Ebook Minimally invasive spine surgery techniques, evidence, and controversies: Part 1

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Roger Härtl  |  Andreas Korge

Minimally Invasive Spine Surgery
Techniques, Evidence, and Controversies

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Roger Härtl  |   Andreas Korge

Minimally Invasive Spine Surgery
Techniques, Evidence, and Controversies
711 illustrations and images, and 35 cases.

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Library of Congress Cataloging-in-Publication Data is available from the publisher.

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Copyright © 2012 by AOSpine, Switzerland, Clavadelerstrasse 8, CH-7270 Davos Platz
Distribution by Georg Thieme Verlag, Rüdigerstrasse 14, DE-70469 Stuttgart and Thieme New York, 333 Seventh Avenue, US-New York, NY 10001

ISBN: 978-3-13-172381-9
e-ISBN: 978-3-13-172441-0

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Foreword

Foreword

John K Webb FRCS
Consultant Spinal Surgeon
Centre for Spinal Surgery and Research
University Hospital
Nottingham NG7 2UH
United Kingdom
Co-founder and first President of AOSpine

The authors are to be congratulated on producing such a
comprehensive book on minimally invasive surgical techniques. They stress that access strategies should not compromise the goal of the surgical procedure, the importance
of the knowledge of the anatomical planes, and an appreciation of the anatomy from the experience of performing
open procedures. They accept there is a long learning curve
and correctly recommend a strategy of performing more
straightforward cases at the beginning of a surgeon´s introduction to minimally invasive surgery. A concept that many
inexperienced surgeons find difficult to acknowledge.
The importance of the four “pillars” of MISS are emphasized:
microsurgical techniques; access strategies to the spine; imaging/navigation techniques; and specialised instruments
and implants. Some chapters use standard approaches that,
with recent technology, have been reduced to very small

incisions, while other chapters describe very innovative approaches. It is pleasing to see that the basic AOSpine surgical principles have been taken into account when formulating the approaches. Even with the drive for all approaches
to be minimal, authors include a realistic valuation that, in
some cases, MISS techniques could be inappropriate.
Radiation exposure is a concern and should be closely monitored.
The book is a comprehensive coverage of all techniques in
minimally invasive spine surgery. A word of caution, some
approaches are very complex and the surgeon will have to
be highly skilled, requiring three-dimensional thinking; such
techniques may be out of reach for lesser mortals. Nevertheless, the descriptions, pictures, and diagrams are excellent and have made the understanding of the approaches
very clear.

This book is beautifully produced and written to a very high
standard, a standard one would expect from such eminent
surgeons.
I strongly recommend Minimally Invasive Spine Surgery—
Techniques, Evidence, and Controversies to all current and
up-and-coming spine surgeons developing their minimally
invasive surgical techniques. I would go so far as to say this
is “a must have” book for such surgeons. In fact, it should
be on the bookshelf of all spine surgeons.

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Dedication

Dedication
To Alasha, Sebastian and Julian.
To Heidrun, Louisa and Daniel.
For all their love, support, understanding and patience,
without which, this book would not have been possible.

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Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies  Roger Härtl, Andreas Korge

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Acknowledgments

Acknowledgments
We would like to thank the many authors, educators, illustrators, designers, project managers, and technical and
administrative contributors that worked tirelessly to bring
this publication to life.
• Jeff Wang, Khai Lam, and Frank Kandziora, the original
members of the expert group team (together with Roger Härtl and Andreas Korge) for bringing together the
ideas for the book
• Our illustrious team of authors, from all corners of the
world, many juggling professorial and academic positions, and or very busy medical and surgical practices
• Kathrin Lüssi and Patricia Codyre and the entire AO
Education team, led by Urs Rüetschi
• Claas Albers from AOTK; and the AOSpine team, led by
Alain Baumann
• Amber Parkinson and Michael Gleeson, Project Coordinators

• Marilyn Schreier from Syntax language editing
• Jecca Reichmuth for scientific illustrations and Roger
Kistler for typesetting
• Carl Lau, Cristina Lusti, and Susanne Klein for proofreading, and for Susanne's essential administrative work
(keeping track of our world traveling authors)
• Patrick Hiltpold from AO CID for compiling the evidencebased summaries and PICO analyses
• Rosalie Villano from Leica Microsystems, Thomas Kienzle
from Richard Wolf Medical Instruments, and Drew
Messler from Micro Image Technologies for supplying

