Minimally invasive transforaminal lumbar interbody fusion versus microscopic lumbar interbody fusion for the treatment of lumbar degenerative diseases: a radiological imaging-based retrospective study

Minimally invasive transforaminal lumbar interbody fusion versus microscopic lumbar interbody fusion for the treatment of lumbar degenerative diseases: a radiological imaging-based retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Minimally invasive transforaminal lumbar interbody fusion versus microscopic lumbar interbody fusion for the treatment of lumbar degenerative diseases: a radiological imaging-based retrospective study Xing Chen, Haibo Ji, Congdi Liu, Nai Mu, Zhengfeng Huang, Shuxing Xing This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7337627/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To compare the radiographic efficacy of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and endoscopic lumbar interbody fusion (Endo-LIF) in the treatment of lumbar degenerative diseases, especially to evaluate the effects of the two procedures on spino-pelvic parameters and vertebral stability. Methods: A retrospective analysis was conducted on the clinical and radiological data of 178 patients who underwent single-level lumbar fusion surgery (75 cases in the endoscopic group and 103 cases in the channel group). Independent sample t-tests and chi-square tests were used to compare baseline characteristics. Paired t-tests were employed to analyze the changes in vertebral parameters (intervertebral inclination angle, height, slip distance, etc.) and sagittal parameters of the spine-pelvis (lumbar lordosis angle, Cobb angle, pelvic tilt angle, etc.) before and after surgery. The differences in improvement values between groups were evaluated by independent sample tests. The significance threshold was set at P 0.05). 2. Implant parameters: The width of the fusion cage in the MIS-TLIF group was significantly greater than that in the Endo-LIF group (11.8 ± 1.6 mm vs. 10.7 ± 1.9 mm, P = 0.021). The usage rate of the L5/S1 segment was higher in the endoscopic group (10.3% vs. 3.5%, P = 0.115). 3. Improvement of vertebral parameters: The intervertebral inclination angle correction was significantly greater in the Endo-LIF group (7.2°→ 6.1°, Δ = -1.1°, P = 0.002), while there was no improvement in the MIS-TLIF group (6.5°→ 6.8°, Δ = 0.3°, P = 0.361); the difference in improvement between the groups was -1.4° (P = 0.007). There was no difference in intervertebral height recovery and slip correction between the groups (P > 0.05). 4. Sagittal balance parameters: The Cobb angle correction was more significant in the MIS-TLIF group (Δ = -1.82° vs. -0.43°, P = 0.003 between groups). The improvement of pelvic tilt angle in the MIS-TLIF group was better than that in the Endo-LIF group (Δ = -2.64° vs. +1.95°, P = 0.002 between groups). The stability of lumbar lordosis was better in the MIS-TLIF group (P = 0.021 between groups). Conclusion: Endo-LIF surgery has a significant advantage in correcting the intervertebral inclination angle, which may be attributed to the precise endoscopic operation. MIS-TLIF surgery is more effective in improving sagittal plane deformities (Cobb angle, pelvic tilt angle). The difference in fusion cage width suggests that endoscopic surgery tends to choose larger implants to enhance stability. The choice of clinical surgical methods should be combined with the type of deformity: Endo-LIF surgery is suitable for cases that require fine adjustment of intervertebral alignment, while MIS-TLIF surgery is more appropriate for patients with sagittal imbalance. Minimally invasive spinal surgery Endoscopic lumbar interbody fusion Transforaminal lumbar interbody fusion Lumbar degenerative diseases Sagittal plane balance Radiological imaging Background Lumbar Degenerative Disease (LDD) is the main cause of chronic low back pain and neurological dysfunction, mainly including lumbar spinal stenosis, lumbar spondylolisthesis and lumbar instability, among which lumbar spondylolisthesis and intervertebral disc degeneration caused by collapse of intervertebral space are common pathological types. These diseases are important precipitating factors of low back pain and leg pain in middle-aged and elderly people, and their incidence is increasing, which brings heavy burden to families and society. Surgical intervention is necessary in patients who fail to respond to long-term conservative treatment. Lumbar interbody fusion is currently recognized as an effective treatment for LDD[ 1 , 2 ]. Although traditional open interbody fusion can effectively stabilize the spine, it has drawbacks such as extensive muscle dissection and slow postoperative recovery[ 3 , 4 ]. The development of minimally invasive surgical techniques has significantly improved the clinical outcomes of lumbar fusion. Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF), which operates through an expandable channel to reduce soft tissue damage, has been proven to shorten hospital stays and lower the risk of complications[ 5 ].The development of minimally invasive surgical techniques has significantly improved the clinical outcomes of lumbar fusion. Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF), which operates through an expandable channel to reduce soft tissue damage, has been proven to shorten hospital stays and lower the risk of complications[ 6 ]. However, the regulation mechanism of sagittal spinal-pelvic balance between the two minimally invasive procedures is still controversial. The channel limitation of MIS-TLIF may affect the adjustment of implant position, which in turn restricts the correction of deformity[ 5 ];Although Endo-LIF provides an enlarged field of view, its lack of operating space may limit the implantation of large-size cages[ 6 , 7 ]. Existing studies have focused on short-term pain scores and complications[ 1 , 5 – 8 ], and lack systematic imaging evaluation of three-dimensional interbody alignment (such as intervertebral tilt Angle) and sagittal parameters (such as Cobb Angle and pelvic tilt Angle). Especially for LDD patients with spinal imbalance, there is a lack of imaging evidence to support the choice of surgical methods[ 9 ]. Therefore, the present study, by retrospectively analyzing the imaging data of 178 patients undergoing single-level lumbar fusion, aims to: 1.The correction effect of Endo-LIF and MIS-TLIF on intervertebral alignment parameters (intervertebral tilt Angle, intervertebral height, slip distance) was quantified and compared. The sagittal spino-pelvic alignment (lumbar anteversion, Cobb Angle, pelvic tilt, etc.) was compared between the two groups. To explore the correlation between implant size selection and imaging outcome, and to provide a basis for clinical accurate surgical selection. Methods and Materials 1. Study design and ethical review This study was a single-center retrospective cohort study, which was approved by the Institutional Ethics Committee of the Fifth People's Hospital of Chengdu (Approval number: Lunzheng 2023022 (Department) -01). Informed consent was waived (historical anonymous data were used). Reporting followed STROBE guidelines[ 10 ]. 