Minimally invasive spine surgery is expanding, but surgeons are drawing a sharper distinction between smaller incisions and better outcomes. While many see clear benefits for routine decompressions and disc herniations, questions remain about its value in complex fusions, deformity cases and procedures where limited exposure could compromise long-term results.
Here is where 10 spine surgeons believe MIS delivers, and where the enthusiasm may be outpacing the evidence.
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Editor’s note: Responses have been lightly edited for clarity and length.
Question: Minimally invasive spine surgery keeps expanding, but not every smaller operation is necessarily a better one. Where do you think MIS delivers its clearest advantage, and where is the enthusiasm getting ahead of the evidence?
Bryce Basques, MD. Spine Surgeon and Director of Minimally Invasive and Endoscopic Spine Surgery at Brown University (Providence, R.I.): The clearest advantage of MIS is when it enables a faster recovery than standard open techniques, and this is where MIS delivers true value. MIS reduces the expense of care by allowing procedures to move to a lower-cost, higher-efficiency setting such as an ASC, and it enables patients to recover and get back to work faster. The advantages of MIS fall apart when the approach becomes the point. If a surgery takes significantly longer, uses expensive implants or is massively reliant on complex technology without clear clinical benefit, the patient hasn’t gained anything from the smaller incision.
Michael Conti Mica, MD. Orthopedic Spine Surgeon at Spine Institute of Arizona (Scottsdale): As we surgically treat our patients to reduce pain and restore or preserve function, innovative techniques such as minimally invasive and ultra-minimally invasive surgery have helped us accomplish these goals with many benefits, including decreased morbidity, reduced hospitalization and a faster return to a more normalized lifestyle, among others. In certain situations, these approaches have afforded us the ability to preserve motion while addressing the offending pathology. When fusion is the appropriate treatment, they allow us to accomplish this while minimizing collateral damage to the intervening tissues.
Techniques and enabling technologies must and will advance, but principles remain constant. New techniques or technologies that violate the principles of surgery or compromise the ability to achieve the primary goals of the surgery performed can be a disservice to our patients.
There is much to be optimistic about in the field of spine surgery. We have come so far in such a short period of time, yet we are certainly not finished, and I am excited about how we will deliver spine care in the future.
Todd Lanman, MD. Spinal Neurosurgeon at Lanman Spinal Neurosurgery (Beverly Hills, Calif.): Minimally invasive spine surgery is not new. Tubular approaches have been used for more than 20 years, and their value depends on whether they allow the surgeon to accomplish the full surgical objective with less tissue disruption.
In my experience, the clearest advantage is in a younger patient with a focal disc herniation who needs a microdiscectomy. A limited approach can provide access to remove the herniated material and adequately decompress the affected nerve.
I am more cautious when enthusiasm extends to middle-aged and older patients with stenosis caused by bone spurs, spondylosis and degenerative disc protrusions. These cases may require broader decompression, particularly in the lateral recess. A narrow working corridor can make that more demanding, and camera-based systems with two-dimensional visualization introduce limitations in depth perception.
Experienced surgeons can achieve excellent results with MIS techniques, but those results should not be assumed across every patient or surgeon, particularly during early adoption. In some cases, a limited open approach provides the exposure needed for a more complete decompression.
The measure of success should be adequate decompression and a durable clinical result. A smaller incision is valuable when it supports those goals.
Jason Liauw, MD. Spine Surgeon at DISC Newport Beach (Calif.) and DISC Carlsbad (Calif.): Overall, I believe the greatest benefits of minimally invasive spine surgery are realized in smaller, targeted procedures, such as laminectomies and microdiscectomies. Endoscopic decompressions and rhizotomies, in particular, truly capitalize on the advantages of minimally invasive techniques by enabling precise anatomical targeting and enhanced visualization while minimizing disruption to surrounding tissues.
When it comes to spinal fusion, however, I believe the term “minimally invasive” is often more of a marketing distinction than a reflection of a genuinely less invasive surgical exposure or reduced tissue disruption.
Jonathan Rasouli, MD. Spinal Neurosurgeon at NeuroSpine Plus (Paramus, N.J.): To me, the clearest advantage is treating lumbar disc herniations at one or more levels, where we can directly address the pathology while limiting disruption of the surrounding bony anatomy and soft tissues. That is a straightforward application of minimally invasive surgery with a clear clinical objective. I am less convinced that endoscopic fusion currently offers enough additional benefit over established minimally invasive fusion techniques to justify its added complexity. A smaller incision is valuable, but we still need to demonstrate that it translates into a better outcome for the patient.