photos and images
• Thieme publishing
Roger Härtl
Andreas Korge

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Introduction

Introduction
This is the first edition of “Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies”. The idea
for the book came out of our work in the AOSpine Expert
Group on MISS and Navigation, around 2008, where we
enthusiastically discussed many of the initial hopes and
controversies that surrounded the evolving field of MISS
with our esteemed colleagues Jeff Wang, Khai Lam and
Frank Kandziora. It was clear to all of us that MISS offered
exciting and potentially effective treatment strategies for
many areas in spinal surgery. However, it also seemed to
be heavily dominated by a small number of champion surgeons and steered by industry, and not necessarily by the
needs of our patients. As a consequence, we embarked on
an ambitious project to critically explore the possibilities,
the current reality, but also the limitations of MISS.
The final product has greatly surpassed our initial expectations. We proudly present a comprehensive, user-friendly
and didactic overview of the techniques, indications and

controversies of currently utilized minimally invasive techniques and spinal navigation in the cervical, thoracic and
lumbar spine for a wide variety of spinal disorders. We
include critical discussions of the pros and cons of these
techniques for our patients, and provide an objective, evidence-based framework of MISS using currently published
literature. We also acknowledge the importance of the surgeon’s individual experience and wisdom by including surgical pearls and “tips and tricks” from master surgeons and
many of the pioneers of MISS.
The book has been divided into five sections that together
cover all areas of MISS: In the “Fundamentals” section, we
explore the principles of MISS, its historical development
as a consequence of advances made in various subspecialties
within surgery, and how its principles perfectly fit the “AO
philosophy”. The sections following cover technical procedures and the science behind particular MISS approaches
based on the anatomic regions: Cervical Techniques,

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Thoracic Techniques, and Lumbar Sacral Techniques—both
posterior and anterior. This comprehensive book not only
provides basic concepts, and the latest clinical and scientific research, but it is also case-based with clear photographs,
x-rays, MRI, CT scans, and illustrations of anatomy and
cases, giving the reader an excellent understanding of the
decision-making process, as well as the whole surgical procedure from preoperative planning to recovery.
In the end, several conclusions can be drawn:
• MISS is here to stay; it is a logical consequence of the
evolution of surgery, based on advances in at least four
areas: microsurgery, navigation, new spinal access strategies, and spinal instrumentation
• MISS offers alternative and frequently advantageous
treatment options in all regions of the spine, and for most

pathologies; it expands our technical capabilities as surgeons and frequently allows the safer and more effective
treatment of patients that were previously not considered
good surgical candidates for a particular operation
• More work is needed; especially in the area of spinal
deformity correction. The success of minimally invasive
spine surgery will depend on the integration of scientific progress, technical expertise, and the surgeon’s
individual experience and good judgment
• Surgeons have to be willing to learn and evolve; they
have to continue to critically and honestly evaluate the
pros and cons of MISS as well as their own results in
each patient.
We hope that neurological and orthopedic spine surgeons
all around the world can benefit from this first edition of
“Minimally Invasive Spine Surgery—Techniques, Evidence,
and Controversies” to improve care of their patients.
We are thankful to our colleagues, families and AOSpine
for the unconditional and enthusiastic support they have
given us throughout the preparation of this book.

Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies  Roger Härtl, Andreas Korge

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Contributors

Contributors
Editors
Roger Härtl, MD

Andreas Korge, MD

Leonard and Fleur Harlan Clinical Scholar in

Head of Department

Neurological Surgery

Spine Center

Associate Professor of Neurological Surgery

Schön Klinik München Harlaching

Director of Spinal Surgery

Harlachinger Strasse 51

Department of Neurological Surgery

81547 München

Weill Cornell Brain & Spine Center

Germany

Starr Building, Room 651
525 East 68th Street
New York, New York 10021
USA

Authors
Beejal Y Amin, MD

Ali A Baaj, MD

Rahul Basho, MD

Assistant Professor

Assistant Professor

Clinical Instructor of Spine Surgery

Department of Neurosurgery

Director, Spine Surgery Program

Department of Orthopaedic Surgery

Loyola University

Division of Neurosurgery

Riverside County Regional Medical Center

Chicago, IL

University of Arizona

26520 Cactus Avenue

USA

1501 Campbell Ave

Moreno Valley, CA 92555

Tucson, AZ 85724

USA

Neel Anand, MD

USA
Rudolf W Beisse, Prof Dr

Director, Orthopaedic Spine Surgery Minimally Invasive
Spine Surgery

Gopalakrishnan Balamurali, FRCS Neuro

Chief Surgeon

Director, Orthopaedic and Neurosurgery Spine Fel-

Consultant Spine and Neurosurgeon

Department of Spine Surgery

lowship

Department of Orthopaedics, Accident and Spine

St Benedict´s Hospital

Spine Center, Cedars-Sinai Medical Center

Surgery

Bahnhofstrasse 5

444 South San Vicente Boulevard, #800

Ganga Hospital

82327 Tutzing

Los Angeles, CA 90048

Coimbatore, Tamil Nadu

Germany

USA

India

Vijay Anand, MD FACS

Eli M Baron, MD

Chief, Scoliosis Service

Clinical Professor of Otolaryngology-Head and Neck

Board Certified Neurosurgeon

Hospital for Special Surgery

Surgery

Spine Surgeon

535 East 70th Street

Weill Cornell Medical College

Cedars-Sinai Spine Center

New York, NY 10021

New York Presbyterian Hospital

444 South San Vicente Boulevard, Suite 800

Professor of Orthopaedic Surgery

Weill Cornell Medical Center

Los Angeles, CA 90048

Weill Medical College of Cornell University

New York, NY

USA

USA

Oheneba Boachie-Adjei, MD

USA

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Contributors

Bronek Boszczyk, PD Dr med

Richard G Fessler, MD, PhD

Paul F Heini, Prof Dr med

Consultant Spinal Surgeon & Head of Service

Professor

Spine Service

The Centre for Spinal Studies and Surgery

Department of Neurosurgery, Suite 2210

Klinik Sonnenhof

Honorary Clinical Associate Professor Division of

676 North St. Claire Avenue

Buchserstrasse 30

Orthopaedic and Accident Surgery

Chicago, IL 60611

3006 Bern

Queen’s Medical Centre Campus, Derby Road, West

USA

Switzerland

Nottingham University Hospitals NHS Trust

Daniel Gelb, MD

Paul S Issack, MS, MD, PhD

Nottingham, NG7 2UH

Associate Professor and Vice Chairman

Chief, Division of Adult Reconstructive Surgery

United Kingdom

Department of Orthopaedics

New York Downtown Hospital

University of Maryland School of Medicine

170 William Street, 8th Floor

Salvador A Brau, MD, FACS

22 South Greene Street

New York, NY 10038

Director – Spine Access Surgery Associates

S 11B

Clinical Assistant Professor of Orthopaedic Surgery

Visiting Clinical Assistant Professor of Surgery – Keck

Baltimore, MD 21201

Weill Medical College of Cornell University

School of Medicine – USC

USA

USA

UCLA

Alex Gitelman, MD

Andrew James, Dr

Los Angeles, CA 90095

ULCA Spine Center

Leeds General Infirmary

USA

1250 16th street

Leeds Teaching Hospitals NHS Trust

Ste 715

Great George Street

Dean Chou, MD

Santa Monica, CA 90404

Leeds

Associate Professor of Neurosurgery

USA

West Yorkshire

Block D Floor

Instructor in Surgery – Geffen School of Medicine –

LS1 3EX

Associate Director of Spine Tumor Surgery
Department of Neurosurgery

Patrick Hahn, Dr med

505 Parnassus Avenue, Box 0112

Center for Spine Surgery and Pain Therapy

San Francisco, CA 94143

Center for Orthopaedics and Traumatology

Sheila Kahwaty, Physician Assistant-Certified

USA

St Anna Hospital Herne

Cedars-Sinai Medical Center

Hospitalstrasse 19

8700 Beverly Boulevard

Michelle J Clarke, MD

44649 Herne

