Evolution, Current Trends and Latest Advances of Endoscopic Spine Surgery: A Narrative Review

1. Introduction

2. