels within the scanned region, with manual refinements applied as needed. Pedicle screw trajectories are planned on a three-dimensional model using simultaneous axial, sagittal, and coronal views. Each trajectory is adjusted to optimize placement within the pedicle walls while preserving the integrity of adjacent neurovascular structures. Screw diameter and length are selected according to vertebral morphology and bone quality (Fig. 4A). The platform also allows virtual templating of interbody cages. Cage height, width, length, and lordotic angle are selected based on measured disc space parameters and overall sagittal alignment objectives. The selected implant can then be navigated intraoperatively, enabling real-time guidance and positional verification during insertion.

Fig. 4.

Pedicle screw trajectory planning on a three-dimensional model (A) and fusion of preoperative magnetic resonance imaging with intraoperative cone beam computed tomography (B).

To enhance anatomical precision, preoperative imaging datasets, such as MRI scans, can be fused with intraoperative CBCT. This multimodal integration facilitates correlation between osseous anatomy and soft tissue structures, improving localization of facet cysts, disc herniation, nerve root compression, and foraminal stenosis (Fig. 4B). All finalized implant plans are then stored within the navigation system and executed intraoperatively using either robotic guidance or navigated freehand instrumentation.

2.6. Robotic, navigated, and neuromonitored pedicle screw placement

Pedicle screw placement is performed using a robotic-guided, navigation-assisted, and neuromonitoring-integrated workflow to ensure maximum precision and safety. This approach combines intraoperative imaging for trajectory planning, robotic alignment for mechanical accuracy, and continuous electromyographic monitoring to mitigate the risk of neural injury.

The robotic arm is manually positioned near the intended pedicle screw entry point. Once approximately aligned, the robotic end effector performs automatic fine adjustments to match the planned trajectory. Small (1–2 cm) longitudinal skin and fascial incisions are created at each entry site. Through these incisions, the navigated drill guide is advanced (Fig. 5A) and docked onto the posterior cortical surface of the vertebra (Fig. 5B). Continuous visual feedback on the navigation platform confirms trajectory alignment in real time, reducing the risk of deviation and enhancing procedural safety. Its serrated tip ensures stable engagement and minimizes skiving, particularly in regions with steep bony anatomy. Drilling is then performed with a 2.6 mm bit to a depth of approximately 25–30 mm under continuous navigation, robotic stabilization, and neuromonitoring as described below (Fig. 5C). A K-wire is then inserted through the guide and gently advanced into the cancellous bone (Fig. 5D). The robotic arm is repositioned sequentially for each planned screw. Once all K-wires are placed, they are left in situ for subsequent pedicle screw insertion following decompression and interbody cage placement. When robotic guidance is unavailable or not desired, the same drill-based technique can be performed using manual navigation. In this workflow, the navigated drill guide is aligned with the preplanned screw trajectory directly under real-time navigation guidance without robotic support. As in the robotic workflow, the guide is introduced through a small incision, docked onto the posterior cortex, and drilling is performed with concurrent tEMG monitoring. A K-wire is inserted and electrically tested prior to screw placement (Fig. 6).

Fig. 5.

Robotic screw trajectory drilling. The robotic arm is manually positioned near the planned skin entry point (A), then the drill guide is inserted (B). Drilling is performed under continuous neuromonitoring (C), and the K-wire is then placed in the drilled hole (D).

Fig. 6.

Manual navigated screw trajectory drilling under continuous neuromonitoring.

2.7. Intraoperative neuromonitoring integration

Intraoperative neurophysiological monitoring represents a fundamental component of our navigated and robot-assisted workflow for minimally invasive lumbar fusion. At our institution, the NVM5 system® (NuVasive) is used to provide continuous feedback on neural integrity throughout the procedure, enhancing safety during critical steps such as drilling, K-wire placement, and definitive screw insertion. Following electrode placement and prone positioning, neuromuscular blockade is minimized in coordination with the anesthesia team to ensure reliable EMG signal acquisition.