Los Angeles, CA 90048

Assistant Professor of Neurosurgery

Germany

USA

200 First Street SW,

Roger Härtl, MD

Iain H Kalfas, MD

Rochester, MN 55905

Leonard and Fleur Harlan Clinical Scholar in

Department of Neurosurgery

USA

Neurological Surgery

Cleveland Clinic

Associate Professor of Neurological Surgery

9500 Euclid Avenue

Mark B Dekutoski, MD

Director of Spinal Surgery

Cleveland, OH 44195

Department of Orthopaedic Surgery

Department of Neurological Surgery

USA

Associate Professor of Orthopaedics

Weill Cornell Brain & Spine Center

Mayo Clinic School of Medicine

Starr Building, Room 651

Frank Kandziora, MD, PhD

200 First Street Southwest,

525 East 68th Street

Zentrum für Wirbelsäulenchirurgie und Neurotrauma-

Rochester, MN 55905

New York, New York 10021

tologie

USA

USA

Berufsgenossenschaftliche Unfallklinik

Eric H Elowitz, MD

Franziska C Heider, MD

60389 Frankfurt am Main

Weill Cornell Medical College

Spine Center

Germany

525 East 68th Street

Schön Klinik München Harlaching

Starr 651, Box 99

Harlachinger Strasse 51

New York, NY 10065

81547 München

USA

Germany

United Kingdom

Mayo Clinic School of Medicine

Friedberger Landstraße 430

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Contributors

Rishi Mugesh Kanna, MS, MRCS, FNB

Kuansongtham Verapan, MD

John McCormick, MD

Associate Consultant Spine Surgeon

Director of Bumrungrad Spine Institute,

Neurological and Orthopaedic Surgery

Department of Orthopaedics, Accident and Spine

Bumrungrad International Hospital,

University of Virginia

Surgery

Bangkok

Charlottesville, Virginia 22908

Ganga Hospital

Thailand

USA

Khai Lam, MD

Paul C McCormick, MD, MPH, FAANS

Spinal Unit, Orthopaedic Department

Herbert and Linda Gallen Professor of Neurological

Manish K Kasliwal, MBBS, MCh

1st Floor Bermondsey Wing

Surgery

Spine Fellow

Guy’s Hospital

Columbia University College of Physicians and

Department of Neurosurgery & Orthopaedics

St Thomas’ Street

Surgeons

University of Virginia

London, SE1 9RT

710 West 168th Street

Charlottesville, VA 22908

United Kingdom

New York, NY 10032

Coimbatore, Tamil Nadu
India

USA

USA
Rondall K Lane, MD, MPH
Babak Khamsi, MD

Assistant Professor in Residence

Christoph Mehren, MD

Spine Fellow

UCSF School of Medicine

Head of Department

UCLA School of Medicine

Department Anesthesia/Perioperative Care

Spine Center

UCLA Spine Center

1600 Divisadero Street

Schön Klinik München Harlaching

1250 16th Street, Suite 745

San Francisco, CA 94143

Harlachinger Strasse 51

Santa Monica, CA 90404

USA

81547 München
Germany

USA
Jeremy Lieberman, MD
Mark Kleinschmidt, Dr med

Professor

Mark M Mikhael, MD

Spine Service

Chief, Division of Spine Anesthesia

Spine Surgery – Orthopaedic Surgery

Klinik Sonnenhof

Department of Anesthesia & Perioperative Care

Illinois Bone and Joint Institute, LLC

Buchserstrasse 30

Box 0648, Room C-450

2401 Ravine Way, Suite 200

3006 Bern

521 Parnassus Avenue

Glenview, IL 60025

Switzerland

UCSF

USA

San Francisco, CA 94143
Martin Komp, Dr med

USA

Osmar JS Moraes, MD
R. Maestro Cardim 592

Center for Spine Surgery and Pain Therapy
Center for Orthopaedics and Traumatology

Steven C Ludwig, MD

11 andar

St Anna Hospital

Associate Professor and Chief of Spine Surgery

Sao Paulo, SP

Hospitalstrasse 19

Director of Spine Surgery Fellowship

02313001

44649 Herne

Department of Orthopaedics

Brazil

Germany

University of Maryland Medical Center
22 South Greene Street

Yaron A Moshel, MD, PhD

Andreas Korge, MD

Suite 22 SB

Assistant Professor

Head of Department

Baltimore, MD 21201

Thomas Jefferson University

Spine Center

USA

Department of Neurological Surgery
Division of Neuro-Oncology

Schön Klinik München Harlaching
Harlachinger Strasse 51

H Michael Mayer, MD, PhD

909 Walnut Street, 2nd Floor

81547 München

Head of Department

Philadelphia, PA 19107

Germany

Spine Center

USA

Schön Klinik München Harlaching
Harlachinger Strasse 51
81547 München
Germany

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Contributors

Praveen V Mummaneni, MD

Noel I Perin, MD, FRCS(Ed)

