Open versus minimally invasive transforaminal lumbar interbody fusion (MIS TLIF)—a narrative review

Introduction

Lumbar interbody fusion is a well-established surgical strategy for degenerative lumbar spine disease. The transforaminal lumbar interbody fusion (TLIF) technique was first introduced by Harms and Rolinger in 1982 (1). Traditional open TLIF involves a midline posterior approach with significant paraspinal muscle dissection to access the disc space. To reduce the approach-related morbidity of open TLIF like muscle injury, blood loss, and infection risk, minimally invasive TLIF (MIS TLIF) was developed (2). MIS TLIF was first described by Foley and Lefkowitz in 2002, utilizing a paramedian Wiltse muscle-splitting approach with tubular retractors (3). This approach preserves midline musculature and aims to minimize soft-tissue damage while achieving the same goals of decompression and fusion as open surgery (4).

Despite the intuitive benefits of MIS techniques, there have been ongoing debates and research comparing open vs. MIS TLIF regarding their clinical outcomes, fusion success, complications, and cost-effectiveness. Some early studies showed MIS approaches can reduce perioperative morbidity, but questions remained about long-term fusion rates, radiation exposure, the steep learning curve for MIS, and whether MIS truly confers superior overall value. Additionally, some critique that MIS TLIF prohibits correcting or producing adequate segmental alignment, which has been a topic of recent investigations. Bridging these knowledge gaps is important for guiding surgical decision-making and patient counseling.

This review aims to compare open vs. MIS TLIF across surgical, clinical, radiological, and cost-related domains, highlighting the latest high-quality evidence. We present this article in accordance with the Narrative Review reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-62/rc).

Methods

We performed a literature search in PubMed focusing on publications from 2015 through 2025 (with inclusion of earlier landmark studies for historical context). Priority was given to:

• Randomized controlled trials (RCTs) comparing MIS vs. open TLIF;
• Systematic reviews and meta-analyses (especially from high-impact spine journals);
• Large cohort studies with mid- to long-term follow-up;
• Recent narrative reviews in spine specialty journals for context.

Search strategy

We used keywords such as “open TLIF versus MIS TLIF”, “minimally invasive spine fusion outcomes”, “MIS TLIF navigation robotic”, “MIS TLIF learning curve”, and related terms. We included studies of degenerative lumbar conditions treated with TLIF. We excluded small case series (<30 patients) and older studies unless historically important (Table S1 and Table 1).

Discussion

Technical differences

Both open and MIS TLIF share the fundamental goal of achieving a 360° fusion through a posterior approach, but the techniques differ in exposure and muscle disruption. In open TLIF, a midline incision and bilateral muscle detachment from the spine allow wide exposure of the lamina, facet joints, and disc space. The disc is accessed by resecting the facet and performing a thorough discectomy, then placing an interbody cage and bilateral pedicle screws under direct visualization. This extensive exposure facilitates implant placement and neural decompression, but at the cost of significant muscle injury and blood loss. One of the key advantages of the open approach is its direct access to the posterolateral gutters along the transverse processes, enabling placement of bone grafts for supplemental posterolateral fusion.

In MIS TLIF, a similar interbody fusion is accomplished through one or two small paramedian incisions. A tubular retractor, typically around 18–22 mm diameter, is inserted through the natural muscle planes (Wiltse approach) to reach the lamina and facet of the target level. The surgeon uses an operating microscope or endoscope to perform a laminotomy, foraminotomy, and facetectomy through the tube, removing the disc and inserting a cage. Pedicle screws are placed percutaneously through small stab incisions using fluoroscopic or navigated guidance. The MIS approach limits muscle stripping to the immediate path of the tube and screw tracts, preserving the midline attachments and soft tissue. Table 2 outlines key distinctions.

Both approaches can achieve adequate neural decompression and interbody fusion, but MIS proponents emphasize the reduced iatrogenic muscle injury and smaller incision of MIS TLIF. By avoiding extensive muscle stripping, MIS TLIF may preserve postoperative paraspinal muscle function, potentially leading to less postoperative pain and quicker recovery. However, MIS TLIF has a steeper technical learning curve due to the limited operative corridor and reliance on fluoroscopic or navigational imaging, which is discussed further below. Open TLIF offers a familiar, panoramic view of anatomy which some surgeons prefer, especially in complex cases.

Learning curve and technical demands of MIS TLIF

Several recognized challenges of MIS TLIF come from the learning curve associated with mastering the tubular retractor system, fluoroscopic navigation, and percutaneous instrumentation techniques. Early in a surgeon’s experience, MIS TLIF often takes significantly longer operative time and may have higher complication rates compared to their open cases. Studies have attempted to quantify this learning curve. A 2024 systematic review on learning curves in MIS spine surgery found that for lumbar fusion procedures, the operative time tended to stabilize (plateau) after roughly 30–35 cases of experience with MIS TLIF (5). In other words, a surgeon’s first 30 or so MIS TLIF cases are typically slower and more error-prone, but after this threshold, efficiency improves and approaches that of open surgery.

Several single-surgeon series corroborate that approximately 30–50 cases are required to become proficient in MIS TLIF. For example, Nandyala et al. reported that their complication rates dropped substantially after the first around 33 MIS TLIF cases, reflecting improved technique with experience (6). Similarly, Lee et al. noted operative times significantly decreased after around 30–40 MIS TLIF cases as the surgeon’s skill with the minimally invasive approach matured (7). Common early complications during the learning phase include technical issues like pedicle screw misplacement or dural tears, often related to the constrained visualization (5). With experience and the aid of technology (navigation/robotics), these complication rates decline to be on par with open surgery (5).

It is important to note that the learning curve is procedure-specific and also technology-dependent. Surgeons already comfortable with microsurgery and fluoroscopy may adapt faster to MIS TLIF. Structured training, cadaver labs, and proctorship can mitigate the learning curve. In recent years, the learning process has improved with advanced imaging, real-time neuronavigation and robotic guidance help surgeons place screws and navigate anatomy more confidently even in their early MIS cases. Nonetheless, the consensus is that MIS TLIF is technically demanding, and adequate case volume is required to achieve optimal results. This factor underscores the importance of patient selection early on, surgeons in the learning phase might select relatively straightforward cases, single-level, non-obese patients with clear anatomy, for MIS TLIF and reserve more complex cases for open surgery until sufficient MIS expertise is gained.

Technological advances: navigation and robotics in MIS TLIF

The evolution of MIS TLIF has been closely tied to advances in intraoperative imaging and robotic technology. Initially, MIS TLIF was performed with fluoroscopy guidance, which prolonged radiation exposure and had a steep learning curve for accurate screw placement. Modern navigation systems and robotic-assisted platforms have greatly enhanced the precision and ease of MIS instrumentation. Spinal surgery has progressed from relying on C-arm fluoroscopy to using computer-assisted navigation and now robotic guidance, improving accuracy while reducing the radiation to surgeons (5).

Navigation

In navigated MIS TLIF, an intraoperative 3D scan is obtained (using O-arm or similar platform) and instruments are tracked in real time on the patient’s anatomy. This allows surgeons to visualize pedicle trajectories on a screen without continuous fluoroscopy. Navigation increases confidence in screw placement and cage positioning through small incisions, potentially shortening the learning curve. A study by Shafi et al. showed navigation can improve screw accuracy and reduce malposition rates compared to freehand fluoroscopy in MIS cases (8). However, navigation alone still relies on the surgeon’s hand-eye coordination and does not physically constrain the instrument path. Surgeons must still rely on their tactile feedback and working knowledge of spinal anatomy to ensure safe and proper placement of instrumentation.

Robotic assistance

The latest innovation is integrating robotic guidance with navigation. Robotic systems use preoperative or intraoperative imaging to plan optimal trajectories for pedicle screws, then a robotic arm guides the surgical drill along the planned path. This has specific biomechanical advantages. Shafi et al. study compared MIS TLIF done with robotic navigation (RN) vs. standard navigation alone (8). They found the robot-assisted group was able to safely use larger diameter and longer pedicle screws on average: mean screw diameter 7.25 mm with robot vs. 6.72 mm without robot (P<0.001), and screw length 48.4 vs. 45.6 mm (P<0.001). Accuracy of screw placement was similarly high in both groups (~88% ideal placement), but the robot group had zero high-grade breaches (0%) vs. 1.2% breaches with navigation alone. The ability to insert bigger screws via a minimally invasive approach can increase construct stability, which may enhance fusion rates. The authors conclude that robotic platforms enable placement of an “optimal screw” with maximal purchase while maintaining safety.