2. Screening and grouping of patients Inclusion criteria: (1) age 20–80 years old; (2) Diagnosis of single-segment lumbar degenerative disease requiring interbody fusion; (3) underwent Endo-LIF or MIS-TLIF surgery (January 2021-December 2024); (4) complete preoperative and postoperative imaging data within 1 month. Exclusion criteria: (1) revision surgery, fracture, infection or tumor; (2) multi-segment fusion with more than 2 segments; (3) missing more than 20% of imaging data; (4) the body cannot tolerate surgery or has clear surgical contraindication; (5) patients with mental illness or Alzheimer's disease. Grouping: Endo-LIF group (microsurgery, n = 75), MIS-TLIF group (channel surgery, n = 103) 3. Surgical techniques Endo-LIF group[ 11 ]: Full endoscopic visualization system (Joimax®) was used through Kambin triangle approach. The key steps were to establish an 8mm working channel and continuously perfused with normal saline. Nerve decompression and endplate processing were performed under microscope. An interbody fusion cage filled with autologous bone was implanted (width 11.8 ± 1.6mm, Table 2). Bilateral pedicle screws were inserted percutaneously. MIS-TLIF group[ 8 ]: transforaminal approach using Quadrant expandable channel (Medtronic®). The key steps were: 3cm incision, layer by layer expansion to 20mm channel; Decompression was performed under direct vision and the cage was implanted (width 10.7 ± 1.9mm, Table 2). A screw-rod system was inserted via the Wiltse approach.The same PEEK and fixation system were used in both groups. 4. Imaging evaluation All patients underwent standing whole spine X-ray (Siemens Axiom Luminos dRF®) and lumbar 3D-CT (slice thickness 1mm) at 1 month before surgery and 1 month after surgery. Partial measurement parameters were defined[ 9 , 12 – 15 ](Table 3, Table 4): (1) Intervertebral height: the average intervertebral height before and after the lesion segment; (2) Slip degree (distance and percentage) : the slip distance of the next segment relative to the last segment. This distance accounted for the percentage of the upper endplate of the vertebral body at the next segment. (3) Cobb Angle: On the X-ray film of scoliosis, the upper and lower vertebrae with the most severe tilt were found, and straight lines were drawn on the upper edge of the upper vertebra and the lower edge of the lower vertebra. The Angle between the two lines was the Cobb Angle. (4) Pelvic incidence (PI) : the Angle between the line perpendicular to the midpoint of the sacral endplate and the line connecting the femoral head. The pelvic incidence Angle in patients with spondylolisthesis is greater than the normal value, and the greater the degree of spondylolisthesis, the greater the pelvic incidence Angle. (5) Sacral slope (SS) : the Angle between the horizontal line and the parallel line of the sacral endplate. (6) Pelvic tilt (PT) : the Angle between the vertical line of the femoral head and the line connecting the midpoint of the femoral head and the sacral endplate. (7) Slip Angle: refers to the Angle between the vertical line of the posterior edge of S1 and the line of the inferior endplate of L5. When the slip Angle is more than 30°, it has some value in predicting the progression of slip. Measurement method: Blinded evaluation by 3 senior spine surgeons (using Surgimap® software), intraclass correlation coefficient (ICC) > 0.85 was considered credible. 5. Statistical Analysis Using SPSS 26.0: Continuous variables (such as age, Cobb angle, etc.) are presented as mean ± standard deviation. Comparisons between groups are conducted using the independent sample T-test (for normal distribution) or the Mann-Whitney U test (for non-normal distribution). Categorical variables (such as gender, segment distribution) are expressed as frequency (%) and are analyzed using the χ² test or Fisher's exact test. Intra-group comparisons before and after surgery are performed using the paired T-test. The difference in improvement values between groups = (Endo-LIF group postoperative - preoperative) - (MIS-TLIF group postoperative - preoperative). Independent sample tests are used to evaluate significance; significance threshold: P 0.05) by Shapiro-Wilk test and independent sample T test. The results were expressed as mean ± standard deviation. There were 9 cases with missing BMI values, including 2 cases in the endoscopic group and 7 cases in the channel group. Gender was used as a categorical variable, and the chi-square test was used. The expected frequency of all cells was > 5, which met the test hypothesis. The fusion segments were only shown frequency distribution without statistical test, and there were two groups of missing values: one case in each group. Statistical conclusions of Table 1: P values > 0.05 for all comparisons. There were no significant differences in age, gender, BMI and length of hospital stay between the two groups, and the distribution pattern of fusion segments was similar (L4/L5 accounted for the highest proportion). In the data processing of this study, we excluded non-fusion segment information or null value records (n = 6), filtered invalid data of screw/cage size (n = 9), and finally effective data: 68 cases of endoscopic surgery and 86 cases of channel surgery (Table 2). The fusion level was mainly L4/L5 in both groups (> 89%), but the proportion of L5/S1 in microsurgery was higher (10.3% vs 3.5%). In terms of screw parameters, there was no significant difference in screw length and diameter between the two groups (P > 0.05). The upper screw was generally used in 6.5mm diameter. The width of the cage was significantly larger (11.8mm vs 10.7mm, P = 0.021), and there was no significant difference in the length and height of the cage between the two groups (P > 0.05). In terms of screw length, the mean value of the two groups was 43-44mm, and the two groups were consistent (P = 0.359). The width of the cage in the microscope group was significantly larger than that in the channel group (P = 0.021), which may be related to the higher requirements for the stability of the implant under microscope, but further biomechanical studies are needed to verify it. In conclusion, the difference of cage width may reflect a preference for larger cage size to provide higher stability in endoscopic surgery. The utilization rate of L5/S1 segment microsurgery is higher, which may be related to the difficulty of anatomical operation of this segment. In terms of vertebral body related data before and after operation (Table 3), including intervertebral tilt Angle, intervertebral height, slip distance, slip degree (slip distance/length of vertebral body), length and height of vertebral body. In terms of the correction of intervertebral slope Angle, there was a significant improvement in the endoscopic group (7.2°→ 6.1°, P = 0.002), but no change in the tunnel group (6.5°→6.8°, P = 0.361). The difference of improvement between the two groups was − 1.4° (P = 0.007), and the correction effect of the microscopic group was significantly better than that of the channel group. The recovery of intervertebral height was significantly increased in both groups (+ 2.9mm in the endoscopic group and + 2.5mm in the channel group, p < 0.001). There was no significant difference between the two groups (P = 0.187). In terms of slip correction, the slip distance was significantly reduced in both groups (-1.9mm in the microscope group and − 1.3mm in the channel group, p < 0.001), and the slip correction in the microscope group was greater than that in the channel group, but the difference between the two groups was not significant (P = 0.132). There were no significant differences in anatomical parameters, including vertebral length and height, between the two groups (p > 0.05), and the baseline was well matched. Therefore, endoscopic surgery had a significant advantage in the correction of intervertebral slope Angle (p 0.05), but the effect of channel surgery on the correction of intervertebral slope Angle was limited (no statistical significance). We compared radiographic data before and after the procedure (Table 4), including the comparison between the two surgical procedures and the comparison and change in the same group before and after the procedure. The imaging parameters included lumbar anteversion Angle, Cobb Angle, pelvic incidence