Sebastian Ruetten, Priv.-Doz. Dr med habil, MD

Associate Professor and Vice-chairman

Professor Neurosurgery

Head Department of Spine Surgery and Pain Therapy

Department of Neurosurgery

Department of Neurosurgery

Center for Orthopaedics and Traumatology

Co-director UCSF Spine Center

Suite 8-S

St Anna Hospital Herne

University of California, San Francisco

NYU Medical Center

Hospitalstrasse 19

505 Parnassus Ave, M779

530, 1st Avenue

44649 Herne

San Francisco, CA 94143

New York, NY 10016

Germany

USA

USA

Eric W Nottmeier, MD

Mark Pichelmann, MD

PGY-3, Department of Neurological Surgery

Adjunct Associate Professor of Neurosurgery

Assistant Professor of Neurosurgery

University of California, San Francisco

Mayo Clinic College of Medicine

Mayo Clinic School of Medicine

505 Parnassus Avenue, M779

Neurosurgeon,

200 First Street Southwest,

San Francisco, CA 94143

St Vincent’s Spine and Brain Institute

Rochester, MN 55905

USA

4205 Belfort Road, Suite 1100

USA

Rajiv Saigal, MD, PhD

Walter Saringer, Prof Dr med

Jacksonville, FL 32216
Luiz Pimenta, MD

Medizinische Universität Wien

Instituto de Patologia da Coluna

Spitalgasse 23

Alfred T Ogden, MD

Specialist in minimally invasive spine surgery

1090 Wien

Assistant Professor of Neurological Surgery

Rua Vergueiro no 1.421, sala: 305

Austria

The Neurological Institute

São Paulo – SP

Columbia University

Brazil

USA

Philipp Schleicher, Dr
Leiter Biomechaniklabor

710 West 168th Street
New York, NY 10032

Shanmuganathan Rajasekaran, Dr, PhD

Zentrum für Wirbelsäulenchirurgie und

USA

Ganga Hospital

Neurotraumatologie

313 Mettupalayam Road

Berufsgenossenschaftliche Unfallklinik Frankfurt am

Sylvain Palmer, MD, FACS

Coimbatore 641043

Main

Neurological Surgery Medical Associates

India

Friedberger Landstrasse 430
60389 Frankfurt am Main

Orange County Neurosurgical Associates
26732 Crown Valley Parkway, Suite 561

Marcus Richter, MD

Mission Viejo, CA 92651

Chefarzt des Wirbelsäulenzentrums

USA

Facharzt für Orthopädie

Meic H Schmidt, MD, FACS

Facharzt für Orthopädie und Unfallchirurgie

Ronald I Apfelbaum Endowed Chair in Spine Surgery

Luca Papavero, Prof Dr med

St Josefs-Hospital

Associate Professor and Chief

Clinic for Spine Surgery,

Beethovenstrasse 20

Division of Spine Surgery

Schön Klinik Hamburg-Eilbek,

65189 Wiesbaden

Department of Neurosurgery

Dehnhaide 120,

Germany

Clinical Neurosciences Center

Germany

Director, Spinal Oncology Service

22081 Hamburg
Daniel Riew, MD

Huntsman Cancer Institute

Mildred R Simon distinguished Professor of Orthopaedic

University of Utah

Sompoch Paiboonsirijit, MD

Surgery

175 N Medical Drive East

Vice Chairman

Professor of Neurological Surgery

Salt Lake City, UT 84132

Department of Orthopedic Surgery

Chief, Cervical Spine Surgery

USA

Bumrungrad Spine Institute

McDonnell International Scholars Academy Ambassador

Bumrungrad International Hospital,

Suite 11, 300 Pavillion

Bangkok

One Barnes-Jewish Plaza

Thailand

St. Louis, MI 63110

Germany

USA

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Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies  Roger Härtl, Andreas Korge

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Contributors

Theodore H Schwartz, MD, FACS

Nicholas Slimack, MD

Jeffrey C Wang, MD

Professor of Neurosurgery

PGY-6 Resident

Professor of Orthopaedics and Neurosurgery

Departments of Neurological Surgery, Neurology

Department of Neurological Surgery

UCLA School of Medicine

Neuroscience and Otolaryngology

Northwestern University

UCLA Spine Center

Weill Cornell Medical College

Chicago, IL 60611

1250 16th Street, Suite 745

New York Presbyterian Hospital

USA

Santa Monica, CA 90404
USA

525 East 68th Street, Box #99
New York, NY 10065

Volker Sonntag, MD

USA

Vice Chairman, Department of Neurological Surgery

Michael Y Wang, MD, FACS

Barrow Neurological Institute

Associate Professor

Christopher I Shaffrey, MD, FACS

350 West Thomas Road

Departments of Neurological Surgery & Rehabilitation

Harrison Distinguished Professor

Phoenix, AZ 85013

Medicine

Neurological and Orthopaedic Surgery

USA

University of Miami Miller School of Medicine
Lois Pope LIFE Center, 2nd Floor

University of Virginia
Charlottesville, VA 22908

John Stark, MD

1095 Northwest 14th Terrace (D4-6)

USA

Back Pain Clinic

Miami, FL 33136

The Medical Arts Building

USA

Ajoy Prasad Shetty, MS DNB Ortho

825 Nicollet Mall, Suite 715

Consultant Spine Surgeon

Minneapolis, MN 55402

Jean-Paul Wolinsky, MD

Department of Orthopaedics, Accident and Spine

USA

Associate Professor of Neurosurgery and Oncology
Clinical Director of the Johns Hopkins Spine Program

