The first documented spinal surgery is believed to be a laminectomy performed by Paul of Aegina around 650 A.D [1]. Spinal surgery had evolved from open spinal surgery to endoscopic spinal surgery and other adjuncts to help with minimally invasive spinal surgery. Traditionally, spinal surgeons approach the posterior spinal structures by making a large open wound, stripping paraspinal muscles off the lamina and using bare human eyes without magnification. Microscopic spinal surgery was introduced by pioneers such as Drs. Caspar, Yasargil,and Williams; this helped in magnification to avoid complications in spinal surgery. Subsequently, Dr. William S. Halsted shifted the belief of speed which was the main critical determinant of patient outcome to minimizing soft tissue disruption, respecting anatomical structures and preserving and proper closing of anatomic layers as essential to improve patients’ outcomes [1]. The use of tubular retractors introduced by Fessler [2] in 1990s helped in achieving some of these principles laid out by Dr. Halsted, however, the limitations of approach angles, rigid and hard soft tissue retraction with stretching of the paraspinal muscles by stiff tubular retractors limited the approaches and visualization of the deeper structures in spinal column.

The evolution of spinal endoscopy with uniportal spinal endoscopy and unilateral biportal endoscopy addresses many of the limitations of tubular microscopic surgery and traditional open spinal surgery by the use of an endoscope, a visualization device with light, optical fiber input and continuous usage of saline incorporated into the same device, the endoscope. Using the endoscope to perform spinal surgery allows skilled endoscopic surgeons to reach deep structures in spinal columns, which was previously deemed difficult to access, such as lumbar foramen, thoracic prolapsed disc and cervical prolapsed disc. Endoscopy allows flexibility in motion while performing surgery, precision surgery with higher magnification under normal saline irrigation, optimal hemostasis with precise targeted radiofrequency ablation of bleeding nervous tissue and power tool of drills, chisels to allow precise, focused, conservative bone removal to achieve nervous tissue liberation while preserving maximal anatomical stability. It follows the modern minimally invasive surgical principle of respect for anatomical integrity, with the philosophy of enough, not too much, i.e., less is more. This advancement in technique had led to ambulatory spinal surgery a popular choice in both uniportal and biportal endoscopic spinal surgeries [3,4]. Uniportal and biportal spinal endoscopy can be used in cervical, thoracic and lumbar cases in both decompression and instrumentation [5,6].

Future humanity and treatment of spinal conditions will add on to the current knowledge and skills of human using adjuncts such as robots, navigation with real time intraoperative imaging and artificial intelligence (AI) with machine learning. In our article, we term it as EARNS framework of spinal surgery which stands for Endoscopic Spinal Surgery, Artificial Intelligence, Robotics, and Navigation Spinal Surgery framework (Figure 1).

With spinal endoscopy, and the videos obtained during surgeries, provide useful real time endoscopic surgeries data for machine learning it makes the next part of spinal surgery development possible for future humanity as it allows machine learning of vital structures, bleeding tendency and digitalization of video data processing. Being a minimally invasive spinal surgery, endoscopic spinal surgery can be performed in a repetitive and systematic way to allow AI to learn and formulate scenarios to improve outcomes [7,8].

AI and machine learning will develop in areas of preoperative analysis and planning with the analysis of the feed with preoperative computed tomography/magnetic resonance imaging scans, biomechanical markers and bone density analysis to synchronize a plan for decompression or fusion levels, implant suggestions and predict the outcome of surgery and complications with a more concise consent taking and personalized predicted postoperative functional recovery trajectory [9].

Intraoperative machine learning with analysis of endoscopic videos allows constant tracking of instruments to prevent deviation of sharp instruments to critical structures, it can provide warning to surgeons such as “drill is critically close to dura,” “your current tissue morphology suggest it is dura, careful decompression advised.” This proactive real time feedback allow surgeons with or without robotic assistance to be conscious of the possible dangers during surgery.

Postoperative monitoring and outcomes assessment will also evolve from traditionally lack of complications and feedback of feeling better in pain scores and outcome scores to more real time feedback on gaits, activity level at home or in play to optimize physiotherapy and rehabilitation.

Robotic surgeon’s hand, guided by preoperative surgical planning, feeding of intraoperative real time data allows steady holding of instruments, avoiding physiological tremors and lapses of concentration is a sophisticated extension of the surgeons’ will. Future robotic arms may incorporate improved dexterous, flexible snake-like instruments to navigate past delicate structures of spine through more natural anatomical corridors. It will be a useful adjunct to spinal endoscopy and other complex open spinal procedures [10].

Navigation in spinal surgery with augmented reality overlay, 3-dimensional (3D) reconstruction of deformity and real time directional navigation of surgical equipment will be key to improving precise surgery and provision of feedback to spinal surgeons during surgery to prevent surgeons from being disoriented while performing minimally invasive surgery and spinal endoscopy. Future navigation may move into real time biomechanical sensors in spinal segments, which allows instant 3D feedback to the navigation system as a spinal deformity is corrected by rods and set screws, it will help to predict final global alignment before closure. The promise of navigation is also less fluoroscopy exposure, achieving clear images with lower radiation and ultimately eliminate the need for intraoperative fluoroscopy [11].

The future of spinal surgery is bright and ultimately it will be about precision spinal paradigm shift. Data informed action, optimized visualization with precise equipment allows personal catered treatment for individuals. However, spinal surgeons must embrace such technologies and techniques with careful ethical considerations. We need honest feedback, nonbiased data, defining boundaries and clear liabilities framework and yet ensuring patient data privacy and anonymity. The ultimate goal of technology in our EARNS framework is adjunct and augmentation of our current techniques and decisions and not autonomy of AI/robotics/spinal endoscopy. We elevate spinal surgeons’ will, compassion and physical limitations to help create a better tomorrow for our patients.