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Minimally Invasive & Advanced

Minimally invasive and endoscopic spinal techniques, including MI-TLIF and UBE, for degenerative conditions and deformities to reduce perioperative morbidity vs open surgery.

Overview

Minimally invasive spinal techniques, including endoscopic decompression and biportal endoscopy, offer feasible and safe alternatives for degenerative central lumbar spinal stenosis, unilateral biportal endoscopic discectomy, and multi-level lumbar spinal stenosis [2, 3, 5, 10]. These approaches generally favor short-term outcomes such as decreased blood loss and shorter hospital stays compared to traditional open techniques [6]. While data for minimally invasive posterior lumbar fusion are promising, achieving results similar to open techniques without significantly increased risk, the literature regarding superior long-term results, including patient-reported outcomes and arthrodesis success, remains equivocal [4, 6]. Comparative analysis of multifidus muscle degeneration in thoracolumbar fractures treated with open versus minimally invasive approaches showed no advantage of the minimally invasive approach regarding fatty degeneration or clinical outcome [1].

Advanced minimally invasive strategies for lumbar instability and interbody fusion include biportal endoscopic transforaminal lumbar interbody fusion with large cages, which is a straightforward and safe method [8]. Both unilateral biportal endoscopic lumbar interbody fusion (ULIF) and endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) present distinct advantages and drawbacks in treating lumbar spinal stenosis and intervertebral disc herniation [19]. In the context of hip pathology, computer navigation-assisted osteochondroplasty may improve the accuracy of resection planning for femoroacetabular impingement syndrome compared with freehand arthroscopic techniques, though clinical benefits in measures such as mHHS, revision, or conversion rates remain limited [36]. For unicompartmental knee arthroplasty, the Oxford Phase 3 minimally invasive procedure yields excellent, durable, and reliable results when strict indication criteria are followed [18].

Anatomy & Pathophysiology

Kinematics and Motion Segments

Percutaneous full-endoscopic anterior transcorporeal cervical discectomy and channel repair achieves less damage to the disc and retained cervical motion segment [26]. Wearable technologies and biofeedback modalities are utilized to modulate spine motor control [29]. Following anterior vertebral body tethering, motion in the coronal plane decreases by 77%, while sagittal motion remains greater than coronal motion at 1 year [31]. The interlaminar dynamic stabilization system (IntraSPINE) effectively maintains intervertebral height, preserves partial mobility of the operated and adjacent segments, and alleviates postoperative stress concentration on the intervertebral disc and facet joints [32]. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) can correct and maintain proper spinopelvic alignment in isthmic spondylolisthesis [41]. Growth modulation with vertebral body tethering is safe, achieves good results, and preserves motion in select patients [45]. Initial studies suggest that the results of posterior dynamic stabilization may be comparable to those of fusion [47]. Correction loss for minimally invasive spine implant systems has been quantified [48]. The one-hole split endoscope (OSE) technique has no significant impact on lumbar spine stability in the early postoperative period [52].

Osseous Stability and Instrumentation

Simulated orthopaedic spine surgery elicits modest but significant increases in energy expenditure over resting levels [42]. Unstable spine fractures might benefit from stabilization with conventional implants like the Universal Spinal System (USS) [48]. OLIF augmented with bilateral pedicle screw fixation (OLIF+BPSF) demonstrates a greater ability to retain lumbar stability, resists cage subsidence, and maintains disc height compared to other instrumentation types [56]. Spine robots demonstrate clear advantages in screw implantation accuracy, with different systems achieving optimal results under specific surgical requirements [57]. Percutaneous and open techniques for surgical treatment of thoracolumbar fracture in ankylosing spondylitis improve pain, neurological function, and kyphotic deformity, achieving effects similar to traditional methods [58]. The average difference in angles between the Caspar pin and cervical endplate is less than 7° when using the aiming device for cervical distractor pin insertion [59]. Facetectomy in a diameter of 15 mm changes the mechanical effect on the operating segment more significantly than facetectomy in diameters of 7.5 mm and 10 mm, with a corresponding effect on adjacent segments [65]. 3D-printed guide plate-assisted percutaneous pedicle screw implantation achieves better amelioration of back pain and recovery of function [66].

Soft Tissue and Joint Pathology

Posterior and posterior superior labral (PPS) injuries produce alterations in glenohumeral kinematics, with implications for glenohumeral joint instability, increased joint loading, and potential joint damage [50]. Augmented reality (AR) technology in spine surgery offers greater accuracy, surgeon comfort, and reduced operating time [54].

Classification

Minimally Invasive vs. Open Approaches: No advantage of the minimally invasive approach over the open approach regarding fatty degeneration of the multifidus muscle or clinical outcome in thoracolumbar fractures was found [1]. Minimally invasive posterior lumbar fusion has achieved results similar to open techniques without a significant increase in risk [4]. Long-term outcomes for minimally invasive spine surgery appear similar to conventional open surgery, with specific complications varying by procedure type [11]. Minimally invasive hybrid lumbar interbody fusion involves a significant amount of hidden blood loss despite being a minimally invasive surgery [13]. Benefits seen with minimally invasive total knee arthroplasty techniques may be due to the surgical approach rather than incision length or instrumentation [73].