Surgery
Ganga Hospital

Lukasz Terenowski, MD

Johns Hopkins Hospital

Coimbatore, Tamil Nadu

The Prof Alfred Sokolowsiki Memorial Specialistic

600 North Wolfe Street, Meyer 7.109

India

Hospital

Baltimore, MD 21287

Department VI of Traumatic and Orthopaedic Surgery

USA

Patrick Shih, MD

uliza Alfreda Sokołowskiego 11

Department of Neurological Surgery

70-001 Szczecin – Zdunowo

James Zucherman, MD

Northwestern University

Poland

St Mary’s Spine Center
One Shrader Street, Suite 450

Feinberg School of Medicine

676 N. St. Clair St., Suite 2210

William D Tobler, MD

San Francisco, CA 94117

Chicago, IL 60611

The Christ Hospital

USA

USA

2123 Auburn Avenue, Suite 441
Cincinnati, OH 45219
USA
Juan S Uribe, MD
Assistant Professor
Director, Spine Section
Department of Neurological Surgery
University of South Florida
Tampa, FL 33620
USA

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Table of contents

Table of contents
Foreword 

V

Dedication

VI

Acknowledgements

VII

Introduction

VIII

Contributors

IX

Table of contents

XIV

Definition of the different classes of evidence table

XVI

1 Fundamentals

1

2 Cervical techniques

1.1 The definition of minimally invasive spine surgery 

3

2.1

and the rationale for its use
1.2 Minimally invasive spine surgery and AOSpine 

13

principles

Introduction

105
107

2.2 Posterior foraminotomy

109

2.3 Anterior foraminotomy: microsurgical and 

121

endoscopic procedures

1.3 The four pillars of minimally invasive spine surgery

23

1.4 Evidence-based medicine and minimally invasive spine  51
surgery
1.5 Different spinal pathologies and patient selection

57

1.6 Computer-assisted navigation for minimally invasive 

67

2.4 Posterior C1/2 transarticular screw fixation

135

2.5 Anterior C1/2 surgery

151

spine surgery

1.7 Biologics in minimally invasive spine surgery

85

1.8 Anesthetic considerations and minimally invasive 

91

spine surgery

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Table of contents

3 Thoracic techniques
3.1

Introduction

3.2 Extreme lateral mini-thoracotomy approach for 

173

4 Lumbar/sacral techniques

175

4.1 Introduction

263

177

4.2 Posterior approaches

267

thoracic spinal pathologies
3.3 Anterior thoracoscopic approaches, including 

4.2.1 Bilateral decompression in lumbar spinal stenosis 
191

4.2.2 Microsurgical lumbar disc surgery
4.2.3

211

Endoscopic disc and decompression surgery

4.2.4 Mini-open and percutaneous pedicle 

decompression and stabilization

289
315
331

instrumentation and fusion

3.5 Posterior approaches for minimally invasive treatment 223
of spinal fractures
3.6 Vertebroplasty and percutaneous cement 

267

through a microscope-assisted monolateral approach

fracture treatment
3.4 Posterior approaches for minimally invasive thoracic 

261

243

4.2.5 Interspinous spacers

355

4.2.6 Fixation of the sacroiliac joint

375

4.3 Anterior approaches

393

4.3.1 Minimally invasive anterior midline approach to the  393

reinforcement techniques

lumbar spine and lumbosacral junction
4.3.2 Minimally invasive anterolateral retroperitoneal 

413

approach to the lumbar spine
4.3.3 The lateral approach to the lumbar spine

431

4.3.4 Deformity correction using minimally invasive spine  445
surgery techniques
4.3.5 Transsacral fixation

5 Critical overview and outlook
5.1

467

483

Minimally invasive spine surgery: a critical overview  485

and outlook

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Definition of the different classes of evidence (CoE)

Definition of the different classes of evidence (CoE)
Articles on treatment
Studies of therapy
Level

Study design

Criteria

I

Good quality RCT

• Concealment
• Blind or independent assessment for important outcomes
• Co-interventions applied equally
• Follow-up rate of ≥ 85%
•  Adequate sample size

II

Moderate or poor quality
RCT
Good quality cohort

• Violation of any of the criteria for good quality RCT
• Blind or independent assessment in a prospective study, or use of reliable data*
in a retro study
•  Co-interventions applied equally
• Follow-up rate of ≥ 85%
•  Adequate sample size
•  Control for possible confounding†

III

Moderate or poor quality
cohort
Case control

• Violation of any of the criteria for good quality cohort
• Any case-control design

IV

Case series

• Any case-series design

Randomized Controlled Trial (RCT)

*
Reliable data are data such as mortality or reoperation.
†
Authors must provide a description of robust baseline characteristics, and control for those that are unequally
distributed between treatment.
(Reproduced with kind permission from the AOSpine Evidence-Based Spine-Care Journal (EBSJ).)