Angle, sacral slope Angle, pelvic tilt Angle, and slip Angle. There was no significant difference in baseline characteristics between the microscopic group (n = 60) and the channel group (n = 65) (P > 0.05). All parameters were confirmed to be normal distribution by Shapiro-Wilk test, and missing data were processed by multiple imputation (missing rate < 5%). In terms of Cobb Angle correction, the correction effect of the channel group was significantly better than that of the microscopic group (P = 0.003). The Cobb Angle of the channel group improved by 1.82°(P < 0.001), and there was no significant change in the microscopic group (P = 0.532). In terms of biomechanical parameters, pelvic tilt Angle was significantly improved in the channel group (-2.64°, P = 0.009), but increased in the microscope group (+ 1.95°, P = 0.083). The stability of lumbar anteversion Angle in the channel group was better than that in the endoscopic group (P = 0.021). In terms of stability parameters, there was no significant difference in pelvic incidence Angle (P = 0.832) and slip Angle (P = 0.615) between the two groups, but there was significant difference in the change of sacral slope Angle (P = 0.041). Therefore, we can obtain the following results: the channel fusion showed a significant advantage in the correction of sagittal balance parameters (Cobb Angle, pelvic tilt Angle), while the two procedures had similar effects in the maintenance of pelvic stability parameters (incidence Angle, slip Angle). It is recommended that channel fusion be given priority in cases with significant spinal deformity. Discussion This is the first systematic radiographic evaluation to reveal the differential effects of Endo-LIF and MIS-TLIF in vertebral alignment and sagittal balance regulation. The core findings can be summarized into three points: Endo-LIF significantly improved the intervertebral slope (difference between groups − 1.4°, P = 0.007), but MIS-TLIF was superior in sagittal deformity correction (Cobb Angle, pelvic tilt). The two procedures have similar effects in intervertebral height restoration and slip correction. Endo-LIF tended to use a wider cage (11.8 mm vs. 10.7 mm, P = 0.021), which might be related to the operating characteristics under the microscope. 1. Mechanism of difference in surgical methods for correction of interbody alignment Intervertebral tilt, a key parameter for assessing coronal alignment, improved significantly more in the Endo-LIF group than in the MIS-TLIF group (Table 3). We believe that this is attributable to the following: the magnified endoscopic field of view can accurately identify the hyperplastic osteophytes of the facet joint, achieve targeted grinding, and optimize the joint alignment. The aqueous medium operation can reduce the bleeding of the venous plexus around the nerve root, maintain a clear surgical field, and facilitate the symmetrical treatment of the endplate[ 16 ].In contrast, MIS-TLIF is limited by the fixed Angle of the channel (usually 15° -20 °) and the low degree of freedom of the device operation, which makes it difficult to fine-adjust the insertion Angle of the cage[ 2 ]. This may be due to the superior ability of the endoscopic technique to regulate the 3D interbody alignment compared to the tubular channel system. 2. Limitation analysis of sagittal balance correction The correction of Cobb Angle (Δ=-1.82° vs. -0.43°, P = 0.003) and pelvic tilt Angle (Δ=-2.64° vs. +1.95°, P = 0.002) was significantly better in the MIS-TLIF group than in the Endo-LIF group (Table 4), possibly because: The channel surgery provides more space for manipulation and allows the insertion of cages with larger lordosis angles (e.g. 12° -15 °), which directly improves local kyphosis[ 6 ];Under direct vision, the intervertebral space is more fully extended, which is conducive to the restoration of lumbar lordosis[ 16 ]༛Endo-LIF is difficult to provide adequate lordosis support due to the narrow working channel (only 8mm) and the limited cage size (in this study, only 17.6% of the fusion cage width > 12mm)[ 6 , 17 ]. It is worth to note that the postoperative pelvic tilt Angle in Endo-LIF group was increased (+ 1.95°), which may be related to the compensatory pelvic retroversion caused by excessive pursuit of intervertebral space distraction under microscope[ 7 ]. MIS-TLIF is still a better choice for patients with sagittal imbalance, such as Cobb Angle > 10° or PT > 25°[ 18 ]. 3. Clinical significance of cage size selection The Endo-LIF group used a wider cage (11.8 ± 1.6 mm vs. 10.7 ± 1.9 mm, P = 0.021). This difference has important clinical value: biomechanical advantage: increasing the width of the cage can improve anti-rotation stability and compensate for the initial loss of stability caused by the inability of the endoscopic technique to extensively strip muscle groups[ 4 ];Technical suitability: The boundary of the cartilage endplate could be clearly identified under the microscope to reduce the risk of endplate injury when the wide cage was implanted[ 19 ]. 4. Clinical Decision Making Recommendations Based on the above findings, we propose a hierarchical strategy for surgical selection. Endo-LIF is preferred for patients with mainly nerve root compression symptoms and fine decompression is needed. There was coronal facet malalignment (intervertebral slope Angle > 8°). Patients with osteoporosis (reduced muscle stripping reduces risk of screw loosening)[ 16 – 21 ]. MIS-TLIF is preferred when combined with sagittal imbalance (Cobb Angle > 10° or PT > 25°). High lordosis cage (> 12°) was needed. L5/S1 segment (In this study, the proportion of L5/S1 in Endo-LIF group was 10.3%, but the operation was more difficult)[ 1 , 2 , 16 , 18 , 22 – 24 ]. 5. Research limitations Retrospective design: there was selection bias (such as uneven distribution of L5/S1 cases); The follow-up time was short: the imaging was only evaluated at 1 month after surgery, and there was a lack of long-term settling data. Clinical function scores, such as ODI and VAS, need to be further correlated with imaging improvement and symptom relief. Measures of muscle damage such as serum creatine kinase or extent of muscle edema on MRI were not quantified. Conclusion Endo-LIF has a significant advantage in the correction of intervertebral tilt Angle, which may be due to the precision endoscopic operation. MIS-TLIF was more effective in improving sagittal deformity (Cobb Angle, pelvic obturation). The difference in cage width suggests that larger implants are preferred to enhance the stability of the implants. Endo-LIF is suitable for patients with fine adjustment of interbody alignment, while MIS-TLIF is more suitable for patients with sagittal imbalance. Fund support Mirna-related informatics analysis based on the concept of co-reduction of muscle and bone in elderly patients with osteoporotic pathological fracture, Department of Science and Technology of Sichuan Province, China 2023YFS0235 Key technology research and application of fusion cage for anatomical lateral lumbar interbody fusion based on big data 2022-YF05-01676-SN Chengdu Science and Technology Bureau Declarations Author Contribution Xing Chen, Shuxing Xing and Haibo Ji were responsible for the design and production of the Horizontal Calibrator. Congdi Liu, Nai Mu and Zhengfeng Huang are responsible for data collection, sorting and analysis. Xing Chen, Shuxing Xing and Haibo Ji were responsible for the writing and revision of the paper. References Liu D, Huang X, Zhang C, Wang Q, Jiang H. Meta-analysis of minimally invasive transforaminal lumbar interbody fusion versus oblique lumbar interbody fusion for treating lumbar degenerative diseases. 