Endoscopic Decompression and Discectomy: Endoscopic decompression through a bilateral transforaminal approach is a feasible, safe, and clinically effective procedure for degenerative central lumbar spinal stenosis [2]. Unilateral biportal endoscopy via two different approaches for upper lumbar disc herniation achieves minimal invasiveness without requiring special instruments [5]. Lu's retractor demonstrates potential utility as an effective alternative in unilateral biportal endoscopic discectomy procedures [3]. Research advances in unilateral endoscopic spinal surgery include conceptual designs for a novel integrated non-coaxial spinal endoscope and identify intelligent solutions and instrument innovation as crucial future directions [27].

Unilateral Biportal Endoscopic Fusion: Unilateral biportal endoscopic transforaminal lumbar interbody fusion (ULIF) is an effective minimally invasive lumbar fusion surgical technique [15]. Biportal endoscopic transforaminal lumbar interbody fusion with a large cage is a straightforward, safe, and minimally invasive method for treating lumbar instability [8].

Robot-Assisted and Revision Techniques: A modified minimally invasive procedure for tracer fixation in robot-assisted pedicle screw insertion results in minimal trauma and is simple, reliable, and highly safe [7]. A 1.5-stage revision does not show inferior results compared to a two-stage technique and reduces the number of additional surgical procedures [28].

Morphology-Guided Decision Making: The Song's classification system has demonstrated significant value in guiding personalized surgical decision-making for various morphologies of calcified lumbar disc herniation treated using a unilateral biportal endoscopic technique [39].

Clinical Presentation

The clinical presentation of spinal pathology treated via minimally invasive approaches varies by etiology but consistently demonstrates specific procedural advantages and limitations. Degenerative stenosis and disc herniation are effectively managed through endoscopic decompression via a bilateral transforaminal approach [2], unilateral biportal endoscopy [5, 10], or total endoscopic resection via an interlaminar approach for ligamentum flavum cysts [38]. For complex cases involving lumbar kyphoscoliosis with multiple comorbidities, percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation offers a promising solution [40]. In the context of L5–S1 disc herniation, both full and intermittent endoscopy techniques achieve good outcomes, though intermittent endoscopy is more effective for reducing surgical duration and hospitalization expenses [44].

Fusion and fixation procedures, including minimally invasive posterior lumbar fusion and hybrid lumbar interbody fusion, yield results comparable to open techniques without a significant increase in risk [4]. However, surgeons must account for hidden blood loss associated with minimally invasive hybrid lumbar interbody fusion [13]. For thoracic and lumbar tuberculosis, the minimally invasive lateral approach interbody fusion provides advantages of reduced injury and rapid recovery [12]. In robot-assisted pedicle screw insertion, a modified minimally invasive procedure for tracer fixation is simple, reliable, and highly safe [7]. Quantitative MRI comparisons of multifidus muscle degeneration in thoracolumbar fractures reveal no significant difference in fatty degeneration or clinical outcomes between open and minimally invasive treatments [1].

Infectious and cystic pathologies require specific minimally invasive considerations. Percutaneous endoscopic treatment serves as an effective alternative for lumbar infectious spondylitis in patients with poor responses to conservative therapy prior to major open surgery [16]. Advances in biologic therapies are reshaping paradigms for aneurysmal and simple bone cysts, though standardized outcome measures remain needed [9]. Hip and soft tissue disorders are addressed via ultrasound-guided release of lateral snapping hip [14] or sonographically controlled A1 pulley release [22]. For primary total hip replacement, a single posterior mini-incision technique allows immediate weight-bearing and early function, though objective evaluation is required to disentangle surgical approach effects from patient selection variables [23].

Outcomes and discharge planning reflect a dichotomy between short-term benefits and long-term equivocal data. Minimally invasive techniques generally favor short-term outcomes, including decreased blood loss and shorter hospital stays [6]. Surgeons experienced in minimally invasive spine surgery may consider same-day discharge for patients undergoing minimally invasive unilateral TLIF procedures [17]. Despite these short-term gains, the literature remains equivocal regarding superior long-term results, including patient-reported outcomes and arthrodesis success, for minimally invasive techniques compared to open techniques [6]. The management of early onset scoliosis remains challenging regardless of the approach [37].

Investigations

MRI: Quantitative MRI comparison of multifidus muscle degeneration showed no significant difference in fatty degeneration or clinical outcomes between open and minimally invasive approaches for thoracolumbar fractures [1]. Metal suppression magnetic resonance imaging techniques provide a comprehensive overview of metal artifacts in orthopaedic MRI, factors affecting their magnitude, and recent technological advances to facilitate diagnostic decisions [30].

CT: CT scanning is used frequently for follow-up imaging evaluation following complex spine surgery, with prevalence increasing more than two-fold from 6 months to 5 years post-surgery [49]. Preoperative imaging planning is important to identify patients who are not suitable for extreme lateral interbody fusion (XLIF) at the L4/5 level [34].

