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- •Foreword
- •Reference
- •Contents
- •References
- •1: The Epidemiology of Adult Spinal Deformity and the Aging Population
- •1.1 The Aging Population
- •1.2 Incidence of Spinal Disorders and Deformity in Our Aging Population
- •1.3 Incidence of Spinal Surgery for Adult Spinal Deformity in Our Aging Population
- •1.4 Incidence of Medical Morbidity Associated with Surgery for Adult Spinal Deformity in Our Aging Population
- •Conclusion
- •2.1 Introduction
- •2.2.1 The King System
- •2.2.2 The Coonrad System
- •2.2.3 The Lenke System
- •2.3.2 The Schwab System
- •2.3.3 The SRS System
- •2.3.4 The SRS-System
- •Conclusion
- •References
- •3: Indications for Adult Spinal Deformity Surgery
- •3.1 Introduction
- •3.2 Symptom-Driven Treatment
- •3.2.1 Pain
- •3.2.2 Axial Pain
- •3.2.3 Radicular Pain
- •3.2.4 Disability
- •3.4.1 Imaging Analysis and Diagnosis
- •3.4.2 X-Ray
- •3.4.3 MRI
- •3.4.4 CT
- •3.4.5 EMG
- •3.5 Operative Indications
- •3.7 Risks of Surgical Treatment
- •3.8 Risk Factors for Surgical Complications
- •3.9 Minimizing Surgical Risk
- •Conclusion
- •References
- •4: Sagittal Balance
- •4.1 Local Spinal Alignment
- •4.2 Global Alignment
- •4.3 Imaging
- •4.4 Outcomes
- •References
- •5: Lumbopelvic Parameters
- •5.1 Introduction
- •5.2 Pelvic Incidence
- •5.3 Pelvic Tilt
- •5.4 Sacral Slope
- •5.5 Lumbar Lordosis
- •5.6 Pelvic Obliquity
- •5.7 The Spinopelvic Relationship and Pelvic Translation
- •5.8 Clinical Relevance
- •Conclusions
- •References
- •6: The Importance of the Fractional Curve
- •6.1 Introduction
- •6.2 Biomechanics of the Fractional Curve
- •6.5.1 Curve Under-Correction
- •Conclusions
- •References
- •7: Radiation Safety
- •7.1 Introduction
- •Conclusion
- •References
- •8: Costs of Minimally Invasive Spine Surgery
- •8.1 Introduction: Costs of Spinal Surgery
- •8.2 Cost Analysis
- •8.4 Increased Costs with MIS Spine Surgery
- •Conclusions
- •References
- •9: The MiSLAT Algorithm: Minimally Invasive Evaluation and Treatment for Adult Degenerative Deformity
- •9.1 Introduction
- •9.3 Patient Evaluation
- •9.5 The MiSLAT Algorithm
- •9.5.1 MiSLAT Treatment Level I
- •9.5.2 MiSLAT Treatment Level II
- •9.5.3 MiSLAT Treatment Level III
- •9.5.4 MiSLAT Treatment Level IV
- •Conclusions
- •References
- •10: Fluoroscopic Techniques in MIS Surgery
- •10.1 Introduction
- •10.4 Standard Fluoroscopic Images of the Spine
- •10.5 Tips and Tricks for Successful C-Arm Usage
- •Conclusion
- •References
- •11: Image Guidance for Minimally Invasive Deformity Surgery
- •11.1 Introduction
- •11.2 Potential Advantages and Disadvantages of CAS
- •11.5 One- or Two-Level MIS TLIF
- •12.2 Anatomy
- •12.2.1 Pedicle
- •12.2.2 Thoracic Spine
- •12.2.3 Lumbar Spine
- •11.6 Complex and Deformity Surgery
- •11.7 Navigation Without K-Wires
- •11.8 Radiation Exposure
- •11.10 Impact of Navigation on Screw Accuracy and Clinical Outcome
- •11.11 Robotic Surgery
- •11.12 Future Developments and Outlook
- •References
- •12: Nuances of Percutaneous Thoracolumbar Pedicle Screw Fixation
- •12.1 Introduction
- •12.3 Principles of Minimally Invasive Spinal Instrumentation
- •12.3.1 Preoperative Planning
- •12.3.2 Fluoroscopic Imaging
- •12.3.3 Facet or Intertransverse Fusion
- •12.3.4 Marking Out the Surgical Incision
- •12.3.5 Percutaneous Pedicle Targeting
- •12.3.6 Pedicle Screw and Rod Insertion
- •Conclusion
- •References
- •13: Rod Contouring, Passage, and Connection
- •References
- •14: Percutaneous Sacropelvic Fixation
- •14.1 Introduction
- •14.2 Surgical Technique for Image-Based Iliac Targeting
- •14.3 Clinical Applications
- •References
- •15: Management of Osteoporotic Bone
- •15.1 Introduction
- •15.3 Preoperative Evaluation and Medical Management
- •15.4 Surgical Strategies for the Osteoporotic Spine
- •15.5 Vertebroplasty/Kyphoplasty for Osteoporotic Fractures
- •Conclusions
- •References
- •16: Minimally Invasive Cement-Augmented Pedicle Screw Fixation
- •16.2 Augmentation Techniques
- •16.3 Screw Geometry/Insertion
- •16.4 Cement Augmentation
- •16.5 Conclusion
- •16.6 Technique
- •16.6.1 Technique
- •16.6.2 Case Example Number 2
- •References
- •17: Interbody Cage Options
- •17.1 Material Options
- •17.1.1 Metallic Devices
- •17.1.2 Polymer Devices
- •17.1.3 Biodegradable
- •17.2 Design Options
- •17.2.2 Size of Cages: Just Fit into Versus Distraction of the Intervertebral Space
- •17.2.3 Number of Cages: One Versus Two
- •17.2.5 Lordotic Versus Non-lordotic Cages
- •17.3 Consequences of the Material Types: Subsidence
- •17.4 Ideal Interbody Cage
- •References
- •18: Multilevel TLIF for Spinal Deformity
- •18.1 Introduction
- •18.2 Use of Open Multilevel TLIF for Coronal and Sagittal Deformity Correction
- •18.3 The Use of MIS Multilevel MIS TLIF in Adult Deformity Surgery
- •18.4 Surgical Technique
- •18.5 Future Advances
- •References
- •19: Expandable Cages for Thoracic Spinal Deformity
- •19.1 Introduction
- •19.2 Kyphotic Deformity of the Thoracic Spine
- •19.3 Conservative Management and Treatment of Thoracic Kyphotic Deformity
- •19.4 Indications and Goals for Surgical Correction of Thoracic Kyphotic Deformity
- •19.5 Surgical Approaches to Treating Thoracic Kyphotic Deformity
- •19.5.1 Posterior
- •19.5.2 Anterolateral
- •Conclusion
- •References
- •20: Expandable Cages for Lumbar Spinal Deformity
- •20.1 Introduction
- •20.4 Kambin’s Triangle and the Geometry of Interbody Cages
- •20.5 The Role of Expandable Cages
- •20.6 Case Illustration
- •Conclusions
- •References
- •21: Lumbar Endoscopic Fusion
- •21.1 Introduction
- •21.2 ETLIF
- •21.2.1 Indications: Special Considerations
- •21.2.2 Surgical Technique
- •21.3 LALIF
- •21.3.2 Surgical Technique
- •21.4 ELLIF
- •21.4.2 Surgical Technique
- •21.5 PELIF
- •21.5.1 Indications: Special Considerations
- •21.5.2 Surgical Technique
- •21.6 Final Considerations
- •References
- •22: Minimally Invasive Osteotomy Techniques
- •22.1 Introduction
- •22.3 Posterior Column Osteotomies (Grades I and II)
- •22.4 Three-Column Osteotomies (Grades III through IV)
- •22.6 Future Directions
- •References
- •23: Thoracoscopic Approaches
- •References
- •24: Role of Neuromonitoring in Minimally Invasive Lateral Approaches to the Spine
- •24.1 Introduction
- •24.2 Anatomy
- •24.3 Types of Monitoring
- •24.5 Recommendations
- •References
- •25: Lateral Interbody Decompression and Fusion: Which Side to Approach From?