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Neurosurgery 82(3): 289-298, 2018 Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Table1.xlsx Table2.xlsx Table3..xlsx Table4.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7337627","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":504905060,"identity":"93f8d9ab-ce30-47ed-b2fc-824514140de5","order_by":0,"name":"Xing Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACNvb+5x8+8NgwyzMzHyBOCx/PGTbGGTJp7IbtbQnEaZGTyGFj5rE5zM9w5owBkQ5jyD32mCcnTZpxRs7HG28Y7OR0GwhqOZduOOeMjTG7RO5myzkMycZmBwhpYWwwkHjbk5bMOCN3mzQPw4HEbQS1MDMYSPD+O1zfcCPnGZFa2HjMJHl4DjMDvc9GpBYetmTDGTxpzMBANracY0CEX+TnPz74ABqVD2+8qbCTI6gFBUjwEBk1yFpI1TEKRsEoGAUjAgAA3wc+/pH/vaMAAAAASUVORK5CYII=","orcid":"","institution":"Chengdu Fifth People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xing","middleName":"","lastName":"Chen","suffix":""},{"id":504905061,"identity":"28928d39-9672-4be3-8d92-6af4527ec258","order_by":1,"name":"Haibo Ji","email":"","orcid":"","institution":"Chengdu Fifth People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haibo","middleName":"","lastName":"Ji","suffix":""},{"id":504905062,"identity":"529aa7bc-4f92-4c79-a871-6001e901689a","order_by":2,"name":"Congdi Liu","email":"","orcid":"","institution":"Chengdu Fifth People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Congdi","middleName":"","lastName":"Liu","suffix":""},{"id":504905063,"identity":"5115bbfb-e361-4186-a4d3-a62084db61fd","order_by":3,"name":"Nai Mu","email":"","orcid":"","institution":"Chengdu Fifth People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nai","middleName":"","lastName":"Mu","suffix":""},{"id":504905064,"identity":"44332145-7991-47cb-ad78-1ca395fc8eb8","order_by":4,"name":"Zhengfeng Huang","email":"","orcid":"","institution":"Chengdu Fifth People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhengfeng","middleName":"","lastName":"Huang","suffix":""},{"id":504905065,"identity":"c1db14aa-c35a-4531-8506-921e3a64cd77","order_by":5,"name":"Shuxing Xing","email":"","orcid":"","institution":"Chengdu Fifth People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shuxing","middleName":"","lastName":"Xing","suffix":""}],"badges":[],"createdAt":"2025-08-10 08:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7337627/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7337627/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101463026,"identity":"bc0f25a3-de0c-4c2a-9606-0c06ca711206","added_by":"auto","created_at":"2026-01-30 02:40:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":561724,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7337627/v1/78e4d205-cc07-497e-a90e-c89e83d08245.pdf"},{"id":90388772,"identity":"46b192ab-7cdc-44df-8dee-4b3fbae4e386","added_by":"auto","created_at":"2025-09-02 08:07:28","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":11700,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7337627/v1/63198c554724e4284ddc6cb4.xlsx"},{"id":90388389,"identity":"79653d31-f95e-43a4-a1ff-1ecc4e6047ff","added_by":"auto","created_at":"2025-09-02 07:59:28","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":11764,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7337627/v1/4e4d4a3df0938e81e46de134.xlsx"},{"id":90388397,"identity":"f8ab4dc8-e318-44d5-bbef-3bc37e353d6a","added_by":"auto","created_at":"2025-09-02 07:59:28","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":11764,"visible":true,"origin":"","legend":"","description":"","filename":"Table3..xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7337627/v1/9211a4a1894e7ff65c9e837a.xlsx"},{"id":90388774,"identity":"a13852ab-70bf-46af-8937-164e82d0b599","added_by":"auto","created_at":"2025-09-02 08:07:28","extension":"xlsx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":12052,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7337627/v1/710ceba6354974cefc7ed834.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Minimally invasive transforaminal lumbar interbody fusion versus microscopic lumbar interbody fusion for the treatment of lumbar degenerative diseases: a radiological imaging-based retrospective study","fulltext":[{"header":"Background","content":"\u003cp\u003eLumbar Degenerative Disease (LDD) is the main cause of chronic low back pain and neurological dysfunction, mainly including lumbar spinal stenosis, lumbar spondylolisthesis and lumbar instability, among which lumbar spondylolisthesis and intervertebral disc degeneration caused by collapse of intervertebral space are common pathological types. These diseases are important precipitating factors of low back pain and leg pain in middle-aged and elderly people, and their incidence is increasing, which brings heavy burden to families and society. Surgical intervention is necessary in patients who fail to respond to long-term conservative treatment. Lumbar interbody fusion is currently recognized as an effective treatment for LDD[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although traditional open interbody fusion can effectively stabilize the spine, it has drawbacks such as extensive muscle dissection and slow postoperative recovery[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe development of minimally invasive surgical techniques has significantly improved the clinical outcomes of lumbar fusion. Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF), which operates through an expandable channel to reduce soft tissue damage, has been proven to shorten hospital stays and lower the risk of complications[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].The development of minimally invasive surgical techniques has significantly improved the clinical outcomes of lumbar fusion. Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF), which operates through an expandable channel to reduce soft tissue damage, has been proven to shorten hospital stays and lower the risk of complications[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, the regulation mechanism of sagittal spinal-pelvic balance between the two minimally invasive procedures is still controversial. The channel limitation of MIS-TLIF may affect the adjustment of implant position, which in turn restricts the correction of deformity[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e];Although Endo-LIF provides an enlarged field of view, its lack of operating space may limit the implantation of large-size cages[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Existing studies have focused on short-term pain scores and complications[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and lack systematic imaging evaluation of three-dimensional interbody alignment (such as intervertebral tilt Angle) and sagittal parameters (such as Cobb Angle and pelvic tilt Angle). Especially for LDD patients with spinal imbalance, there is a lack of imaging evidence to support the choice of surgical methods[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTherefore, the present study, by retrospectively analyzing the imaging data of 178 patients undergoing single-level lumbar fusion, aims to: 1.The correction effect of Endo-LIF and MIS-TLIF on intervertebral alignment parameters (intervertebral tilt Angle, intervertebral height, slip distance) was quantified and compared. The sagittal spino-pelvic alignment (lumbar anteversion, Cobb Angle, pelvic tilt, etc.) was compared between the two groups. To explore the correlation between implant size selection and imaging outcome, and to provide a basis for clinical accurate surgical selection.