Other Considerations: Endoscopic decompression through a bilateral transforaminal approach is a feasible, safe, and clinically effective minimally invasive procedure for degenerative central lumbar spinal stenosis [2]. Lu's retractor demonstrates potential utility as an effective alternative in unilateral biportal endoscopic discectomy procedures [3]. Data for minimally invasive posterior lumbar fusion are promising, showing results similar to open techniques without a significant increase in risk [4]. Unilateral biportal endoscopy via two different approaches for upper lumbar disc herniation achieved minimal invasiveness without requiring special instruments [5]. A modified minimally invasive procedure for tracer fixation in robot-assisted pedicle screw insertion results in minimal trauma and is simple, reliable, and highly safe [7]. Biportal endoscopic transforaminal lumbar interbody fusion with a large cage is a straightforward, safe, and minimally invasive method for inserting large cages in the treatment of lumbar instability [8]. Advances in minimally invasive and biologic therapies are reshaping treatment paradigms for aneurysmal and simple bone cysts, though standardized outcome measures and head-to-head comparative trials remain needed [9]. Minimally invasive lateral approach interbody fusion technology offers advantages of less injury and quick recovery, serving as an effective and safe treatment for thoracic and lumbar spinal tuberculosis [12]. Ultrasound-guided release of lateral snapping hip is a novel surgical option with encouraging results for patients who have failed conservative protocols [14]. Unilateral biportal endoscopic transforaminal lumbar interbody fusion (ULIF) is an effective minimally invasive lumbar fusion surgical technique [15]. Percutaneous full-endoscopic anterior transcorporeal cervical discectomy and channel repair is a feasible, safe, and minimally invasive procedure that achieves less damage to the disc and retains the cervical motion segment [26]. The combined XOLIF-PELD approach may offer a minimally invasive alternative to PLIF for selected patients with adjacent segment disease, demonstrating reduced surgical trauma, faster recovery, and fewer minor complications [51]. Percutaneous pedicle screw fixation is accurate but requires caution in cases with ligamentous disruption, and overall functional and radiographic outcomes vary compared to open approaches [53]. Microscopic tubular unilateral laminotomy for bilateral decompression is a viable alternative to traditional open decompression for lumbar canal stenosis, though broader validation in multicenter trials is needed [62]. Judicious pedicle screw insertion in patients with minimal bone destruction in thoracolumbar pyogenic spondylitis can minimize surgical invasiveness [64].

Treatment

Non-Operative

Conservative management remains a primary consideration for specific pathologies, with minimally invasive surgery and conservative treatment achieving similar clinical outcomes in patients with type II fragility fractures of the pelvis [46]. For hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint, treatment options range from non-operative measures to surgical procedures including cheilectomy, arthroplasty, and arthrodesis [72]. Selection of treatment for hallux rigidus depends on disease stage and patient factors [72]. Moderate nonprogressive coxa vara deformity in childhood often does not require surgery [70].

Operative

Indications: Surgical management is indicated for progressive, painful, unilateral coxa vara deformity or leg-length discrepancy in childhood [70]. Minimally invasive endoscopic treatment is an effective alternative for lumbar infectious spondylitis in patients with a poor response to conservative treatment prior to major open surgery [16]. Ultrasound-guided release of lateral snapping hip is a novel ultraminimally invasive surgical option with encouraging results for patients who have failed conservative protocols [14].

Surgical Approach / Technique: Minimally invasive approaches for thoracolumbar fractures do not demonstrate a significant advantage over open approaches regarding multifidus muscle fatty degeneration or clinical outcomes [1]. Endoscopic decompression via a bilateral transforaminal approach is a feasible, safe, and clinically effective treatment for degenerative central lumbar spinal stenosis [2]. Unilateral biportal endoscopy for upper lumbar disc herniation achieves minimal invasiveness without requiring special instruments [5]. Minimally invasive lateral approach interbody fusion offers advantages of less injury and quick recovery for thoracic and lumbar spinal tuberculosis [12]. Non-contact orthopedic robot navigation is a minimally invasive, precise, and stable surgical method for the treatment of lumbar spondylolisthesis [74].

Implant Selection: Implantation of a bone-anchored annular closure device is safe and viable as an adjunct to tubular minimally invasive discectomy for lumbar disc herniation [20]. Biportal endoscopic transforaminal lumbar interbody fusion with a large cage is a straightforward, safe, and minimally invasive method for treating lumbar instability [8]. Hybrid cervical disc arthroplasty and anterior cervical discectomy and fusion is a safe and effective intervention for multilevel spinal disease with non-inferiority compared to multilevel anterior cervical discectomy and fusion [35].

Alignment / Balancing Strategy: Advances in minimally invasive and biologic therapies are reshaping treatment paradigms for aneurysmal and simple bone cysts, though standardized outcome measures and head-to-head comparative trials are still needed [9]. Understanding current evidence and appropriate indications is of critical importance for the utilization of emerging technologies in orthopaedic trauma [33].

Adjuncts: Lu's retractor demonstrates potential utility as an effective alternative in unilateral biportal endoscopic discectomy procedures [3]. Sonographically controlled, minimally-invasive A1 pulley release can be performed safely and effectively with appropriate surgical instruments and practice [22].

Pain Management: Minimally invasive techniques for transforaminal lumbar interbody fusion are associated with decreased blood loss and shorter hospital stays compared to traditional open techniques [6]. The literature remains equivocal regarding superior long-term patient-reported outcomes and arthrodesis success for minimally invasive versus open transforaminal lumbar interbody fusion [6]. Both unilateral biportal endoscopic lumbar interbody fusion and endoscopic transforaminal lumbar interbody fusion possess their own distinct advantages and drawbacks for treating lumbar spinal stenosis with intervertebral disc herniation [19].

Setting of Care: Unilateral biportal endoscopic technique is a safe and feasible minimally invasive surgical treatment for multi-level lumbar spinal stenosis [10]. Unilateral biportal endoscopic transforaminal lumbar interbody fusion is an effective minimally invasive lumbar fusion surgical technique [15]. Oxford Phase 3 unicompartmental knee arthroplasty yields excellent, durable, and reliable results when strict indication criteria are followed [18].

Complications

Muscle Degeneration: Quantitative MRI comparison of multifidus muscle degeneration in thoracolumbar fractures treated with open and minimally invasive approaches found no significant difference in the amount of fatty degeneration between the two techniques [1].

Blood Loss: Minimally invasive hybrid lumbar interbody fusion is associated with a significant amount of hidden blood loss despite being a minimally invasive procedure [13].

General Outcomes and Fusion: Long-term outcomes for minimally invasive spine surgery appear similar to conventional open surgery, with specific complications varying by procedure type [11]. Minimally invasive posterior lumbar fusion has achieved results similar to open techniques without a significant increased risk [4]. The literature remains equivocal regarding superior long-term results, including patient-reported outcomes and arthrodesis success, for minimally invasive techniques compared to open techniques [6]. MitlIF and OTLIF provide equivalent long-term clinical outcomes [21]. Endo-TLIF is similar to MIS-TLIF in terms of long-term clinical outcomes, fusion rates, and complication rates [25]. Minimally invasive techniques generally favor short-term outcomes such as decreased blood loss and shorter hospital stays compared to open techniques [6].

Infection and Wound Complications: Thoracoscopy combined with transforaminal endoscopy produces fewer complications compared to thoracoscopy alone for decompression and reconstruction of spinal TB lesions [55]. The minimal skin incision and multifidus-sparing approach of the MED had a positive effect on clinical outcomes, which were stable throughout the 2-year follow-up period [61].

Other Considerations: In the era of minimally invasive techniques, the use of three-column osteotomies has decreased while the use of anterior and lateral interbody fusions has increased [71].

Recovery

Light activity (weeks): Patients undergoing minimally invasive posterior lumbar fusion or unilateral TLIF may be considered for same-day discharge, facilitating an immediate return to light activities [17]. Minimally invasive approaches for thoracolumbar fractures and total hip replacement via a single posterior mini-incision allow for immediate weight-bearing and early function [1, 23]. In the short term, patients with greater than 50% inferior articular process (IAP) defects show no difference in lumbar stability or clinical outcomes compared to those with 50% or less defects following percutaneous endoscopic interlaminar lumbar discectomy [63].

Full activity (months): Minimally invasive techniques generally favor short-term outcomes such as decreased blood loss and shorter hospital stays compared to open techniques [6]. Mobile and fixed-bearing all-polyethylene tibial component total knee arthroplasty designs functioned equivalently at the time of early follow-up in a low-to-moderate-demand patient group [76]. Minimally invasive Oxford unicompartmental knee arthroplasty ensures good long-term survivorship with an excellent functional outcome [60].

Complete recovery / outcome plateau (months): The literature remains equivocal regarding superior long-term results, including patient-reported outcomes and arthrodesis success, for minimally invasive techniques compared to open techniques [6]. Long-term outcomes for minimally invasive spine surgery appear similar to conventional open surgery, with specific complications varying by procedure type [11]. Minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open transforaminal lumbar interbody fusion (OTLIF) provide equivalent long-term clinical outcomes [21]. Endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) is similar to minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in terms of long-term clinical outcomes, fusion rates, and complication rates [25]. Anterior vertebral body tethering may indicate long-term survivorship as no additional patients had conversion to posterior spinal fusion [77].

Rehabilitation protocol: Minimally invasive endoscopic treatment for lumbar infectious spondylitis is an effective alternative for patients with a poor response to conservative treatment before major open surgery [16]. Full-endoscopic lumbar decompression via an interlaminar approach can be safely performed even during the early learning period by surgeons with adequate microscopic surgical experience [75]. Open fixation remains a safe and reliable option for thoracolumbar fractures in patients with ankylosing spinal diseases, though longer-term follow-up studies are needed [24]. A 1.5-stage revision for total hip replacement does not show inferior results compared to the two-stage technique and reduces the number of additional surgical procedures [28].

Functional milestones: Minimally invasive approaches for thoracolumbar fractures do not demonstrate a significant advantage over open approaches regarding fatty degeneration of the multifidus muscle or resulting clinical outcomes [1]. Minimally invasive posterior lumbar fusion achieves results similar to open techniques without a significant increase in risk [4].

Other Considerations: Advances in minimally invasive and biologic therapies are reshaping treatment paradigms for aneurysmal and simple bone cysts, though standardized outcome measures and head-to-head comparative trials remain needed [9]. Complete loss of the inferior articular process remains a concern for long-term instability following percutaneous endoscopic interlaminar lumbar discectomy [63]. Further studies are needed to determine the long-term efficacy of one-hole split endoscope versus unilateral biportal endoscopy for lumbar spinal stenosis [67]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [68]. Differences in long-term functional and pain outcomes between minimally invasive TLIF and open TLIF in obese patients remain a source of controversy [69].