- •25.1 Background
- •25.2 Anterior Interbody Versus Posterior Interbody
- •25.3 Approaching from the Concave or Convex Side of the Spine
- •25.4 Concave Approach
- •25.5 Convex Approach
- •25.6 Other Considerations
- •Conclusion
- •References
- •26: Stand-Alone Lateral Surgery for Spinal Deformity
- •26.1 Introduction
- •26.2 Patient Selection
- •26.4 Biomechanics
- •26.5 Anatomical Considerations
- •26.6 Operative Considerations
- •26.7 Case Illustration
- •Conclusions
- •References
- •27: Complications of the Lateral Lumbar Transpsoas Approach
- •27.1 Complications of Positioning
- •27.3 Complications Encountered During Discectomy and Graft Placement
- •27.4 Complications Encountered in the Postoperative Period
- •Conclusions
- •References
- •28: Minimally Invasive Anterior Column Reconstruction for Sagittal Plane Deformities
- •28.1 Introduction
- •28.2 Patient Selection
- •28.3 Advantages and Disadvantages
- •28.4 Anterior Longitudinal Ligament Section via the Lateral Transpsoas Approach
- •28.5 Anatomic Consideration
- •28.5.1 Anterior Longitudinal Ligament
- •28.5.2 Lumbar/Sympathetic Plexus
- •28.5.3 Great Vessels
- •28.6 Operative Considerations
- •28.7 Case Illustration
- •28.8.1 Introduction
- •28.9 Case Illustration
- •Conclusions
- •References
- •29: MIS Thoracic Interbody Surgery
- •29.1 Evolution of MIS Thoracic Interbody Techniques
- •29.2 Anterior Techniques
- •29.3 Posterior Techniques
- •29.4 Indications for MIS Thoracic Interbody Surgery
- •29.5 Contraindications for MIS Thoracic Interbody Surgery
- •29.7 Extracoelomic Approach to the Thoracolumbar Junction
- •29.8 MIS Thoracic Interbody Surgery via Posterolateral Extracavitary Approach
- •29.9 MIS Corpectomy and Vertebral Body Replacement
- •29.10 MIS Deformity Correction
- •29.12 Clinical Results
- •References
- •30: Mini-Open ALIF for Fusing the Lumbosacral Junction
- •30.1 Indications
- •30.2 Contraindications
- •30.3 Alternative Treatments
- •30.4 Results
- •30.5 Technique
- •30.5.1 Setup
- •30.5.2 Instruments
- •30.5.3 Procedure
- •30.5.4 Wound Closure
- •30.5.5 Postoperative Regimen
- •References
- •31: Presacral Approach for Discectomy and Interbody Fusion in the Setting of Minimally Invasive Spine Surgery Deformity Correction
- •31.1 Indications for Fusion to the Sacrum in Deformity Correction
- •31.1.1 Surgical Anatomy
- •31.1.2 Device
- •31.2.1 AxiaLIF in the Setting of Deformity
- •31.2.1.1 Procedure
- •31.3 Outcomes in Terms of Deformity Correction
- •31.4 Complications
- •Conclusions
- •References
- •32: Minimally Invasive Sacroiliac Joint Fusion
- •References
- •33: Bone Graft Extenders
- •33.1 Introduction
- •33.2 Bone Formation
- •33.2.1 Autograft
- •33.2.2 Allograft-Based Extenders
- •33.2.3 Growth Factor-Based Extenders
- •33.2.4 Cell-Based Extenders
- •33.2.5 Ceramic-Based Extenders
- •33.2.6 Polymer-Based Extenders
- •33.3 Clinical Research
- •Conclusion
- •References
- •34: Minimally Invasive Wiltse Approaches for Posterolateral Fusion
- •34.1 Introduction
- •34.2 Intermuscular Approach
- •34.3 Facet Fusion
- •34.5 Medialized Screw Fixation
- •34.6 Discussion
- •References
- •35: Minimally Invasive Thoracolumbar Facet Joint Fusion
- •35.1 Introduction
- •35.3 Surgical Technique Section
- •35.4 Clinical Data
- •Conclusion
- •References
- •36: Clinical Research in MIS Surgery: Current State and Future Challenges
- •36.1 Introduction
- •36.3.2 Complication Rates
- •36.3.3 Patient-Reported Outcome Measures
- •36.7 Clinical Research in MIS Surgery: Future Challenges
- •Conclusion
- •References
- •37: MIS in Adolescent Deformity
- •37.1 Indications for MIS in AIS
- •37.2 Technique of MIS in AIS
- •References
- •38: The Future of MIS Spine Surgery
- •38.1 Introduction
- •38.2 What Is MISS?
- •38.3 Where Should MISS Go in the Future?
- •38.4.1 Patient Demand
- •38.4.2 Skill Level and Education
- •38.4.3 Instrumentation
- •38.4.4 Image Guidance
- •38.4.5 Cost, Quality of Life (QOL)
- •38.4.6 Health-Care Policy
- •References
- •Index

Michael Y. Wang
Yi Lu
D. Greg Anderson
Praveen V. Mummaneni
Editors
Minimally Invasive
Spinal Deformity Surgery
An Evolution of
Modern Techniques
123

Minimally Invasive Spinal Deformity
Surgery


Michael Y. Wang • Y i L u
D. Greg Anderson
Praveen V. Mummaneni
Editors
Minimally Invasive
Spinal Deformity
Surgery
An Evolution of Modern Techniques

Editors
Michael Y. Wang, M.D., M.S.
Department of Neurological Surgery
University of Miami Miller
School of Medicine
Miami, FL
USA
Yi Lu , M.D., Ph.D.
Department of Neurosurgery
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA
USA
D. Greg Anderson
Department of Orthopaedics
Thomas Jefferson University
Philadelphia, PA
USA
Praveen V. Mummaneni, MD
Department of Neurological Surgery
University of California
San Francisco, CA
USA
ISBN 978-3-7091-1406-3 ISBN 978-3-7091-1407-0 (eBook)
DOI 10.1007/978-3-7091-1407-0
Springer Wien Heidelberg Dordrecht London New York
Library of Congress Control Number: 2013957182
© Springer-Verlag Wien 2014
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of
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or by similar or dissimilar methodology now known or hereafter developed. Exempted from this
legal reservation are brief excerpts in connection with reviews or scholarly analysis or material
supplied specifi cally for the purpose of being entered and executed on a computer system, for
exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is
permitted only under the provisions of the Copyright Law of the Publisher's location, in its
current version, and permission for use must always be obtained from Springer. Permissions for
use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable
to prosecution under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specifi c statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of
publication, neither the authors nor the editors nor the publisher can accept any legal responsibility
for any errors or omissions that may be made. The publisher makes no warranty, express or
implied, with respect to the material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (
www.springer.com)

Foreword
Minimally Invasive Spinal Deformity Surgery: An Evolution of Modern
Techniques is intended to provide an educational resource for surgeons in an
area where there has until now been a paucity of literature. Many advances in
the area of minimally invasive spine surgery (MISS) are occurring through
small series of patients operated on by innovative thought leaders. This book
provides the opportunity to put this collection of surgical techniques and
early outcomes into one place so that the student of this advancing fi eld may
gain a broader exposure to the current knowledge base.
With the increasingly aging patient population, it is now common to see in
one’s practice older patients with advanced degenerative spine disease and
deformity. These issues can be incapacitating, causing pain and immobility,
and reducing the patient’s quality of life. Multiple medical comorbidities
often exist in these patients, along with osteoporosis, causing challenges and
often complicating treatment. As a consequence, surgical treatment of adult
spinal deformities is fraught with hazards and complications, which has led
thought leaders to seek better solutions. Contemporary spine surgeons, both
orthopedic surgeons and neurosurgeons, are recognizing that MISS is an
increasingly desirable option for managing this diffi cult patient population.