Another benefit of robotics is reduced radiation to the surgical team (9,10). Since the robotic system guides the instruments, surgeons are not as reliant on continuous fluoroscopy, which is especially advantageous in multi-level cases or when operating with heavy protective lead aprons. Early data also suggest that robotic MIS TLIF may modestly improve operative efficiency once the team overcomes the setup time, particularly for complex anatomies where finding pedicles percutaneously is challenging.

Despite these advantages, robotic systems also have important limitations. These include longer setup times, potential for systematic registration errors or skiving during screw placement, and the rigidity of the robotic arm, which limits its use to minimally invasive techniques. Additionally, current platforms provide limited planning support for interbody fusion and do not assist with decompression or discectomy work (11).

Perioperative outcomes: operative time, blood loss, hospital stay, and radiation exposure

One practical way to compare open and MIS TLIF is by perioperative metrics such as operative duration, blood loss, and length of hospital stay. Earlier criticisms of MIS TLIF were that it took significantly longer and had similar or greater complication rates early on. However, with growing experience and better tools, many studies now show MIS TLIF can be performed in comparable time to open, with certain clear perioperative advantages.

Operative time

The evidence on operative times is mixed. Some individual studies show MIS TLIF taking longer than open, especially in a surgeon’s initial cases, whereas others show no significant difference once the surgeon is proficient. A comprehensive 2019 meta-analysis by Hammad et al. found no significant difference in operative time between MIS and open TLIF on average (P=0.78) (2). Similarly, a 2020 meta-analysis of 7 RCTs reported only around 4 minutes difference favoring open, which was not statistically significant (12). However, registry data from the Quality Outcomes Database (QOD) indicate MIS TLIF can still be somewhat longer in real-world practice, in a series of around 300 patients with degenerative spondylolisthesis, MIS cases averaged 228 vs. 190 minutes for open (P<0.001) (13). In summary, operative times tend to equalize with surgeon experience, and high-volume centers have reported performing single-level MIS TLIF in approximately the same time as open.

Blood loss

Virtually all studies conclude that MIS TLIF results in significantly less intraoperative blood loss than open TLIF. By minimizing muscle dissection and exposure, MIS reduces venous oozing and muscle bleeding. The meta-analysis by Hammad et al. found MIS had dramatically reduced blood loss (pooled analysis, P<0.001) (2). Miller et al. in a meta-analysis of RCTs quantified this as roughly 200 mL less blood loss on average with MIS (12). Another meta-analysis by Li et al. of RCTs similarly found a 290 mL mean reduction in blood loss with MIS TLIF (14). Large cohort comparisons echo this: in the QOD study, open TLIF patients lost 300 vs. 110 mL with MIS TLIF (P<0.001) (13). This sizeable difference often translates to lower transfusion rates and less postoperative anemia in MIS patients. Reduced blood loss is one of the clearest perioperative benefits of MIS TLIF.

Hospital stay

A faster recovery and shorter hospitalization are a proposed benefit of MIS surgery due to less pain and morbidity. Many studies do show a modest reduction in length of stay (LOS) with MIS TLIF. Miller et al. reported MIS TLIF patients were discharged about 2.2 days earlier than open on average (P<0.001) (12). Not all studies show a large difference; Li et al. did not find a statistically significant LOS difference (14), possibly due to heterogeneity in discharge criteria. In the QOD registry data, MIS patients had a slightly shorter mean stay (2.9 vs. 3.3 days, P=0.08) that did not reach significance (13), but note that both those LOS values are relatively short, reflecting many centers’ move toward <3 day stays even for open. Importantly, MIS techniques have enabled more patients to be discharged home earlier, and even same-day or next-day discharges in select cases (15,16). Thus, while the exact LOS benefit may vary, MIS TLIF generally allows at least a mildly shorter hospital course on average, potentially reducing hospital-related costs and infection risk.