Key Evidence

  • [L3] No advantage of the minimally invasive approach displaying a significant difference in the amount of fatty degeneration and resulting in a better clinical outcome could be found compared to the open approach. (10.1186/s12891-018-2001-2)
  • [L4] It is a feasible, safe, and clinically effective minimally invasive procedure. (10.1186/s12891-020-03722-3)
  • [L3] These findings support its potential utility as an effective alternative in minimally invasive spinal procedures. (10.1186/s13018-025-05932-8)
  • [L5] Data are more promising for minimally invasive posterior lumbar fusion, which has achieved results similar to open techniques without significant increased risk. (10.5435/00124635-200706000-00001)
  • [L4] This technique achieved minimal invasiveness without requiring special instruments and has potential for clinical application. (10.1186/s12891-024-07339-8)
  • [L1] While minimally invasive techniques generally favor short-term outcomes such as decreased blood loss and shorter hospital stays, the literature remains equivocal regarding superior long-term results, including patient-reported outcomes and arthrodesis success, necessitating further study. (10.5435/jaaos-d-15-00756)
  • [L1] The modified minimally invasive procedure for tracer fixation results in minimal trauma and is simple, reliable, and highly safe. (10.1186/s12891-020-03239-9)
  • [L4] The technique is a straightforward, safe, and minimally invasive method for inserting large cages in the treatment of lumbar instability. (10.1186/s13018-024-05018-x)
  • [L4] Advances in minimally invasive and biologic therapies are reshaping treatment paradigms for aneurysmal and simple bone cysts, yet standardized outcome measures and head-to-head comparative trials remain needed. (10.1186/s13018-026-06792-6)
  • [L4] It is a safe and feasible minimally invasive surgical treatment method for multi-level lumbar spinal stenosis. (10.1186/s13018-024-04575-5)
  • [L4] Minimally invasive lateral approach interbody fusion technology has the advantage of less injury and quick recovery after surgery, which is an effective and safe treatment for thoracic and lumbar spinal tuberculosis. (10.1186/s12891-018-2187-3)
  • [L4] Although minimally invasive hybrid approach is minimally invasive surgery, there is still a significant amount of hidden blood loss. (10.1186/s12891-022-06079-x)
  • [L4] Ultrasound-guided release of the LSH is a novel surgical option with encouraging results in patients for whom conservative protocols have failed. (10.1186/s13018-021-02461-y)
  • [L3] ULIF is an effective minimally invasive lumbar fusion surgical technique. (10.1186/s13018-024-04674-3)
  • [L4] This procedure could be an effective alternative for patients who have a poor response to conservative treatment before a major open surgery. (10.1186/1471-2474-15-105)
  • [L3] Surgeons experienced in minimally invasive spine surgery can consider same-day discharge for patients having minimally invasive unilateral TLIF procedures. (10.1007/s11999-013-3366-z)
  • [L3] When strict indication criteria are followed, excellent, durable, and reliable results can be expected for this procedure. (10.1007/s00167-010-1213-2)
  • [L3] Both surgical methods have their own advantages and drawbacks. (10.1186/s12891-024-07287-3)
  • [L4] The results demonstrate the safety and viability of the annular closure device as an adjunct to minimally invasive discectomy. (10.1186/s12891-018-2178-4)
  • [L1] MITLIF and OTLIF provide equivalent long-term clinical outcomes. (10.1186/s13018-019-1266-y)
  • [L4] Sonographically controlled, minimally-invasive A1 pulley release can be performed safely and effectively with appropriate surgical instruments and practice. (10.1186/s12891-023-06982-x)
  • [L4] The study reports early results of a single posterior mini-incision technique, noting that while it allows immediate weight-bearing and early function, objective evaluation is needed to disentangle the effects of the surgical approach from changes in patient selection, expectations, and perioperative management. (10.2106/jbjs.d.02847)
  • [L1] However, studies with longer-term follow-up are needed, and open fixation remains a safe and reliable option. (10.5435/jaaos-d-24-01277)
  • [L1] Endo-TLIF is similar to MIS-TLIF in terms of long-term clinical outcomes, fusion rates, and complication rates. (10.1186/s13018-024-04549-7)
  • [L4] This is a feasible, safe, and minimally invasive procedure that achieves less damage to disc and retained cervical motion segment. (10.1186/s12891-019-2659-0)
  • [L4] It formulates conceptual designs for a novel integrated non-coaxial spinal endoscope and identifies intelligent solutions and instrument innovation as crucial future directions. (10.1186/s13018-025-06071-w)
  • [L1] The 1.5-stage revision does not show inferior results compared to the two-stage technique and reduces the number of additional surgical procedures. (10.1016/j.arth.2025.10.075)
  • [L1] The review identifies a range of wearable technologies and biofeedback modalities used to modulate spine motor control, highlighting the need for standardized reporting and further research to establish clinical efficacy. (10.1186/s12891-024-07867-3)
  • [L5] This review provides a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude, discussing commonly applied techniques and recent technological advances to facilitate better-informed diagnostic decisions. (10.5435/jaaos-d-24-01057)
  • [L4] Motion in the coronal plane decreased by 77% following anterior vertebral body tethering. (10.2106/jbjs.20.01533)
  • [L5] Its unique dynamic stabilization properties can effectively maintain intervertebral height, preserve partial mobility of the operated and adjacent segments, and alleviate postoperative stress concentration on the intervertebral disc and facet joints. (10.1186/s12891-026-09492-8)
  • [L4] Preoperative imaging planning is important to identify patients who are not suitable for this procedure. (10.1186/s13018-022-03320-0)
  • [L3] Findings confirm that hybrid surgery is a safe and effective intervention for multilevel spinal disease which demonstrates non-inferiority in relation to the current gold standard mACDF. (10.1186/s12891-023-06284-2)
  • [L2] However, clinical benefits over freehand technique were limited in other measures such as mHHS, revision, or conversion rates. (10.1016/j.arthro.2025.07.048)
  • [L1] The management of EOS remains challenging. (10.1186/s13018-022-03200-7)
  • [L4] Total endoscopic resection via an interlaminar approach provides a new minimally invasive approach for the surgical treatment of lumbar ligamentum flavum cyst, which can be used as a reference by clinicians. (10.1186/s13018-023-03824-3)
  • [L4] The Song's classification system has initially demonstrated significant value in guiding personalized surgical decision-making. (10.1186/s13018-025-06342-6)
  • [L4] The innovative technique may serve as a promising solution in treating spinal stenosis patients with lumbar kyphoscoliosis and multiple comorbidities. (10.1186/s12891-020-03745-w)
  • [L3] It can correct and maintain a proper spinopelvic alignment. (10.1186/s13018-022-03144-y)
  • [L4] Simulated orthopaedic spine surgery elicited modest but significant increases in energy expenditure over resting levels. (10.5435/jaaos-d-18-00284)
  • [L5] The text is a fine fundamental textbook with a strong foundation in basic sciences, particularly strong in early chapters on anatomy and biomechanics and later chapters on tumors, though it lacks discussion on certain deformities and techniques. (10.2106/00004623-199072070-00032)
  • [L3] Both the full endoscopy technique and intermittent endoscopy technique achieved good outcomes, whereas the intermittent endoscopy technique is a more effective option for a shorter duration surgery and lower hospitalization expenses. (10.1186/s13018-017-0662-4)
  • [L4] Early outcome studies show that growth modulation with vertebral body tethering is safe, can achieve good results, and preserve motion in select patients. (10.5435/jaaos-d-23-00312)
  • [L3] Minimally invasive surgery and conservative treatment achieve similar clinical outcomes in patients with FFP II fractures. (10.1186/s13018-025-05581-x)
  • [L5] Initial studies suggest that the results of posterior dynamic stabilization may be comparable to those of fusion; however, longer periods of clinical and radiographic follow-up are required to fully define the role these devices may play in the management of the degenerative lumbar spine. (10.5435/00124635-201010000-00001)
  • [L5] These findings quantify the correction loss for minimally invasive spine implant systems and imply that unstable spine fractures might benefit from stabilization with conventional implants like the USS. (10.1186/s12891-016-0983-1)
  • [L3] CT scanning is used frequently for follow-up imaging evaluation following complex spine surgery, with prevalence increasing more than two-fold from 6 months to 5 years post-surgery. (10.1186/s12891-017-1420-9)
  • [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. (10.1016/j.jse.2024.12.023)
  • [L3] The combined XOLIF-PELD approach may offer a minimally invasive alternative to PLIF for selected patients with adjacent segment disease, demonstrating reduced surgical trauma, faster recovery, and fewer minor complications. (10.1186/s13018-025-06011-8)
  • [L4] The OSE technique has no significant impact on lumbar spine stability in the early postoperative period. (10.1186/s12891-024-07443-9)
  • [L4] Current literature provides sufficient preclinical and clinical data evidence for the use of AR technology in spine surgery, offering greater accuracy, surgeon comfort, and reduced operating time. (10.5435/jaaos-d-23-00023)
  • [L3] Thoracoscopy combined with transforaminal endoscopy produces equivalent long-term results with shorter operation time, less intraoperative blood loss, fewer complications, and higher surgical safety compared to thoracoscopy alone, while fully decompressing and facilitating early recovery of spinal cord function. (10.1186/s13018-024-05242-5)
  • [L5] The biomechanical FE analysis indicated the greater ability of OLIF+BPSF to retain lumbar stability, resist cage subsidence, and maintain disc height. (10.1186/s13018-022-03143-z)
  • [L1] Spine robots demonstrate clear advantages in screw implantation accuracy and different robots may achieve optimal results under specific surgical requirements. (10.1186/s13018-025-06005-6)
  • [L3] This procedure can improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to traditional methods, making it an ideal surgical treatment for thoracolumbar fractures in AS patients. (10.1186/s13018-022-03378-w)
  • [L5] The study shows that the average different angles between the Caspar pin and cervical endplate are less than 7°. (10.1186/s12891-021-04533-w)
  • [L3] Oxford UKA of the medial compartment ensures good long-term survivorship with an excellent functional outcome. (10.1007/s00167-018-5299-2)
  • [L2] The minimal skin incision and multifidus-sparing approach of the MED had a positive effect on clinical outcomes, which were stable throughout the 2-year follow-up period. (10.5435/jaaos-d-15-00588)
  • [L4] The findings suggest it is a viable alternative to traditional open decompression, though broader validation in multicenter trials is needed. (10.1186/s13018-025-06564-8)
  • [L4] In the short term, patients with > 50% IAP defects show no difference in lumbar stability or clinical outcomes compared to those with ≤ 50% defects, though complete IAP loss remains a concern for long-term instability. (10.1186/s12891-025-09004-0)
  • [L3] Judicious PS insertion in patients with minimal bone destruction in thoracolumbar pyogenic spondylitis can minimize surgical invasiveness. (10.1186/s12891-024-07565-0)
  • [L5] Compared with the facetectomy in diameters 7.5 mm and 10 mm, the mechanical effect brought by facetectomy in diameter 15 mm on the operating segment changed more significantly, and had a corresponding effect on the adjacent segments. (10.1186/s13018-021-02733-7)
  • [L3] The novel 3D-printed guide plate-assisted percutaneous pedicle screw implantation can achieve better amelioration of back pain and recovery of function. (10.1186/s13018-024-05135-7)
  • [L3] Further studies are needed for long-term efficacy. (10.1186/s13018-024-04743-7)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L1] However, differences in the long-term functional and pain outcomes between MI-TLIF and Open-TLIF remain a source of controversy, which should be further verified in future randomized-control trials. (10.1186/s12891-018-1937-6)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L3] In the era of minimally invasive techniques, the use of three-column osteotomies has decreased, while the use of anterior and lateral interbody fusions has increased. (10.2106/jbjs.21.01172)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L1] This may indicate that the benefits seen with MIS techniques are due to the surgical approach rather than incision length or instrumentation. (10.1016/j.arth.2008.11.082)
  • [L3] The non-contact orthopedic robot navigation for the treatment of lumbar spondylolisthesis was demonstrated to be minimally invasive, precise, and stable surgical method. (10.1186/s12891-024-08019-3)
  • [L4] However, the procedure can be safely performed even during the early learning period by surgeons with adequate microscopic surgical experience. (10.1186/s13018-025-05699-y)
  • [L1] The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. (10.2106/jbjs.j.00157)
  • [L3] No additional patients had conversion to a posterior spinal fusion, which may indicate long-term survivorship. (10.2106/jbjs.23.01229)