MISS techniques are reported to minimize blood loss and surgical site pain
and to speed up recovery. Recent work by McGirt et al. [1] showed that the
number of surgical site infections with two-level fusions performed via MISS
was signifi cantly reduced as compared to that seen with open lumbar twolevel fusions.
This book is divided into sections that will help provide good background
information to readers wishing to become knowledgeable in all areas of
MISS. The “Deformity Surgery Principles” section includes not only epidemiology and classifi cation but important issues for adult deformity surgery,
such as sagittal balance and lumbopelvic parameters. The next section,
“Percutaneous Segmental Fixation,” reviews techniques of screw insertion
with a subsection on osteoporotic bone. The use of interbody fusion devices
is separately discussed in the more popular “Posterior Approaches” and a
section covering “Lateral Approaches.” The lateral approach section includes
a chapter on the role of neuromonitoring, the use of which is vitally important
in making this procedure safe. “Dealing with the Lumbo-Pelvic Junction”
discusses the importance of good distal fi xation, not only to S1 but also to the
ilium, and the minimally invasive techniques to accomplish this fi xation are
also well discussed. “Achieving Intersegmental Arthrodesis” discusses the
v

vi
very important issue of bone grafting techniques. Much of what has been
learned in adult deformity surgery is being incorporated into MISS approaches
for posterior adolescent idiopathic scoliosis surgery and is covered in the
“Future Directions” section.
I applaud the editors of this book for soliciting highly relevant information on this subject; they have done an outstanding job to make sure that
signifi cant, new information is available to surgeons wishing to learn some
of these techniques in order to take care of this increasing patient
population.
Reference
1. McGirt MJ, Parker SL, Lerner J, Engelhart L, Knight T, Wang MY. Comparative
analysis of perioperative surgical site infection after minimally invasive versus open
posterior/transforaminal lumbar interbody fusion: analysis of hospital billing and
discharge data from 5170 patients. J Neurosurg Spine 2011;14(6):771–8.
Philadelphia, PA Randal R. Betz, M.D.
Foreword

Contents
Part I Deformity Surgery Principles
1 The Epidemiology of Adult Spinal Deformity
and the Aging Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Joseph S. Cheng, Jonathan Forbes, Cyrus Wong,
and Edward Perry
2 Classifi cation Schema for Scoliosis. . . . . . . . . . . . . . . . . . . . . . . 11
Olaolu C. Akinbo, Tsung-Hsi Tu, John E. Ziewacz,
and Praveen V. Mummaneni
3 Indications for Adult Spinal Deformity Surgery. . . . . . . . . . . . 21
Jeffrey H. Weinreb, Kristina L. Bianco,
Virginie Lafage, and Frank Schwab
4 Sagittal Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Jeffrey B. Knox and Baron S. Lonner
5 Lumbopelvic Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Manish K. Kasliwal, Justin S. Smith, Manish Singh,
and Christopher I. Shaffrey
6 The Importance of the Fractional Curve. . . . . . . . . . . . . . . . . . 47
Michael Y. Wang
7 Radiation Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
D. Greg Anderson
8 Costs of Minimally Invasive Spine Surgery. . . . . . . . . . . . . . . . 59
Kevin S. Cahill
9 The MiSLAT Algorithm: Minimally Invasive Evaluation
and Treatment for Adult Degenerative Deformity . . . . . . . . . . 67
Praveen V. Mummaneni, Michael Y. Wang,
Fernando E. Silva, Lawrence G. Lenke, John E. Ziewacz,
Beejal Y. Amin, and Tsung-Hsi Tu
vii

viii
Part II Percutaneous Segmental Fixation