\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n"},{"header":"Methods and Materials","content":"\u003ch3\u003e1. Study design and ethical review\u003c/h3\u003e\u003cp\u003e This study was a single-center retrospective cohort study, which was approved by the Institutional Ethics Committee of the Fifth People's Hospital of Chengdu (Approval number: Lunzheng 2023022 (Department) -01). Informed consent was waived (historical anonymous data were used). Reporting followed STROBE guidelines[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003ch3\u003e2. Screening and grouping of patients\u003c/h3\u003e\u003cp\u003eInclusion criteria: (1) age 20–80 years old; (2) Diagnosis of single-segment lumbar degenerative disease requiring interbody fusion; (3) underwent Endo-LIF or MIS-TLIF surgery (January 2021-December 2024); (4) complete preoperative and postoperative imaging data within 1 month.\u003c/p\u003e\u003cp\u003eExclusion criteria:\u003c/p\u003e\u003cp\u003e(1) revision surgery, fracture, infection or tumor; (2) multi-segment fusion with more than 2 segments; (3) missing more than 20% of imaging data; (4) the body cannot tolerate surgery or has clear surgical contraindication; (5) patients with mental illness or Alzheimer's disease.\u003c/p\u003e\u003cp\u003eGrouping: Endo-LIF group (microsurgery, n = 75), MIS-TLIF group (channel surgery, n = 103)\u003c/p\u003e\u003ch3\u003e3. Surgical techniques\u003c/h3\u003e\u003cp\u003eEndo-LIF group[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]: Full endoscopic visualization system (Joimax®) was used through Kambin triangle approach. The key steps were to establish an 8mm working channel and continuously perfused with normal saline. Nerve decompression and endplate processing were performed under microscope. An interbody fusion cage filled with autologous bone was implanted (width 11.8 ± 1.6mm, Table\u0026nbsp;2). Bilateral pedicle screws were inserted percutaneously.\u003c/p\u003e\u003cp\u003eMIS-TLIF group[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]: transforaminal approach using Quadrant expandable channel (Medtronic®). The key steps were: 3cm incision, layer by layer expansion to 20mm channel; Decompression was performed under direct vision and the cage was implanted (width 10.7 ± 1.9mm, Table\u0026nbsp;2). A screw-rod system was inserted via the Wiltse approach.The same PEEK and fixation system were used in both groups.\u003c/p\u003e\u003ch3\u003e4. Imaging evaluation\u003c/h3\u003e\u003cp\u003eAll patients underwent standing whole spine X-ray (Siemens Axiom Luminos dRF®) and lumbar 3D-CT (slice thickness 1mm) at 1 month before surgery and 1 month after surgery.\u003c/p\u003e\u003cp\u003ePartial measurement parameters were defined[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e](Table\u0026nbsp;3, Table\u0026nbsp;4): (1) Intervertebral height: the average intervertebral height before and after the lesion segment; (2) Slip degree (distance and percentage) : the slip distance of the next segment relative to the last segment. This distance accounted for the percentage of the upper endplate of the vertebral body at the next segment. (3) Cobb Angle: On the X-ray film of scoliosis, the upper and lower vertebrae with the most severe tilt were found, and straight lines were drawn on the upper edge of the upper vertebra and the lower edge of the lower vertebra. The Angle between the two lines was the Cobb Angle. (4) Pelvic incidence (PI) : the Angle between the line perpendicular to the midpoint of the sacral endplate and the line connecting the femoral head. The pelvic incidence Angle in patients with spondylolisthesis is greater than the normal value, and the greater the degree of spondylolisthesis, the greater the pelvic incidence Angle. (5) Sacral slope (SS) : the Angle between the horizontal line and the parallel line of the sacral endplate. (6) Pelvic tilt (PT) : the Angle between the vertical line of the femoral head and the line connecting the midpoint of the femoral head and the sacral endplate. (7) Slip Angle: refers to the Angle between the vertical line of the posterior edge of S1 and the line of the inferior endplate of L5. When the slip Angle is more than 30°, it has some value in predicting the progression of slip.\u003c/p\u003e\u003cp\u003eMeasurement method: Blinded evaluation by 3 senior spine surgeons (using Surgimap® software), intraclass correlation coefficient (ICC) \u0026gt; 0.85 was considered credible.\u003c/p\u003e\u003ch3\u003e5. Statistical Analysis\u003c/h3\u003e\u003cp\u003eUsing SPSS 26.0: Continuous variables (such as age, Cobb angle, etc.) are presented as mean ± standard deviation. Comparisons between groups are conducted using the independent sample T-test (for normal distribution) or the Mann-Whitney U test (for non-normal distribution). Categorical variables (such as gender, segment distribution) are expressed as frequency (%) and are analyzed using the χ² test or Fisher's exact test. Intra-group comparisons before and after surgery are performed using the paired T-test. The difference in improvement values between groups = (Endo-LIF group postoperative - preoperative) - (MIS-TLIF group postoperative - preoperative). Independent sample tests are used to evaluate significance; significance threshold: P \u0026lt; 0.05 (two-sided test).\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eAge, BMI and length of hospital stay were continuous variables, which conformed to normal distribution (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) by Shapiro-Wilk test and independent sample T test. The results were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. There were 9 cases with missing BMI values, including 2 cases in the endoscopic group and 7 cases in the channel group. Gender was used as a categorical variable, and the chi-square test was used. The expected frequency of all cells was \u0026gt;\u0026thinsp;5, which met the test hypothesis. The fusion segments were only shown frequency distribution without statistical test, and there were two groups of missing values: one case in each group. Statistical conclusions of Table\u0026nbsp;1: P values\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all comparisons. There were no significant differences in age, gender, BMI and length of hospital stay between the two groups, and the distribution pattern of fusion segments was similar (L4/L5 accounted for the highest proportion).\u003c/p\u003e\u003cp\u003eIn the data processing of this study, we excluded non-fusion segment information or null value records (n\u0026thinsp;=\u0026thinsp;6), filtered invalid data of screw/cage size (n\u0026thinsp;=\u0026thinsp;9), and finally effective data: 68 cases of endoscopic surgery and 86 cases of channel surgery (Table\u0026nbsp;2). The fusion level was mainly L4/L5 in both groups (\u0026gt;\u0026thinsp;89%), but the proportion of L5/S1 in microsurgery was higher (10.3% vs 3.5%). In terms of screw parameters, there was no significant difference in screw length and diameter between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The upper screw was generally used in 6.5mm diameter. The width of the cage was significantly larger (11.8mm vs 10.7mm, P\u0026thinsp;=\u0026thinsp;0.021), and there was no significant difference in the length and height of the cage between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In terms of screw length, the mean value of the two groups was 43-44mm, and the two groups were consistent (P\u0026thinsp;=\u0026thinsp;0.359). The width of the cage in the microscope group was significantly larger than that in the channel group (P\u0026thinsp;=\u0026thinsp;0.021), which may be related to the higher requirements for the stability of the implant under microscope, but further biomechanical studies are needed to verify it. In conclusion, the difference of cage width may reflect a preference for larger cage size to provide higher stability in endoscopic surgery. The utilization rate of L5/S1 segment microsurgery is higher, which may be related to the difficulty of anatomical operation of this segment.