Robotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion.

Background: Robotic-assisted (RA) minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) is an advantageous combination of 2 techniques utilized to treat lumbar degenerative pathologies. Given the lack of direct visualization of anatomic landmarks in MI-TLIF, radiography is necessary for accurate pedicle screw placement Description: With the patient under general anesthesia and in a prone position, 2 reference arrays attached to the patient via bilateral posterior sacroiliac spine incisions are made in order to perform intraoperative computed tomography (CT) with an array-integrated CT scanner and to calibrate the robotic instruments. Surgical planning for the screws and interbody cage is performed on the interface of the robotic tool. With use of the robotic arm, percutaneous pedicle screws are placed bilaterally. A tubular retractor is then docked over the facet joint. A unilateral facetectomy is performed, followed by a complete discectomy with end plate preparation. Bone graft is placed into the disc space. An expandable interbody cage is filled with bone graft, tamped into place, and expanded. The disc space is then backfilled with more bone graft. Rods are inserted percutaneously. Placement of all instrumentation is confirmed fluoroscopically, and the wounds are closed in a multilayered approach. Alternatives: Nonoperative alternatives to RA MI-TLIF include physical therapy, pharmacologic treatment, and lumbar and interlaminar transforaminal epidural corticosteroid injections. Surgical alternatives include RA open TLIF, MI-TLIF with fluoroscopy or navigation, posterior lumbar interbody fusion, lateral lumbar interbody fusion, and anterior lumbar interbody fusion Rationale: RA screw placement has been shown to be more accurate than fluoroscopy-guided placement, with a lower incidence of pedicle wall penetration or facet joint invasion, better insertion angle, and less blood loss Expected Outcomes: RA MI-TLIF offers several advantages compared with other types of MI-TLIF Important Tips: Because of a smaller Kambin triangle, lateral lumbar interbody fusion is preferred for the upper lumbar levels. If MI-TLIF is chosen, RA is particularly valuable since screw trajectories can be planned to allow for removal of the superior portion of the caudal pedicle without compromising screw fixation.For successful fusion, utilize a large expandable interbody cage with autograft and allograft bone. The contralateral facet can be prepared as a fusion bed, as well. Avoid the use of bone morphogenetic protein, as this can result in neuroforaminal bone growth Acronyms and Abbreviations: RA = robotic-assistedMI = minimally invasiveTLIF = transforaminal lumbar interbody fusionPSIS = posterior superior iliac spinePLIF = posterior lumbar interbody fusionLLIF = lateral lumbar interbody fusionALIF = anterior lumbar interbody fusionDRB = dynamic reference baseBMP = bone morphogenetic proteinBMI = body mass indexCT = computed tomographyXR = X-rayMRI = magnetic resonance imagingOR = operating roomAP = anteroposteriorCSF = cerebrospinal fluidVAS = visual analog scaleEBL = estimated blood lossLOS = length of stayPT = physical therapyPRN = as needed.