10 Fluoroscopic Techniques in MIS Surgery . . . . . . . . . . . . . . . . . 77
D. Greg Anderson
11 Image Guidance for Minimally Invasive
Deformity Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Roger Härtl
12 Nuances of Percutaneous Thoracolumbar
Pedicle Screw Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
D. Greg Anderson
13 Rod Contouring, Passage, and Connection . . . . . . . . . . . . . . . . 109
Bernhard Meyer, Michelle Falcone,
Michael Y. Wang, Yi Lu, and Steven Wu
14 Percutaneous Sacropelvic Fixation. . . . . . . . . . . . . . . . . . . . . . . 113
Michael Y. Wang
15 Management of Osteoporotic Bone . . . . . . . . . . . . . . . . . . . . . . 123
John E. Ziewacz, Darryl Lau, Sigurd H. Berven,
Armed J. Awad, and Praveen V. Mummaneni
16 Minimally Invasive Cement-Augmented
Pedicle Screw Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Brian Hood and Steven Vanni
Contents
Part III Posterior Approaches
17 Interbody Cage Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Asdrubal Falavigna
18 Multilevel TLIF for Spinal Deformity . . . . . . . . . . . . . . . . . . . . 173
Yi Lu, Michelle M. Falcone, Michael Y. Wang, and Steven Wu
19 Expandable Cages for Thoracic Spinal Deformity . . . . . . . . . . 185
Paul E. Kaloostian and Daniel M. Sciubba
20 Expandable Cages for Lumbar Spinal Deformity . . . . . . . . . . 191
Michael Y. Wang
21 Lumbar Endoscopic Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Gun Choi, Guilherme Pereira Corrêa Meyer,
and Daniel H. Kim
22 Minimally Invasive Osteotomy Techniques . . . . . . . . . . . . . . . . 215
Michael Y. Wang
Part IV Lateral Approaches
23 Thoracoscopic Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Jonathan D. Choi and Robert E. Isaacs

Contents
ix
24 Role of Neuromonitoring in Minimally Invasive
Latera Approaches to the Spine . . . . . . . . . . . . . . . . . . . . . . . . . 233
Khoi D. Than, Anthony C. Wang, Brian Bush,
Paul Park, and Frank La Marca
25 Lateral Interbody Decompression and Fusion:
Which Side to Approach From? . . . . . . . . . . . . . . . . . . . . . . . . . 245
Andrew A. Sama
26 Stand-Alone Lateral Surgery for Spinal Deformity . . . . . . . . . 255
Amir Ahmadian and Juan S. Uribe
27 Complications of the Lateral Lumbar Transpsoas Approach . . . 263
Adam S. Kanter and Matthew B. Maserati
28 Minimally Invasive Anterior Column Reconstruction
for Sagittal Plane Deformities. . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Armen Deukmedjian and Juan S. Uribe
29 MIS Thoracic Interbody Surgery. . . . . . . . . . . . . . . . . . . . . . . . 287
Kai-Michael Scheufl er
Part V Dealing with the Lumbo-Pelvic Junction
30 Mini-Open ALIF for Fusing the Lumbosacral Junction . . . . . 303
Robert Watkins IV and Salvadore Brau
31 Presacral Approach for Discectomy and Interbody Fusion
in the Setting of Minimally Invasive Spine Surgery
Deformity Correction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Neel Anand and Eli M. Baron
32 Minimally Invasive Sacroiliac Joint Fusion. . . . . . . . . . . . . . . . 321
Yi Lu and Steven Wu
Part VI Achieving Intersegmental Arthodesis
33 Bone Graft Extenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Sonia Teufack, James Harrop, and Srinivas Prasad
34 Minimally Invasive Wiltse Approaches for
Posterolateral Fusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Steve Ritland
35 Minimally Invasive Thoracolumbar Facet Joint Fusion . . . . . 363
Oliver Tannous, Kelley Banagan, and Steven C. Ludwig
Part VII Future Directions
36 Clinical Research in MIS Surgery: Current State
and Future Challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Christina L. Goldstein and Y. Raja Rampersaud
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