tEMG monitoring is applied during pedicle instrumentation in two key phases. During drilling, a stimulation clamp is connected directly to the navigated drill guide. As the drill advances through the pedicle under navigation or robotic guidance, real-time tEMG feedback allows immediate detection of potential cortical breach or proximity to neural structures. This early warning mechanism is particularly valuable in anatomically complex cases or in the presence of narrow pedicles. Following creation of the pilot tract, the stimulation clamp is transferred to the K-wire. A second stimulation test is performed to confirm the absence of low-threshold responses, thereby verifying safe intrapedicular positioning. Any abnormal signal prompts immediate reassessment of the planned trajectory before proceeding. This dual stage stimulation strategy introduces redundancy into the safety protocol while reducing the likelihood of unrecognized neural compromise. Additional stimulation or intraoperative imaging may be performed after definitive screw placement to confirm appropriate positioning following decompression and interbody cage insertion. The continuous presence of a dedicated neurophysiology specialist is essential for accurate signal interpretation, intraoperative decision-making, and rapid response to alerts. In our experience, this combined approach enhances the safety profile of MISS, particularly in high-risk anatomical zones, by reducing the risk of undetected pedicle breach, such as that caused by skiving, and contributing to improved postoperative neurological outcomes (Kim et al., 2009; Liu et al., 2023).

2.8. Posterior decompression and interbody cage placement

Following K-wire placement, posterior decompression and interbody fusion are performed through a MISS approach. A midline skin incision is made over the target disc space. Incision planning is guided by the navigated probe, enabling precise localization of the operative level according to the preplanned trajectory. This ensures optimal incision placement, limits unnecessary soft tissue exposure, and improves overall workflow efficiency. Subperiosteal dissection is performed to expose the posterior elements while preserving paraspinal musculature. Muscle detachment and lateral retraction are kept to a minimum to maintain a narrow surgical corridor and limit tissue trauma. Navigation assists in identifying the facet joint targeted for partial resection to access the disc space. A partial facetectomy is performed using a chisel or osteotome, followed by partial hemilaminectomy using a high-speed burr and Kerrison rongeurs to expand the working corridor to the disc. Resection of the ligamentum flavum exposes the underlying dura and traversing nerve root, completing neural decompression. After adequate decompression, the dural sac and nerve roots are gently retracted to visualize the intervertebral disc. A wide annulotomy is performed, followed by thorough discectomy using pituitary rongeurs and curettes. Careful endplate preparation is undertaken to remove endplate cartilaginous tissue while preserving the subchondral bone, thereby reducing the risk of cage subsidence. The disc height is then assessed under distraction to guide implant sizing. Trial cages are inserted to confirm appropriate height, footprint, and depth. Local morselized autograft harvested from the resected lamina and facet joint is packed into the disc space to enhance fusion.

The selected interbody cage is templated within the navigation software for size, shape, and trajectory. During insertion, real-time navigation provides spatial guidance, confirming alignment relative to the vertebral endplates and neural structures (Fig. 7). The cage is advanced under direct visualization with careful neural retraction. Final positioning is verified on the navigation display to confirm appropriate depth, orientation, and midline placement, minimizing the risk of malalignment or migration.

Fig. 7.

Intraoperative navigation confirms correct interbody cage depth, orientation, and positioning.

2.9. Screw insertion, rod placement, and intraoperative verification

After completion of decompression and interbody cage placement, pedicle screws are inserted over the previously positioned K-wires. Each screw is advanced manually, with optional navigation guidance using a calibrated screwdriver. Continuous neuromonitoring is maintained during insertion to confirm the absence of nerve root irritation. Prior to final seating, the K-wires are carefully removed to eliminate the risk of inadvertent anterior advancement. Pre-contoured rods are then introduced percutaneously through the distal incisions and seated into the screw tulips. If necessary, the incision is slightly enlarged to facilitate rod passage. Segmental compression or distraction is applied as appropriate to restore alignment, reduce spondylolisthesis, and achieve the desired sagittal profile before final locking. Following definitive tightening of the set screws, intraoperative verification is performed using CBCT. The imaging system is repositioned over the operative field, and a confirmatory scan is obtained to assess pedicle screw trajectory, interbody cage positioning, segmental lordosis, and adequacy of slippage reduction (Fig. 8). This step enables immediate identification of implant malposition and allows correction before wound closure. Implant positioning is also compared with the preoperative plan to evaluate procedural accuracy and reproducibility. Minor deviations are assessed for clinical relevance based on neural clearance and construct stability. Wound closure is performed in layers, and small incisions are closed with resorbable subcuticular sutures or surgical adhesive. A drain is routinely placed to prevent the risk of postoperative hematoma and is typically removed on postoperative day one.

Fig. 8.

Final cone beam computed tomography scan confirms optimal implant placement consistent with the preoperative planning.