Radiation exposure

One trade-off of MIS TLIF is higher intraoperative radiation exposure, due to heavy reliance on fluoroscopy in traditional MIS. Meta-analyses confirm that fluoroscopy time is significantly longer in MIS TLIF (12,14). For instance, one analysis noted MIS cases had to use fluoroscopy on average 48 seconds longer per case than open (12). With current protocols, this is generally a manageable increase and has less relevance as navigation/robotic techniques reduce the need for continuous fluoroscopy. In fact, the use of navigation largely shifts radiation away from the surgeon, and robotics can further cut down real-time fluoroscopy usage. Therefore, while older studies list radiation as a drawback of MIS, this is becoming less of an issue with modern practice.

These perioperative findings are summarized in Table 3, drawing on recent high-level evidence.

Clinical outcomes: patient-reported outcomes and fusion rates

The ultimate measure of any surgical technique is the clinical outcome for the patient: pain relief, functional improvement, and quality of life. An important question has been whether the less invasive approach compromises the effectiveness of the fusion or the durability of symptom relief compared to open TLIF. Based on high-quality evidence over the past decade, MIS TLIF achieves equivalent patient-reported outcomes and fusion rates as open TLIF in appropriately selected patients, with some studies suggesting slight early benefits in patient recovery as reported below.

Pain relief and function

Both open and MIS TLIF result in significant improvements in back and leg pain scores and disability indices from preoperative baselines. Numerous comparative studies and reviews indicate that at short-term and mid-term follow-up (1–2 years), there are no substantial differences in visual analog score (VAS) pain scores or Oswestry Disability Index (ODI) between MIS and open TLIF patients (2,14). For example, Li et al. meta-analysis found no significant difference in postoperative VAS or ODI between groups (14). Miller et al. also reported that one-year pain scores were comparable, and ODI was only slightly better in MIS by 3 points (12).

Importantly, long-term outcomes (≥5 years) appear equivalent. The largest long-term study to date including 297 patients from a multicenter registry, compared MIS vs. open TLIF for grade I degenerative spondylolisthesis with a 5-year follow-up (13). Both groups had significant improvements in ODI and pain scores, and there were no differences in disability, back pain, leg pain, quality of life, or patient satisfaction at 60 months between MIS and open. This robust data suggests that for long-term patient-reported outcomes, MIS TLIF is just as effective as open TLIF. Patients in both categories report similar pain relief and functional gains in the long run.

It is worth noting that some studies have found early postoperative advantages for MIS in terms of quicker mobilization and less immediate postoperative pain (17-19). For instance, a study by Qin et al. reported that MIS TLIF patients experienced lower VAS back pain scores both at 1 week (3.4 vs. 5.0 in open TLIF) and at 6 months (2.0 vs. 3.5) (17). Similarly, Adogwa et al. found that the duration of narcotic use was significantly shorter in the MIS group compared to the open TLIF group (2.0 vs. 4.0 weeks), likely due to reduced soft tissue disruption (17,19). However, by 12 months these differences typically even out. Overall, early recovery might be smoother with MIS, but final outcomes converge.

Fusion rates

A critical outcome for interbody fusions is the fusion (arthrodesis) success rate, since a nonunion (pseudarthrosis) can lead to pain or hardware failure. MIS TLIF achieves fusion rates equivalent to open TLIF in degenerative cases (2,12,20). Earlier concerns that limited exposure might reduce the ability to decorticate and graft effectively have not borne out in the data. Miller et al. reported a 1-year pseudarthrosis incidence of 5.5% in MIS vs. 6.5% in open (risk ratio 0.84, P=0.67) (12). Hammad et al. similarly found no difference in fusion outcomes; both techniques showed high fusion rates (2).

Long-term fusion durability also appears similar. In the 5-year QOD study, there was no difference in cumulative reoperation rates between MIS and open (reoperations 5.6% vs. 11.6%, P=0.14) (13), and clinical adjacent segment disease (ASD) requiring surgery was the most common reason for reoperation in both groups, occurring in 7% of patients in the open group and 4% in the MIS group.

Complication profiles

The Hammad et al. meta-analysis found the pooled complication rate was slightly lower in MIS TLIF (11.3%) vs. open TLIF (14.2%), but this difference just missed statistical significance (P=0.05) (2). Many individual studies show no significant difference in aggregate complications between the two. A systematic review by Qin et al. noted that complication rates were 7% for open and 6.5% for MIS (17). Similar results were noted by Miller et al. meta-analysis of RCTs, overall complication rates were comparable between the two groups (risk ratio, 1.03; P=0.94) (12).

