Optimizing incision placement for maximum disc and endplate preparation in lumbar endo-fusion using parametric modeling, genetic algorithms, and machine learning

Objective: To optimize incision placement for uniportal endoscopic lumbar fusion using computational methods to maximize disc and endplate preparation. Methods: We analyzed 605 axial lumbar MRI images from 121 patients in an institutional development cohort and 120 MRI images from 40 patients in an independent external validation cohort. A parametric MRI-based anatomical delineation system was developed to define the relevant surgical anatomy, and genetic algorithm optimization was used to determine optimal incision placement. Machine learning was then used to predict optimal incision positions from MRI-derived anatomical features, including disc morphology, Kambin’s triangle width, dural sac width, and posterior longitudinal ligament-to-skin distance. Results: Genetic algorithm optimization identified level-specific optimal incision distances: 58.93 ± 10.19 mm (L1-2), 63.31 ± 9.84 mm (L2-3), 67.79 ± 12.82 mm (L3-4), 83.89 ± 13.69 mm (L4-5), and 95.28 ± 19.38 mm (L5-S1). Under a patient-level framework, the artificial neural network (ANN) showed the best performance in predicting the GA-derived optimal incision position from MRI-derived anatomical features (internal validation R² = 0.935; external validation R² = 0.918 [95% CI, 0.869–0.947] and MAE = 6.08 mm [95% CI, 5.17–7.10]). The model was deployed online for real-time patient-specific planning. Conclusion: A web-based computational planning tool was developed to optimize incision placement and maximize disc and endplate preparation in uniportal endoscopic lumbar fusion. This approach may support patient-specific preoperative planning.