\u003c/p\u003e\u003cp\u003eIn terms of vertebral body related data before and after operation (Table\u0026nbsp;3), including intervertebral tilt Angle, intervertebral height, slip distance, slip degree (slip distance/length of vertebral body), length and height of vertebral body. In terms of the correction of intervertebral slope Angle, there was a significant improvement in the endoscopic group (7.2\u0026deg;\u0026rarr; 6.1\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.002), but no change in the tunnel group (6.5\u0026deg;\u0026rarr;6.8\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.361). The difference of improvement between the two groups was \u0026minus;\u0026thinsp;1.4\u0026deg; (P\u0026thinsp;=\u0026thinsp;0.007), and the correction effect of the microscopic group was significantly better than that of the channel group. The recovery of intervertebral height was significantly increased in both groups (+\u0026thinsp;2.9mm in the endoscopic group and +\u0026thinsp;2.5mm in the channel group, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no significant difference between the two groups (P\u0026thinsp;=\u0026thinsp;0.187). In terms of slip correction, the slip distance was significantly reduced in both groups (-1.9mm in the microscope group and \u0026minus;\u0026thinsp;1.3mm in the channel group, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the slip correction in the microscope group was greater than that in the channel group, but the difference between the two groups was not significant (P\u0026thinsp;=\u0026thinsp;0.132). There were no significant differences in anatomical parameters, including vertebral length and height, between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), and the baseline was well matched. Therefore, endoscopic surgery had a significant advantage in the correction of intervertebral slope Angle (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and the two surgeries had similar effects in the restoration of intervertebral height and correction of slip (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), but the effect of channel surgery on the correction of intervertebral slope Angle was limited (no statistical significance).\u003c/p\u003e\u003cp\u003eWe compared radiographic data before and after the procedure (Table\u0026nbsp;4), including the comparison between the two surgical procedures and the comparison and change in the same group before and after the procedure. The imaging parameters included lumbar anteversion Angle, Cobb Angle, pelvic incidence Angle, sacral slope Angle, pelvic tilt Angle, and slip Angle. There was no significant difference in baseline characteristics between the microscopic group (n\u0026thinsp;=\u0026thinsp;60) and the channel group (n\u0026thinsp;=\u0026thinsp;65) (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). All parameters were confirmed to be normal distribution by Shapiro-Wilk test, and missing data were processed by multiple imputation (missing rate\u0026thinsp;\u0026lt;\u0026thinsp;5%). In terms of Cobb Angle correction, the correction effect of the channel group was significantly better than that of the microscopic group (P\u0026thinsp;=\u0026thinsp;0.003). The Cobb Angle of the channel group improved by 1.82\u0026deg;(P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and there was no significant change in the microscopic group (P\u0026thinsp;=\u0026thinsp;0.532). In terms of biomechanical parameters, pelvic tilt Angle was significantly improved in the channel group (-2.64\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.009), but increased in the microscope group (+\u0026thinsp;1.95\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.083). The stability of lumbar anteversion Angle in the channel group was better than that in the endoscopic group (P\u0026thinsp;=\u0026thinsp;0.021). In terms of stability parameters, there was no significant difference in pelvic incidence Angle (P\u0026thinsp;=\u0026thinsp;0.832) and slip Angle (P\u0026thinsp;=\u0026thinsp;0.615) between the two groups, but there was significant difference in the change of sacral slope Angle (P\u0026thinsp;=\u0026thinsp;0.041). Therefore, we can obtain the following results: the channel fusion showed a significant advantage in the correction of sagittal balance parameters (Cobb Angle, pelvic tilt Angle), while the two procedures had similar effects in the maintenance of pelvic stability parameters (incidence Angle, slip Angle). It is recommended that channel fusion be given priority in cases with significant spinal deformity.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first systematic radiographic evaluation to reveal the differential effects of Endo-LIF and MIS-TLIF in vertebral alignment and sagittal balance regulation. The core findings can be summarized into three points: Endo-LIF significantly improved the intervertebral slope (difference between groups \u0026minus;\u0026thinsp;1.4\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.007), but MIS-TLIF was superior in sagittal deformity correction (Cobb Angle, pelvic tilt). The two procedures have similar effects in intervertebral height restoration and slip correction. Endo-LIF tended to use a wider cage (11.8 mm vs. 10.7 mm, P\u0026thinsp;=\u0026thinsp;0.021), which might be related to the operating characteristics under the microscope.\u003c/p\u003e\n\u003ch3\u003e1. Mechanism of difference in surgical methods for correction of interbody alignment\u003c/h3\u003e\n\u003cp\u003eIntervertebral tilt, a key parameter for assessing coronal alignment, improved significantly more in the Endo-LIF group than in the MIS-TLIF group (Table\u0026nbsp;3). We believe that this is attributable to the following: the magnified endoscopic field of view can accurately identify the hyperplastic osteophytes of the facet joint, achieve targeted grinding, and optimize the joint alignment. The aqueous medium operation can reduce the bleeding of the venous plexus around the nerve root, maintain a clear surgical field, and facilitate the symmetrical treatment of the endplate[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e].In contrast, MIS-TLIF is limited by the fixed Angle of the channel (usually 15\u0026deg; -20 \u0026deg;) and the low degree of freedom of the device operation, which makes it difficult to fine-adjust the insertion Angle of the cage[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. This may be due to the superior ability of the endoscopic technique to regulate the 3D interbody alignment compared to the tubular channel system.\u003c/p\u003e\n\u003ch3\u003e2. Limitation analysis of sagittal balance correction\u003c/h3\u003e\n\u003cp\u003eThe correction of Cobb Angle (\u0026Delta;=-1.82\u0026deg; vs. -0.43\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.003) and pelvic tilt Angle (\u0026Delta;=-2.64\u0026deg; vs. +1.95\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.002) was significantly better in the MIS-TLIF group than in the Endo-LIF group (Table 4), possibly because: The channel surgery provides more space for manipulation and allows the insertion of cages with larger lordosis angles (e.g. 12\u0026deg; -15 \u0026deg;), which directly improves local kyphosis[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e];Under direct vision, the intervertebral space is more fully extended, which is conducive to the restoration of lumbar lordosis[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]༛Endo-LIF is difficult to provide adequate lordosis support due to the narrow working channel (only 8mm) and the limited cage size (in this study, only 17.6% of the fusion cage width\u0026thinsp;\u0026gt;\u0026thinsp;12mm)[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. It is worth to note that the postoperative pelvic tilt Angle in Endo-LIF group was increased (+\u0026thinsp;1.95\u0026deg;), which may be related to the compensatory pelvic retroversion caused by excessive pursuit of intervertebral space distraction under microscope[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. MIS-TLIF is still a better choice for patients with sagittal imbalance, such as Cobb Angle\u0026thinsp;\u0026gt;\u0026thinsp;10\u0026deg; or PT\u0026thinsp;\u0026gt;\u0026thinsp;25\u0026deg;[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003e3. Clinical significance of cage size selection\u003c/h3\u003e\n\u003cp\u003eThe Endo-LIF group used a wider cage (11.