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

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.