Comparative literature suggests that MIS TLIF is at least as safe as open TLIF, with several specific complications occurring less frequently in MIS. A meta-analysis reported an infection rate of 1.2% in the MIS group compared to 4.6% in the open group (P=0.0001) (21), and evidence indicates it may also lead to fewer dural tears, though overall durotomy rates are similar (22). Neurologic injury rates are low and not significantly different between techniques (2). Concerns about higher pedicle screw malposition in MIS have diminished with modern techniques, and screw accuracy is comparable with early MIS learning-curve issues notwithstanding (23,24). MIS TLIF can have a slightly higher incidence of cage migration in inexperienced hands (3 cases in MIS TLIF group compared to 1 case in the open TLIF group), but overall implant-related complication rates remain low for both approaches (25). Crucially, the long-term benefit of MIS TLIF in reducing adjacent segment degeneration is becoming clear, with MIS associated with significantly less radiographic and clinical ASD and lower adjacent-level reoperation rates than open TLIF in intermediate and long-term follow-up. In one study with five- to seven-year follow-up, radiographic ASD (R-ASD) was observed in 21.8% of MIS patients vs. 35.7% in the open group (P=0.023). Similarly, symptomatic ASD (S-ASD) occurred in 14.5% of MIS vs. 28.6% of open TLIF patients by five years, while operative ASD (O-ASD) rates did not significantly differ between the groups at seven years (7.2% vs. 11.9%) (26,27).

Radiological and biomechanical outcomes

MIS TLIF is as capable as open TLIF in achieving radiological goals, restoring alignment and disc height and obtaining a solid fusion. There is no evidence of any radiographic disadvantage to MIS; if anything, trends like less soft tissue scarring and possibly less adjacent degeneration are advantages. A study by Modi et al. illustrates the similar lordosis improvements; open TLIF improved segmental lordosis by 2.5° vs. MIS 2.9° with no significant difference (25). These subtle radiographic gains underline that TLIF (open or MIS) is not primarily a deformity correction tool but is effective for stabilizing a motion segment.

Radiographically detected pseudarthrosis rates are comparable. Thus, surgeons should focus on proper techniques like endplate preparation, adequate cage and graft, compression, regardless of approach, rather than worry that MIS per se might fuse less reliably. Current data are reassuring that fusion and alignment outcomes are similar for MIS and open TLIF (12,25).

One significant and previously common critique of MIS TLIF is that it can be a kyphosing procedure. However, several clinical studies and meta-analyses have refuted this claim (28,29), particularly when certain techniques are employed to maximize surgical correction. The first of which is a limited bony resection such as with a transfacet MIS TLIF, where most of the resection involves the superior articular process, leaving the medial inferior process, lateral superior process intact. Additionally, decortication and release of the contralateral facet allows improved contralateral foraminal height increase while also providing an additional point for osseous fusion. Finally, the use of expandable interbody devices has been found to maximize direct and indirect decompression while allowing for the creation of greater segmental lordosis (30). The use of an expandable cage has been found to be a positive predictor for a significant increase in postoperative lordosis after MIS TLIF. Consequently, greater increases in segmental lordosis have been associated with greater reductions in postoperative leg pain (29).

Cost and resource utilization

While MIS TLIF might incur higher upfront operative expenses, it frequently results in overall cost savings by reducing postoperative resource needs. This is reflected in both observational data and meta-analyses. For instance, a 2022 systematic review reported that MIS approaches were associated with significantly lower overall, direct, and indirect surgical costs compared to open techniques, with reported cost savings ranging from 2.5% to 49% in favor of MIS procedures (4). This counterintuitive finding likely includes the net effect of shorter hospitalization and fewer complications. Therefore, from a payer perspective, MIS TLIF can be economically advantageous for the appropriate indication.

It’s important to individualize, in extremely complex cases requiring multiple levels or special implants, open surgery might be more straightforward and cost less operative time. But for the standard 1–2 level degenerative case, MIS TLIF provides equal outcome for equal (or less) cost in the modern setting (2). As technology continues to improve and more procedures shift to outpatient settings, MIS TLIF’s value proposition may further increase.