3. Illustrative case

A 65-year-old male presented with persistent mechanical low back pain and neurogenic claudication, reftractory to six months of conservative management, including physical therapy, anti-inflammatory medication, and epidural steroid injections. Preoperative imaging revealed a degenerative grade I spondylolisthesis at L4–L5, associated with central canal stenosis due to a large facet cyst. The patient had no history of prior lumbar surgery (Fig. 9). Given the segmental instability and failure of nonoperative care, an L4-L5 MIS-TLIF was indicated. A robot-assisted, navigation-guided workflow integrated with intraoperative neuromonitoring was selected to maximize precision and minimize invasiveness. The procedure was performed according to the previously described technical protocol. Four pedicle screws were placed using a drill-based K-wire technique under robotic guidance with continuous neuromonitoring. A partial hemilaminectomy and facetectomy were performed to decompress the traversing nerve roots. Following meticulous endplate preparation and placement of local autograft, a rectangular interbody cage was inserted under real-time navigation guidance. Intraoperative CBCT confirmed accurate screw positioning and optimal cage positioning (Fig. 10). Total operative time was 105 min, with an estimated blood loss of 20 mL. No neuromonitoring alerts occurred during instrumentation. The patient was mobilized on postoperative day one and discharged home on day three without complications. At one-month follow-up, he reported marked improvement in radicular symptoms and had resumed light daily activities.

Fig. 9.

Illustrative case of a patient affected by grade I L4-L5 degenerative spondylolisthesis showing increased slippage upon flexion at dynamic views (A). Magnetic resonance imaging (B) demonstrated facet join effusion with a large facet cyst.

Fig. 10.

Intraoperative imaging demonstrated correct K-wire placement (A) and, subsequently, optimal cage and screw positioning (B), which was then demonstrated at the final cone beam computed tomography check (C).

4. Discussion

The adoption of MISS continues to expand, due to its ability to facilitate complex procedures while minimizing soft tissue disruption. Navigated and robotic systems have emerged as key enablers of this evolution, offering tangible benefits in terms of both surgical accuracy and patient outcomes. Numerous studies have shown that MISS is associated with reduced blood loss, lower risk of facet joint violation, decreased revision rates, shorter hospital stays, and minimized radiation exposure, all while improving screw placement accuracy compared to conventional free-hand techniques (Fatima et al., 2021; Fan et al., 2017; Kantelhardt et al., 2011).

The workflow presented in this technical note integrates three core technologies, namely robotic assistance, real-time navigation, and intraoperative neuromonitoring into a unified, reproducible platform for MIS-TLIF (Vadalà et al., 2025). This structured approach promotes safety and precision across all critical surgical steps, while streamlining intraoperative logistics and supporting team coordination.

Robot-assisted pedicle screw placement has demonstrated improved trajectory accuracy and reduced superior facet joint violation rates compared to both freehand and fluoroscopy-guided techniques (Russo et al., 2025). In this workflow, the use of a drill-based K-wire technique guided by real-time navigation and confirmed by dual-stage tEMG adds an additional layer of safety. This is particularly advantageous in anatomically challenging scenarios, such as narrow pedicles or rotational deformities. Neuromonitoring functions as a dynamic safeguard during both drilling and definitive screw insertion, further reducing the likelihood of neural injury (Biscevic et al., 2020). Whereas surgical workflows of robotic-assisted navigated MIS-TLIF have been previously described, limited attention has been dedicated to the use of tEMG during pedicle screw placement (Wan et al., 2024; Altorfer et al., 2024; Godzik et al., 2019; Palsma and Chua, 2025). This relative underutilization may promote overreliance on navigation-based imaging, which often lacks the direct anatomical visualization and tactile landmarks available in traditional open surgery. However, discrepancies between intraoperative imaging and true anatomy can still occur, potentially leading to serious complications secondary to registration errors, trajectory deviations, soft-tissue or large osteophyte interposition, and intraoperative patient movement (Loggia et al., 2025).

Several robotic and navigation platforms currently in use report high accuracy rates (>95%) for screw placement based on the Gertzbein and Robbins scale (GRS). In a recent analysis of 180 pedicle screws, we have demonstrated that the described workflow resulted in 98.3% of clinically acceptable screws (GRS grades A and B), with minimal facet joint violation, with only 2.5% of screws contacting the superior facet (Yson grade 1) (Vadalà et al., 2026). Interestingly, although millimetric deviations were found compared to the software-planned screw trajectories, these did not result in loss of accuracy or pedicle breaches.