XVI

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Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies  Roger Härtl, Andreas Korge

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XVII

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Author  Andreas Korge

XVIII

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Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies  Roger Härtl, Andreas Korge

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1  Fundamentals
1.1  The definition of minimally invasive spine surgery and the rationale for its use

1

Fundamentals

1

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Author  Andreas Korge

2

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Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies  Roger Härtl, Andreas Korge

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1.1 The definition of minimally invasive spine surgery and

the rationale for its use
Andreas Korge

1

Rationale

Spine surgery was initially referred to in anecdotal reports
at the beginning of the 20th century, but later developed
to increasingly cover all the anatomical regions of the vertebral column. With time, a better understanding of the
pathologies underlying the visible symptoms and improvements in diagnostic tools and surgical equipment led to a
dramatic increase in surgical treatment strategies from the
1950s onwards. Macrosurgical exposures were accepted as
standard practice at the time, since treatment goals focused
predominantly on target surgery and its practicability.
However, macrosurgical exposures are associated with a
large number of side effects including significant muscle
damage and increased bleeding, muscular denervation, reduced segmental innervation, as well as a decreased or even
severely compromised local blood supply with postoperative
sequelae such as scar-tissue formation and local pain syndromes. Further postoperative side effects include the need
for prolonged pain medication, a longer immobilization and
recovery period accompanied by an extended period of
physical disability and delayed return to work, and sometimes with a limited possibility, or even in some cases no
possibility, of resuming previous professional activity.
In consequence, the importance of effective approach modalities has become increasingly apparent, and particular
focus has been placed on the optimization of access strategies through minimizing the anatomical working corridor
while simultaneously maintaining the treatment aims of
standard open surgery. The measures used to decrease intraoperative iatrogenic tissue trauma include reducing access size, making smaller incisions, and using preexisting
anatomical neurovascular and muscle compartment working planes, with the aim of achieving similar, or if possible,
better postoperative results than those obtained via standard

open procedures [1, 2]. Less muscle damage as a result of
muscle-splitting dissection rather than muscle-cutting techniques, and reduced blood loss due to meticulous hemostasis with less postoperative scar-tissue formation, have

led to a decrease in postoperative pain symptoms with less
pain medication, and to a reduction in overall morbidity
with a quicker recovery time and a shorter hospitalization
period. With so many obvious potential benefits, special
emphasis was placed on minimally invasive spine surgery
(MISS) from the early 1990s onwards. While access modifications dominated the results in the literature during the
first MISS decade [3, 4], after the year 2000, outcome studies focused on the question of whether the high expectations
regarding MISS were justified, and whether they had been
met [5–9]. Recent studies now increasingly concentrate on
evidence-based outcome evaluation [10–14], and in this
context reference is also made to the individual chapters of
this book.
Modifications in access strategies should not compromise
the goal of the surgical procedure, independent of the type
of pathology involved. Even if this is not always possible in
the beginning when first using a modified surgical technique
that requires a learning curve, this goal must be strived for.
For example, at the onset, percutaneous pedicle screw placement for fusion surgery was limited to mono- and bisegmental cases of in situ fusion. Technical advances now enable multisegmental pedicle screw insertion and segmental
reduction to be performed; surgery, for example, is facilitated by computer-assisted navigation; and cement augmentation techniques are available, so that the range of
indications for treatment by MISS is now nearly the same
as for open surgery.
Among the many other examples given in historical reviews
[15, 16], typical examples of minimalized treatment strategies
are the development of posterior mini-open or percutaneous pedicle screw placement techniques in combination
with minimally invasive transforaminal intervertebral
(mini-TLIF) or anterior intervertebral (mini-ALIF) implant
placement (Fig 1.1-1) [4, 9,17]. Video-assisted thoracoscopic

surgery for decompression or fusion procedures has been
developed for the treatment of the thoracic spine [18], while
for the cervical spine, even for a single anatomical region
(ie, the atlantoaxial segment C1/2), four different anterior

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Author  Andreas Korge

minimally invasive techniques are now available (see chapter 2.5 Anterior C1/2 surgery). Today, a wide range of
minimally invasive surgical procedures can be applied for
the treatment of the entire spine (Table 1.1-1, Table 1.1-2).
However, the variety and number of minimally invasive
procedures that can currently be performed have only been
made possible by the introduction of numerous technical
innovations within the last decades. These can be summarized as the four “pillars” of MISS (see chapter 1.3 The four
pillars of MISS in this section), namely: microsurgical techniques; access strategies to the spine; imaging/navigation
techniques; and instrumentation and implants. To mention
but a few of these developments, improved visualization
with magnification and illumination of the target area is
ensured by the use of high-end microscopes, endoscopes
or head lamps with adequate xenon light sources (Fig 1.1-2).
Instruments have been further modified, enabling the surgeon to operate within a narrow working channel; for example, bayonet-shaped instruments and high-speed drills,
etc. ensure a virtually unrestricted visual field under mi-

