The evolution and promise of endoscopic spine surgery

In recent years, endoscopic spine surgery (ESS) has emerged from the peripheries of minimally invasive techniques to take a pivotal role in modern spine care. The Journal of Spine Surgery (JSS) has witnessed this trajectory firsthand, with an increase in submissions and published research dedicated to advancing endoscopic techniques, technologies, and patient outcomes. Our special edition in 2020 (1), focusing exclusively on ESS, was a landmark for our journal, reflecting both the interest in, and potential of this field. Since then, endoscopic techniques and surgeon uptake have only gained momentum.

The growth of ESS in the literature aligns with broader shifts in surgical practice—prioritizing less invasive methods with the promise of shorter recovery times, reduced postoperative pain, and lower complication rates. These techniques represent more than just an alternative to traditional surgical methods; they signify a paradigm shift in how degenerative spinal conditions are managed. Endoscopic surgery facilitates a stepwise approach to care, bridging the gap between conservative therapies and invasive interventions such as spinal fusion. This progressive methodology ensures that patients are not prematurely subjected to highly invasive procedures, allowing for a more nuanced escalation of care based on their unique clinical needs. Figure 1 showcases the traditional and emerging techniques that have established ESS as a cornerstone of the future of spine care. Furthermore, the distinction between full-endoscopic (uniportal) and unilateral biportal endoscopic (UBE or biportal) techniques is crucial. UBE has emerged as an approach aimed at overcoming learning curve challenges and cost implications, albeit with greater dissection and multiple incisions.

Figure 1 Evolution of endoscopic techniques supporting diverse surgical approaches. (A) Traditional endoscopic methods, including transforaminal, interlaminar, and facet ablation procedures. (B) Advancements in fusion techniques utilizing both uniportal and biportal approaches. (C) Endoscopic-assisted techniques applied to fusion procedures targeting the anterolateral lumbar spine.

ESS provides a crucial advantage in that it does not preclude further surgical interventions. Unlike some more invasive procedures that may limit future surgical options, endoscopic techniques are inherently tissue-sparing, minimizing disruption to normal anatomy and preserving structural integrity. This preservation ensures that patients retain access to the full spectrum of surgical options, should their condition evolve or require additional interventions in the future. As a result, endoscopy represents a forward-thinking strategy in spinal care, emphasizing flexibility and patient-centered outcomes.

Despite its many benefits, ESS is not without detractors. A common criticism is that the learning curve for mastering these techniques is perceived as steep and difficult (2). While it is true that endoscopic procedures demand a specific skill set, this is no different from the introduction of any new surgical innovation (3). As with robotic surgery or laparoscopic techniques in other fields, success depends on appropriate training and a systematic, stepwise approach to skill acquisition. Institutions that prioritize structured education, simulation-based practice, and mentorship programs have demonstrated that the learning curve can be effectively overcome, allowing surgeons to safely and confidently adopt these methods. It is critical to view this learning curve not as a barrier but as an investment in the future of minimally invasive care, ultimately benefiting both patients and the broader healthcare system.

Another frequently cited concern is the perceived higher cost of ESS compared to traditional techniques (4). While the upfront costs associated with specialized equipment and training may be higher, as with any surgical specialty, these must be weighed against the broader economic implications of surgical care. Endoscopic methods have been shown to reduce hospital stays, facilitate faster recovery, and lower complication rates (4,5). Patients undergoing endoscopic procedures typically experience less postoperative pain, enabling them to return to work and daily activities more quickly. This translates to lower indirect costs, such as lost productivity and long-term disability, resulting in significant savings for both patients and the healthcare system. Viewed holistically, endoscopic surgery often reduces the overall economic burden, making it a cost-effective solution rather than an expensive alternative. Is it conceivable that we will one day encounter an academic article advocating a return to the era of open laparotomy for routine abdominal procedures due to the cost of laparoscopic equipment?

The global spine community is undergoing a transformative shift as surgeons, researchers, and device innovators refine techniques and expand the scope of treatable spinal conditions. However, with this progress comes the responsibility to critically evaluate advancements. New technologies and techniques require robust clinical trials and long-term studies to validate their benefits over traditional approaches. The JSS remains dedicated to upholding rigorous scientific standards, ensuring that published research advances both the science and clinical practice of spine surgery.

The 2020 special edition of JSS on ESS catalyzed scientific dialogue and clinical adoption, sparking growth in submissions and global contributions. These diverse perspectives underscore the universal demand for minimally invasive solutions and the adaptability of endoscopic methods to meet varied healthcare needs. By publishing high-quality research, JSS bridges the gap between evidence-based findings and practical applications, advancing patient care while setting new standards in minimally invasive spine surgery.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-155/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-155/coif). R.J.M. serves as the Editor-in-Chief of Journal of Spine Surgery. R.J.M. provides consultancy services to Elliquence for training junior surgeons. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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