Apart from providing substantial advantages, many navigation systems suffer from practical limitations, including bulky design, complex user interfaces, and the need for additional personnel, which can disrupt the workflow and increase surgical time (Liounakos et al., 2021). Compared to these systems, whose characteristics have been extensively described in the literature, the LoopX® offers distinct advantages. Wireless operation allows image acquisition from outside the OR reducing radiation exposure to staff. Its compact design and rail-mounted mobility improve maneuverability and adaptability to different patient morphologies and table configurations. Nonetheless, certain table-frame combinations, including specific radiolucent frames, may present compatibility constraints that must be considered during preoperative planning.

In our workflow, a “scan-and-plan” strategy is employed. After the reference frame is positioned, the surgical team exits the operating room while the CBCT scan is performed, shielding staff from radiation. Screw planning is conducted by an unscrubbed assistant during surgical exposure of the target level, enabling parallel workflow streams and minimizing idle time. Previous studies have reported a 54–74% reduction in radiation exposure using similar protocols compared to traditional fluoroscopy-based techniques (Kantelhardt et al., 2011; Liounakos et al., 2021; Hyun et al., 2017). The incorporation of a robotic arm further improves trajectory fidelity. For example, in a case series by Pojskic et al. (Pojskić et al., 2021), the robotic alignment module achieved 94% accuracy in thoracolumbar screw placement, though the retrospective nature of the study and heterogeneous patient sample limit generalizability.

Despite these benefits, several practical considerations and pitfalls have been identified. Efficient OR logistics and precise sterile draping are essential to prevent contact with the imaging gantry, which may obstruct image acquisition. The drill guide technique, while highly accurate, requires proper orthogonal alignment to prevent skiving, particularly in cases with a medial entry point and lateral trajectory (Kochanski et al., 2019). To mitigate this, the drill guide includes sharp anchoring teeth designed to improve cortical engagement. Common robotic challenges such as planning inaccuracies, loss of tracking, drill skiving, and software-related delays must also be considered and proactively managed. Indeed, among the various challenges associated with robot-assisted screw placement, the skiving phenomenon may occur unnoticed, potentially causing nerve root injury. Our multimodal approach, combining navigation and neuromonitoring, helps detect this issue in real time. Furthermore, the K-wire–first technique provides additional tactile feedback, allowing the surgeon to recognize the characteristic loss of resistance when entering the cancellous bone, thereby confirming the correct trajectory. Beyond its technical advantages, this workflow holds significant educational value. By breaking the procedure into standardized, verifiable steps supported by multimodal guidance, it may offer a robust platform for training surgical teams and facilitating the broader adoption of advanced MISS techniques. In our institutional experience, proficiency with the proposed workflow can be attained after approximately 25 cases.

Nevertheless, the described approach has limitations. First, it strictly depends on the availability of advanced intraoperative imaging, navigation, robotic platforms, and neuromonitoring systems, which may not be universally accessible. Indeed, such enabling technologies are affected by considerable costs, which might significantly affect their adoption in middle-to-low-income settings and outside highly specialized environments. The learning curve and initial setup time may also increase operative duration during the early phase of implementation, with negative repercussions on cost-efficacy aspects. Furthermore, as the proposed workflow is optimized for the NuVasive neuromonitoring and Brainlab navigation ecosystems, the highlighted advantages might be nuanced in the absence of these specific devices. Future research should focus on long-term clinical outcomes, complication rates, radiation exposure, and cost-effectiveness compared to conventional fluoroscopy-guided MIS-TLIF.

5. Conclusion

This technical note presents a streamlined workflow for MIS-TLIF that integrates robotic guidance, intraoperative CBCT imaging, navigation, and neuromonitoring. By combining these technologies, the approach enhances pedicle screw accuracy, improves intraoperative safety, and reduces variability across surgical teams. The described “scan–plan–execute” strategy facilitates precise instrumentation and efficient workflow coordination, while also minimizing radiation exposure and operative disruptions. In addition to its technical merits, this workflow offers significant value as an educational and training platform for the next generation of spine surgeons.

Declaration of generative AI and AI-assisted technologies in the manuscript preparation process

During the preparation of this work the authors used ChatGPT to prepare Fig. 1D. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.