Patient selection and indications

Patient selection considerations include factors like body habitus, anatomical complexity, number of levels, presence of previous surgeries, and the specific pathology. Based on current evidence:

• Ideal candidates for MIS TLIF:
  • Single-level or two-level degenerative spondylolisthesis or instability with leg pain, back pain, or neurogenic claudication, especially in patients who are obese or at higher risk for wound complications.
  • Patients with BMI ≥30 kg/m²: strong consideration for MIS due to lower infection risk and faster recovery (31).
  • Those with minimal prior surgery at the level, MIS can still be done, avoiding a new large incision through scar.
  • Patients who value a quicker return to work and have support for an MIS approach.
  • Cases where moderate correction of lordosis is needed without complex osteotomy, MIS TLIF can add a few degrees of lordosis effectively (25).
• Patients/scenarios favoring open TLIF:
  • Multi-level fusions (≥3 levels) requiring long constructs, open allows one incision to address all levels more time-efficiently.
  • High-grade spondylolisthesis or severe deformity, open approach facilitates greater reduction and direct visualization of nerve roots, though MIS can be attempted in challenging cases (32).
  • Extensive prior surgery with dense scarring, open may reduce risk of neural injury by providing wide exposure to discern anatomy.
  • Infectious cases: interesting to note, MIS has been used for spinal infections to evacuate abscess and stabilize (2), but if there is a big phlegmon or need for debridement, open might be preferred.

This narrative review synthesizes high-quality evidence, including RCTs, meta-analyses, and large cohort studies, published between 2015 and 2025, with the inclusion of select landmark studies prior to 2015 for historical context. However, it is not a systematic review. As such, formal methodological processes such as comprehensive database searching, risk-of-bias assessments, and meta-analytic pooling of data were not conducted. While every effort was made to highlight relevant and high-impact literature, the potential for selection bias remains. Readers should interpret the findings in the context of this narrative format, which is intended to provide a clinically focused and practical summary rather than a quantitative synthesis.

Conclusions

Over the past decade, a robust body of evidence has emerged comparing open vs. MIS TLIF. High-quality studies, including RCTs, large meta-analyses, and long-term cohort data, consistently demonstrate that MIS TLIF achieves equivalent fusion rates and long-term clinical outcomes as open TLIF, while conferring several short-term advantages. MIS TLIF is associated with significantly less blood loss, smaller incisions, lower infection risk, and faster postoperative recovery. These benefits come with the caveat of a longer learning curve and the need for advanced imaging technology, but with modern navigation and robotics, many historical challenges of MIS have been overcome.

The surgeon’s armamentarium now includes MIS TLIF as a mature, proven technique. When the clinical situation and resources allow, MIS TLIF should be strongly considered given its advantages in morbidity reduction. Open TLIF remains invaluable for cases requiring its strengths. By understanding the nuances of both, surgeons can tailor the approach to each patient to maximize outcomes and safety. The mantra “least invasive approach that achieves the goal” aptly applies, and for many lumbar fusion patients, MIS TLIF has fulfilled that promise in the last 20 years of advancement.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mitchell S. Fourman) for the series “Advances in Minimally Invasive Spine Surgery” published in AME Surgical Journal. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-62/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-62/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-62/coif). The series “Advances in Minimally Invasive Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. S.Q. received consulting fees from BICMD, Inc., Stryker K2M, Globus Medical, and Viseon, Inc.; received royalties from LifeLink.com Inc. and SeeALL AI; and received honoraria from AMOpportunities and speakers bureau participation with Globus Medical, Inc. He received research support from Viseon, Inc. through Hospital for Special Surgery. He has ownership interests in Tissue Differentiation Intelligence, Spinal Simplicity, Sustain Surgical Inc., HS2 LLC, LifeLink.com Inc., and SeeALL AI. He serves as advisory and leadership roles with LifeLink.com Inc., North American Spine Society (NASS) and multiple professional societies. He serves on the editorial boards of Contemporary Spine Surgery, Annals of Translational Medicine, and Hospital for Special Surgery Journal and in committee/leadership roles with SMISS, LSRS, CSRS, ISSAS, ABJS and NASS. He also serves in leadership or fiduciary role in Sustain Surgical Inc., HS2, LLC, SeeALL AI and Minimally Invasive Spine Study Group. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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