See Also

References

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[2] Degenerative central lumbar spinal stenosis: is endoscopic decompression through bilateral transforaminal approach sufficient?. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03722-3

[3] The usefulness and utilisation of Lu’s retractor for unilateral biportal endoscopic discectomy: a retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05932-8

[4] Minimally Invasive Lumbar Spinal Fusion. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200706000-00001

[5] Unilateral biportal endoscopy via two different approaches for upper lumbar disc herniation: a technical note. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07339-8

[6] Transforaminal Lumbar Interbody Fusion: Traditional Open Versus Minimally Invasive Techniques. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-15-00756

[7] Minimally invasive versus conventional fixation of tracer in robot-assisted pedicle screw insertion surgery: a randomized control trial. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03239-9

[8] Biportal endoscopic transforaminal lumbar interbody fusion with large cage: a technique without additional spacer portal. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05018-x

[9] The best solution is the simplest: advances in surgical and minimally invasive management of aneurysmal and simple bone cysts. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06792-6

[10] Early efficacy observation of the unilateral biportal endoscopic technique in the treatment of multi-level lumbar spinal stenosis. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04575-5

[11] Chapter 21 Minimally Invasive Spine Surgery. 2019.

[12] Minimally invasive direct lateral interbody fusion in the treatment of the thoracic and lumbar spinal tuberculosisMini-DLIF for the thoracic and lumbar spinal tuberculosis. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2187-3

[13] Hidden blood loss of minimally invasive hybrid lumbar interbody fusion: an analysis of influencing factors. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-06079-x

[14] Ultrasound-guided surgery for lateral snapping hip: a novel ultraminimally invasive surgical technique. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02461-y

[15] Evaluation of the learning curve and complications in unilateral biportal endoscopic transforaminal lumbar interbody fusion: cumulative sum analysis and risk-adjusted cumulative sum analysis. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04674-3

[16] Minimally invasive endoscopic treatment for lumbar infectious spondylitis: a retrospective study in a tertiary referral center. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-105

[17] Same-day Discharge After Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Series of 808 Cases. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-013-3366-z

[18] Oxford Phase 3 unicompartmental knee arthroplasty: medium‐term results of a minimally invasive surgical procedure. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1213-2

[19] Unilateral biportal endoscopic lumbar interbody fusion (ULIF) versus endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in the treatment of lumbar spinal stenosis along with intervertebral disc herniation: a retrospective analysis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07287-3

[20] Implantation of a bone-anchored annular closure device in conjunction with tubular minimally invasive discectomy for lumbar disc herniation: a retrospective study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2178-4

[21] Open versus minimally invasive TLIF: literature review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1266-y

[22] Sonographically controlled minimally-invasive A1 pulley release using a new guide instrument – a case series of 106 procedures in 64 patients. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06982-x

[23] Early Complications of Primary Total Hip Replacement Performed with a Two-Incision Minimally Invasive Technique. The Journal of Bone and Joint Surgery (American). 2005. DOI: 10.2106/jbjs.d.02847

[24] Minimally Invasive vs Open Surgery for Thoracolumbar Fractures in Patients With Ankylosing Spinal Diseases: A Meta-Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01277

[25] Comparison of clinical outcomes and complications between endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative diseases: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04549-7

[26] Percutaneous full-endoscopic anterior transcorporeal cervical discectomy and channel repair: a technique note report. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2659-0

[27] Research advances in unilateral endoscopic spinal surgery for the treatment of lumbar disc herniation: a review. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06071-w

[28] 2025 ICM: Abbreviated Two- and 1.5-Stage. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.075

[29] Wearable technology mediated biofeedback to modulate spine motor control: a scoping review. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07867-3

[30] Metal Suppression Magnetic Resonance Imaging Techniques in Orthopaedic and Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01057

[31] Measurable Thoracic Motion Remains at 1 Year Following Anterior Vertebral Body Tethering, with Sagittal Motion Greater Than Coronal Motion. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01533

[32] Biomechanical analysis of the interlaminar dynamic stabilization system (IntraSPINE) in unilateral biportal endoscopic discectomy for huge lumbar disc herniation: a finite element study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09492-8

[33] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[34] L4/5 accessibility for extreme lateral interbody fusion (XLIF): a radiological study. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03320-0