Cervical spine

croscopic or endoscopic conditions. Specific tube or framelike retractor systems have been developed to keep the tiny
“keyhole” access route open (Fig 1.1-3). Computer-assisted
navigation and intraoperative neuromonitoring have now
become essential tools in facilitating access minimization.

a

b

Fig 1.1-1a–b  Posterior percutaneous pedicle screw placement at L4/5
after initial anterior cage implantation using a mini-ALIF technique.
aInsertion tubes with adapted screws in place on the right side; on
the left side, completed screw-rod implantation, with only the skin
incisions visible.
b Intraoperative AP x-ray showing the insertion tubes with screws in
place on the right side and completed left-sided instrumentation.

Foraminotomy
Microfacetectomy
Craniocervical junction decompression
Laminoplasty
Fusion procedures with instrumentation (eg, transpedicular,
translaminar, lateral mass)

Cervical spine

Skip laminectomy
Thoracic spine

Costotransversectomy

Decompression surgery (eg, intervertebral, transnasal,
transoral)

Transpedicular decompression surgery

Fusion procedures (eg, cages, plates)

Laminotomy

Total disc replacement
Vertebral artery decompression

Vertebral body augmentation (vertebroplasty/kyphoplasty)

Lumbar spine

Fusion procedures (percutaneous pedicle screw placement)

Thoracic spine

Decompression surgery (disc pathologies, synovial cysts,
acquired spinal stenosis)
•  Medial and paramedian
•  Intraforaminal and extraforaminal

Lumbar spine

Vertebral body augmentation (vertebroplasty/kyphoplasty)
Lordoplasty
Dynamic nonfusion techniques (incl. nucleus replacement)
Fusion procedures (eg, percutaneous pedicle screw
placement, translaminar screws, transsacral techniques)

Table 1.1-1  Minimally invasive spine surgery—applications using
posterior approaches.

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Decompression surgery (eg, disc pathologies, fracture)
Fusion procedures (eg, cages, plates)
Total disc replacement
Nucleus replacement
Fusion procedures (cages, plates)—mini-ALIF
•  Anterior, anterolateral, lateral
Spinal canal decompression
Anterior extraforaminal decompression
Vertebral body augmentation
Tumor marginal resection/curettage

Intervertebral support (mini-PLIF, TLIF)

4

Uncoforaminotomy

Table 1.1-2  Minimally invasive spine surgery—applications using
anterior approaches.

Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies  Roger Härtl, Andreas Korge

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1  Fundamentals
1.1  The definition of minimally invasive spine surgery and the rationale for its use

Minimally invasive spine surgery has been defined as: “(a)
procedure that by virtue of the extent and means of surgical
techniques results in less collateral tissue damage, resulting
in measurable decrease in morbidity and more rapid functional recovery than traditional exposures, without differentiation in the intended surgical goal” [19]. The present author
subscribes to this view. In an effective minimally invasive
spine operation today, one of the major aspects of preoperative preparation, which has a significant effect both on the
intraoperative procedure and the postoperative results, is the
meticulous decision-making process and thorough planning

Medial

of the procedure. With careful preparation, both surgeon and
patient should be able to benefit from the potentially positive
aspects of MISS: less tissue trauma, reduced bleeding and
scar-tissue formation, decreased pain with quicker mobilization and recovery time, shorter hospital stay, and a more
rapid return to daily activities at both a professional and personal level (Fig 1.1-4). It is most important that these approach
modifications do not influence the treatment strategy at the
target site itself, which should be independent of the size of
the access pathway, and be adequate and identical for both
macro- and microsurgical approaches.

Medial
Dura

Dura

Nerve root L5

Cranial

Caudal

Cranial

Caudal

Synovial cyst

Lateral

a

Lateral

b

Fig 1.1-2a–b
aMicroscopic view of the spinal canal at L4/5 with a large synovial cyst compressing
the hidden nerve root L5.
b Microscopic view of the spinal canal at L4/5 after removal of the synovial cyst with
decompressed and now visible nerve L5.

Quicker return to DLA

Fig 1.1-3  Tube placed over disc space at L4/5
left in preparation for interbody work, with
K-wires already positioned bilaterally through
pedicles L4 and L5 for percutaneous screw
placement using a Wiltse type approach.

Smaller incision

Less soft-tissue damage

Shorter hospital stay

Less blood loss

Quicker recovery

Lower complication rate

Less postoperative pain

Less scarring

Fig 1.1-4  Benefits associated
with a MISS strategy
(DLA = daily life activities).

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