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 mm vs. 10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 mm, P\u0026thinsp;=\u0026thinsp;0.021). This difference has important clinical value: biomechanical advantage: increasing the width of the cage can improve anti-rotation stability and compensate for the initial loss of stability caused by the inability of the endoscopic technique to extensively strip muscle groups[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e];Technical suitability: The boundary of the cartilage endplate could be clearly identified under the microscope to reduce the risk of endplate injury when the wide cage was implanted[\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003e4. Clinical Decision Making Recommendations\u003c/h3\u003e\n\u003cp\u003eBased on the above findings, we propose a hierarchical strategy for surgical selection. Endo-LIF is preferred for patients with mainly nerve root compression symptoms and fine decompression is needed. There was coronal facet malalignment (intervertebral slope Angle\u0026thinsp;\u0026gt;\u0026thinsp;8\u0026deg;). Patients with osteoporosis (reduced muscle stripping reduces risk of screw loosening)[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. MIS-TLIF is preferred when combined with sagittal imbalance (Cobb Angle\u0026thinsp;\u0026gt;\u0026thinsp;10\u0026deg; or PT\u0026thinsp;\u0026gt;\u0026thinsp;25\u0026deg;). High lordosis cage (\u0026gt;\u0026thinsp;12\u0026deg;) was needed. L5/S1 segment (In this study, the proportion of L5/S1 in Endo-LIF group was 10.3%, but the operation was more difficult)[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003e5. Research limitations\u003c/h3\u003e\n\u003cp\u003eRetrospective design: there was selection bias (such as uneven distribution of L5/S1 cases); The follow-up time was short: the imaging was only evaluated at 1 month after surgery, and there was a lack of long-term settling data. Clinical function scores, such as ODI and VAS, need to be further correlated with imaging improvement and symptom relief. Measures of muscle damage such as serum creatine kinase or extent of muscle edema on MRI were not quantified.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEndo-LIF has a significant advantage in the correction of intervertebral tilt Angle, which may be due to the precision endoscopic operation. MIS-TLIF was more effective in improving sagittal deformity (Cobb Angle, pelvic obturation). The difference in cage width suggests that larger implants are preferred to enhance the stability of the implants. Endo-LIF is suitable for patients with fine adjustment of interbody alignment, while MIS-TLIF is more suitable for patients with sagittal imbalance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFund support\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eMirna-related informatics analysis based on the concept of co-reduction of muscle and bone in elderly patients with osteoporotic pathological fracture, Department of Science and Technology of Sichuan Province, China 2023YFS0235\u003c/li\u003e\n \u003cli\u003eKey technology research and application of fusion cage for anatomical lateral lumbar interbody fusion based on big data 2022-YF05-01676-SN Chengdu Science and Technology Bureau\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eXing Chen, Shuxing Xing and Haibo Ji were responsible for the design and production of the Horizontal Calibrator. Congdi Liu, Nai Mu and Zhengfeng Huang are responsible for data collection, sorting and analysis. Xing Chen, Shuxing Xing and Haibo Ji were responsible for the writing and revision of the paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eLiu D, Huang X, Zhang C, Wang Q, Jiang H. Meta-analysis of minimally invasive transforaminal lumbar interbody fusion versus oblique lumbar interbody fusion for treating lumbar degenerative diseases. Journal of orthopaedic surgery and research 19(1): 891, 2024\u003c/li\u003e\n \u003cli\u003eKalina R. Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in treatment of degenerative diseases of lumbosacral spine compared to modified open TLIF: a prospective randomised controlled study. Neurologia i neurochirurgia polska 58(5): 503-511, 2024\u003c/li\u003e\n \u003cli\u003eLiawrungrueang W, Lee HJ, Kim SB, Park SM, Cholamjiak W, Park HJ. A systematic review of biportal endoscopic spinal surgery with interbody fusion. Asian spine journal, 2025\u003c/li\u003e\n \u003cli\u003eArts MP, Wolfs JF, Kuijlen JM, de Ruiter GC. Minimally invasive surgery versus open surgery in the treatment of lumbar spondylolisthesis: study protocol of a multicentre, randomised controlled trial (MISOS trial). BMJ open 7(11): e017882, 2017\u003c/li\u003e\n \u003cli\u003eHaibier A, Yusufu A, Hang L, Abudurexiti T. 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 19(1): 92, 2024\u003c/li\u003e\n \u003cli\u003eHe Y, Cheng Q, She J. Unilateral biportal endoscopic lumbar interbody fusion versus minimally invasive transforaminal lumbar interbody fusion for single-segment lumbar degenerative disease: a meta-analysis. BMC musculoskeletal disorders 25(1): 938, 2024\u003c/li\u003e\n \u003cli\u003eLin CH, Wu YJ, Chang CW, Tam KW, Loh EW. Unilateral versus bilateral pedicle screw fixation in minimally invasive transforaminal lumbar interbody fusion: a systematic review and meta-analysis of randomized controlled trials. Archives of orthopaedic and trauma surgery 145(1): 148, 2025\u003c/li\u003e\n \u003cli\u003eVyas DB, Park BJ, Wang MY. Visualization in the Minimally Invasive Transforaminal Lumbar Interbody Fusion: From Tubular to Endoscopic Approaches. Neurosurgery 96(3s): S26-s32, 2025\u003c/li\u003e\n \u003cli\u003eSoriano S\u0026aacute;nchez JA, Soriano Sol\u0026iacute;s S, Soto Garc\u0026iacute;a ME, Soriano Sol\u0026iacute;s HA, Torres BYA, Romero Rangel JAI. Radiological diagnostic accuracy study comparing Lenke, Bridwell, BSF, and CT-HU fusion grading scales for minimally invasive lumbar interbody fusion spine surgery and its correlation to clinical outcome. Medicine 99(21): e19979, 2020\u003c/li\u003e\n \u003cli\u003eCuschieri. The STROBE guidelines %J SAUDI JOURNAL OF ANAESTHESIA. 13(Sup1), 2019\u003c/li\u003e\n \u003cli\u003eMiller LE, Bhattacharyya S, Pracyk J. Minimally Invasive Versus Open Transforaminal Lumbar Interbody Fusion for Single-Level Degenerative Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World neurosurgery 133: 358-365.e354, 2020\u003c/li\u003e\n \u003cli\u003ePark SM, Kim HJ, Lee SY, Chang BS, Lee CK, Yeom JS. Radiographic and Clinical Outcomes of Robot-Assisted Posterior Pedicle Screw Fixation: Two-Year Results from a Randomized Controlled Trial. Yonsei medical journal 59(3): 438-444, 2018\u003c/li\u003e\n \u003cli\u003eCoric D, Nassr A, Kim PK, Welch WC, Robbins S, DeLuca S, Whiting D, Chahlavi A, Pirris SM, Groff MW, Chi JH, Huang JH, Kent R, Whitmore RG, Meyer SA, Arnold PM, Patel AI, Orr RD, Krishnaney A, Boltes P, Anekstein Y, Steinmetz MP. Prospective, randomized controlled multicenter study of posterior lumbar facet arthroplasty for the treatment of spondylolisthesis. Journal of neurosurgery Spine 38(1): 115-125, 2023\u003c/li\u003e\n \u003cli\u003eKlingler JH, Scholz C, Kr\u0026uuml;ger MT, Naseri Y, Volz F, Hohenhaus M, Br\u0026ouml;nner J, Hoedlmoser H, Sircar R, Hubbe U. Radiation Exposure in Minimally Invasive Lumbar Fusion Surgery: A Randomized Controlled Trial Comparing Conventional Fluoroscopy and 3D Fluoroscopy-based Navigation. Spine 46(1): 1-8, 2021\u003c/li\u003e\n \u003cli\u003eLin X, Chang Q, Shang L, Shen S, Fu Z, Zhao G. A comparison of ultrasound volume navigation, O-arm navigation, and X-ray guidance for screw placement in minimally invasive transforaminal lumbar interbody fusion: a randomized controlled trial. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 33(9): 3457-3466, 2024\u003c/li\u003e\n \u003cli\u003eLv Y, Chen M, Wang SL, Qin RJ, Ma C, Ding QR, Qin HN, Wang XF, Ren YX. Endo-TLIF versus MIS-TLIF in 1-segment lumbar spondylolisthesis: A prospective randomized pilot study. Clinical neurology and neurosurgery 212: 107082, 2022\u003c/li\u003e\n \u003cli\u003eWu D, Shu T, Lu Q, Shen M. [Prospective comparative study of unilateral biportal endoscopic transforaminal lumbar interbody fusion and endoscopic transforaminal lumbar interbody fusion for treatment of single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis]. Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery 38(5): 521-528, 2024\u003c/li\u003e\n \u003cli\u003eD\u0026apos;Oria S, Giraldi D, Murrone D, Salamone GG, Tomatis A, Colamaria A, Carbone F, Rossitto M, Fanelli V. Minimally Invasive Transforaminal Interbody Fusion Versus Microdiscectomy Without Fusion for Recurrent Lumbar Disk Herniation: A Prospective Comparative Study. The Journal of the American Academy of Orthopaedic Surgeons 31(22): 1157-1164, 2023\u003c/li\u003e\n \u003cli\u003eCheng X, Zhang K, Sun X, Tian H, Zhao C, Zhao J. Unilateral versus bilateral pedicle screw fixation with transforaminal lumbar interbody fusion for treatment of lumbar foraminal stenosis. The spine journal : official journal of the North American Spine Society 22(10): 1687-1693, 2022\u003c/li\u003e\n \u003cli\u003eXiao C, Yin W, Zhao K, Luo J, Huang W, Liu W. Early Clinical Efficacy of Endo-TLIF in the Treatment of Lumbar Disc Herniation. Zeitschrift fur Orthopadie und Unfallchirurgie 160(6): 670-678, 2022\u003c/li\u003e\n \u003cli\u003eHe W, Wang Q, Hu J, Lin S, Zhang K, Wang F, Xu C, Li F, Xiao J, Li X, Tang F. A randomized trial on the application of a nurse-led early rehabilitation program after minimally invasive lumbar internal fixation. Annals of palliative medicine 10(9): 9820-9829, 2021\u003c/li\u003e\n \u003cli\u003eZou P, Yang JS, Wang XF, Wei JM, Liu P, Chen H, Hao DJ, Li QD, Wei D, Gong HL, Wu XC, Liu BY, Zhang YT, Zhang XF, Zhao YT. Comparison of Clinical and Radiologic Outcome Between Mini-Open Wiltse Approach and Fluoroscopic-Guided Percutaneous Pedicle Screw Placement: A Randomized Controlled Trial. World neurosurgery 144: e368-e375, 2020\u003c/li\u003e\n \u003cli\u003eYongqi L, Dehua Z, Hongzi W, Ke Z, Rui Y, Zhou F, Shaobo W, Yi L. Minimally invasive versus conventional fixation of tracer in robot-assisted pedicle screw insertion surgery: a randomized control trial. BMC musculoskeletal disorders 21(1): 208, 2020\u003c/li\u003e\n \u003cli\u003eChoi WS, Kim JS, Hur JW, Seong JH. Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Banana-Shaped and Straight Cages: Radiological and Clinical Results from a Prospective Randomized Clinical Trial. Neurosurgery 82(3): 289-298, 2018\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Minimally invasive spinal surgery, Endoscopic lumbar interbody fusion, Transforaminal lumbar interbody fusion, Lumbar degenerative diseases, Sagittal plane balance, Radiological imaging","lastPublishedDoi":"10.21203/rs.3.rs-7337627/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7337627/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eTo compare the radiographic efficacy of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and endoscopic lumbar interbody fusion (Endo-LIF) in the treatment of lumbar degenerative diseases, especially to evaluate the effects of the two procedures on spino-pelvic parameters and vertebral stability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective analysis was conducted on the clinical and radiological data of 178 patients who underwent single-level lumbar fusion surgery (75 cases in the endoscopic group and 103 cases in the channel group). Independent sample t-tests and chi-square tests were used to compare baseline characteristics. Paired t-tests were employed to analyze the changes in vertebral parameters (intervertebral inclination angle, height, slip distance, etc.) and sagittal parameters of the spine-pelvis (lumbar lordosis angle, Cobb angle, pelvic tilt angle, etc.) before and after surgery. The differences in improvement values between groups were evaluated by independent sample tests. The significance threshold was set at P \u0026lt; 0.05.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e1. Baseline characteristics: There were no statistically significant differences in age, gender, BMI, hospital stay, and distribution of fusion segments between the two groups (P \u0026gt; 0.05). 2. Implant parameters: The width of the fusion cage in the MIS-TLIF group was significantly greater than that in the Endo-LIF group (11.8 ± 1.6 mm vs. 10.7 ± 1.9 mm, P = 0.021). The usage rate of the L5/S1 segment was higher in the endoscopic group (10.3% vs. 3.5%, P = 0.115). 3. Improvement of vertebral parameters: The intervertebral inclination angle correction was significantly greater in the Endo-LIF group (7.2°→ 6.1°, Δ = -1.1°, P = 0.002), while there was no improvement in the MIS-TLIF group (6.5°→ 6.8°, Δ = 0.3°, P = 0.361); the difference in improvement between the groups was -1.4° (P = 0.007). There was no difference in intervertebral height recovery and slip correction between the groups (P \u0026gt; 0.05). 4. Sagittal balance parameters: The Cobb angle correction was more significant in the MIS-TLIF group (Δ = -1.82° vs. -0.43°, P = 0.003 between groups). The improvement of pelvic tilt angle in the MIS-TLIF group was better than that in the Endo-LIF group (Δ = -2.64° vs. +1.95°, P = 0.002 between groups). The stability of lumbar lordosis was better in the MIS-TLIF group (P = 0.021 between groups). \u003cstrong\u003eConclusion: \u003c/strong\u003eEndo-LIF surgery has a significant advantage in correcting the intervertebral inclination angle, which may be attributed to the precise endoscopic operation. MIS-TLIF surgery is more effective in improving sagittal plane deformities (Cobb angle, pelvic tilt angle). The difference in fusion cage width suggests that endoscopic surgery tends to choose larger implants to enhance stability. The choice of clinical surgical methods should be combined with the type of deformity: Endo-LIF surgery is suitable for cases that require fine adjustment of intervertebral alignment, while MIS-TLIF surgery is more appropriate for patients with sagittal imbalance.\u003c/p\u003e","manuscriptTitle":"Minimally invasive transforaminal lumbar interbody fusion versus microscopic lumbar interbody fusion for the treatment of lumbar degenerative diseases: a radiological imaging-based retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-02 07:59:23","doi":"10.21203/rs.3.rs-7337627/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a10cf5f9-2c5f-48fa-9481-11c5a2c31196","owner":[],"postedDate":"September 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-30T02:39:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-02 07:59:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7337627","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7337627","identity":"rs-7337627","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}