[35] A real-world analysis of hybrid CDA and ACDF compared to multilevel ACDF. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06284-2

[36] Computer Navigation-Assisted Osteochondroplasty May Improve Accuracy of Resection Planning With Limited Outcome Differences Compared With Freehand Hip Arthroscopic Technique in Patients With Femoroacetabular Impingement Syndrome. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2025. DOI: 10.1016/j.arthro.2025.07.048

[37] Magnetically controlled growing rods in the management of early onset scoliosis: a systematic review. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03200-7

[38] Endoscopic treatment of lumbar ligamentum flavum cyst by interlaminar approach: a minimally invasive and effective alternative to open surgery. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03824-3

[39] A novel classification and clinical evaluation of various morphologies of calcified lumbar disc herniation treated using unilateral biportal endoscopic technique. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06342-6

[40] Percutaneous endoscopic unilateral laminotomy and bilateral decompression under 3D real-time image-guided navigation for spinal stenosis in degenerative lumbar kyphoscoliosis patients: an innovative preliminary study. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03745-w

[41] Does minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) influence functional outcomes and spinopelvic parameters in isthmic spondylolisthesis?. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03144-y

[42] Surgeon Energy Expenditure and Substrate Utilization During Simulated Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00284

[43] Microsurgery of The Lumbar Spine. Principles and Techniques in Spine Surgery.. The Journal of Bone & Joint Surgery. 1990. DOI: 10.2106/00004623-199072070-00032

[44] Percutaneous endoscopic interlaminar discectomy of L5–S1 disc herniation: a comparison between intermittent endoscopy technique and full endoscopy technique. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0662-4

[45] Anterior Vertebral Body Tethering: A Review of the Available Evidence. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00312

[46] Minimally invasive surgery and conservative treatment achieve similar clinical outcomes in patients with type II fragility fractures of the pelvis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05581-x

[47] Pedicle Screw-based Posterior Dynamic Stabilization in the Lumbar Spine. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201010000-00001

[48] Biomechanical investigation of a minimally invasive posterior spine stabilization system in comparison to the Universal Spinal System (USS). BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0983-1

[49] Utilization of CT scanning associated with complex spine surgery. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1420-9

[50] 2025 Basic Science Neer Award Winner: The impact of posterior and posterior superior labral injuries and the effect of their treatment on glenohumeral kinematics in the deceleration and follow-through phase of throwing: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.023

[51] An innovative minimally invasive technique for lumbar adjacent segment disease: a retrospective comparative analysis between extreme-oblique lumbar interbody fusion combined with percutaneous endoscopic lumbar discectomy(XOLIF-PELD) and posterior lumbar interbody fusion(PLIF) revision. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06011-8

[52] Short-term lumbar disc and lumbar stability changes of one-hole split endoscope technique treatment of spinal stenosis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07443-9

[53] Chapter 50 Thoracolumbar Minimally Invasive Surgical Techniques. 2020.

[54] Applications of Augmented Reality in Orthopaedic Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00023

[55] Decompression and reconstruction the spinal TB lesion of a single vertebra through thoracoscopy alone or combined with foraminal endoscopy. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05242-5

[56] Biomechanical study of oblique lumbar interbody fusion (OLIF) augmented with different types of instrumentation: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03143-z

[57] Spine-specific robots may offer superior screw placement accuracy in spinal surgery procedures. A systematic review and network and proportional meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06005-6

[58] Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03378-w

[59] The aiming device for cervical distractor pin insertion: a proof-of-concept, feasibility study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04533-w

[60] Minimally invasive Oxford unicompartmental knee arthroplasty ensures excellent functional outcome and high survivorship in the long term. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5299-2

[61] Minimal Incision, Multifidus-sparing Microendoscopic Diskectomy Versus Conventional Microdiskectomy for Highly Migrated Intracanal Lumbar Disk Herniations. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00588

[62] Microscopic tubular unilateral laminotomy for bilateral decompression: a detailed surgical illustration and single-arm cohort study on outcomes in lumbar canal stenosis. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06564-8

[63] Classification of inferior articular process injury after percutaneous endoscopic interlaminar lumbar discectomy based on CT three-dimensional reconstruction and its clinical significance. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09004-0

[64] Pedicle screw insertion into infected vertebrae reduces operative time and range of fixation in minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis: a multicenter retrospective cohort study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07565-0

[65] The biomechanical effect of the relevant segments after facet-disectomy in different diameters under posterior lumbar percutaneous endoscopes: a three-dimensional finite element analysis. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02733-7

[66] Three-dimensional-printed guide plate for direct percutaneous pedicle screw implantation in minimally invasive transforaminal lumbar interbody fusion surgery: a retrospective study of 162 patients. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05135-7

[67] One-hole split endoscope versus unilateral biportal endoscopy for lumbar spinal stenosis: a retrospective propensity score study. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04743-7

[68] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[69] Minimally invasive versus open Transforaminal lumbar Interbody fusion in obese patients: a meta-analysis. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-1937-6

[70] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

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[75] Learning curve for full-endoscopic lumbar decompression via interlaminar approach using the learning curve cumulative summation analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05699-y

[76] Mobile and Fixed-Bearing (All-Polyethylene Tibial Component) Total Knee Arthroplasty Designs. Journal of Bone and Joint Surgery. 2010. DOI: 10.2106/jbjs.j.00157

[77] Anterior Vertebral Body Tethering. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.01229

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a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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