Krishna Satyan, MD. Neurosurgeon at Dallas Neurosurgical & Spine (Dallas): Many patients ask about the most minimally invasive option possible. If I were a patient, I would also be interested in minimally invasive surgery. I enjoy doing minimally invasive surgery as a physician. Through small incisions, you can provide excellent results. However, every approach has its advantages and disadvantages. Minimally invasive surgery is not appropriate for every situation. Patients with larger deformities in their spine, fractures, severe stenosis with calcifications and adhesions, or patients who need more aggressive fusions are not necessarily good candidates for minimally invasive approaches. Patients with tumors in their spine are usually not great candidates for minimally invasive approaches. However, patients with routine lumbar stenosis and disc herniations are potentially very good candidates.
Jeremy Smith, MD. Orthopedic Spine Surgeon and Division Chief of Spine Surgery at Hoag Orthopedic Institute (Irvine, Calif.): Minimally invasive surgery is very effective when it is applied to the right pathology, but it cannot be applied to every pathology. The enthusiasm gets ahead of the evidence when the technique drives the treatment instead of the pathology. Multilevel disease, significant instability, and spinal deformity that requires restoration of sagittal alignment often call for a more extensive approach. A smaller operation in those settings can leave the pathology undertreated and lead to persistent symptoms or revision surgery. In my practice, MIS is an important tool that we use whenever it allows us to fully treat the problem, because the goal is the best long-term outcome, not the smallest incision.
Issada Thongtrangan, MD. Endoscopic and Minimally Invasive Spine Surgeon at MicroSpine (Scottsdale, Ariz.): For me, MIS clearly wins in the bread-and-butter lumbar cases, a straightforward disc herniation or single-level stenosis.
In endoscopic discectomy, we now have a solid 2026 meta-analysis of 17 randomized trials, over 2,200 patients, showing full-endoscopic discectomy gives you the same leg pain relief as a microscope, but with less blood loss, fewer wound infections and hematomas, and return to work about three weeks faster. The trade-off is more fluoroscopy time.
It’s a similar story for stenosis decompression. A meta-analysis of almost 2,000 levels showed endoscopic decompression cut blood loss, cut hospital stay by almost two days, and actually lowered durotomy and surgical site infection rates, with equivalent pain and function out to two years. Another updated systematic review found the same, less back pain and shorter stay, no difference in leg pain or disability.
David Weiner, MD. Assistant Professor at Georgetown University Medical School (Washington, D.C.) and Orthopedic Spine Surgeon at MedStar Health (Columbia, Md.): MIS is most compelling when it reduces approach-related tissue injury and supports an easier early recovery while accomplishing the same decompression, stabilization or correction. It can be a real advantage for a well-selected patient, but incision size is not a clinical outcome. In complex revision or deformity cases, the exposure needed to understand the anatomy and achieve the right correction may matter more than minimizing the incision.
Jacky Yeung, MD. Neurosurgeon at Hartford (Conn.) Healthcare Ayer Neuroscience Institute: Minimally invasive spine surgery delivers its clearest advantage when it achieves the same surgical goal with less tissue disruption, less pain and faster recovery. The enthusiasm gets ahead of the evidence when we start compromising the overall goal of the operation or the intended outcome simply for the sake of being minimally invasive. Bigger problems often require bigger solutions, and the right operation is the one that best addresses the pathology.
Christian Zimmerman, MD. Spinal Neurosurgeon at St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The clearest reported advantages lie in the technical consequence and short-term results of patient comfort and length of hospital stay. In the same reporting, the causatum of long-term outcomes and potential catastrophic nerve root injury or dural breach endures, especially in the more comorbid patient. Younger and more capable patient profiles are clearly more advantageous, while fusion rates remain disputatious among its disputers.
In all aspects of medicine regarding concurrent (patient and provider) expectations, the fresh and gleaming draw the inquisitive short of the residuum. The botheration of industrial hyperbole coupled with omnipresent, representative encumbrance are colloquial and unceasing. As personally observed and interceded, misadventure is reflective and usually transformative for patient and hopefully, practitioner alike. Adeptness in any specialty is acquired and experiential, drawing on years of exposure and tribulation. Granted, the misadventures in any surgical resume prevail in the fraction of numbers as patient-centric outcomes rather than the latest and greatest are sustained.
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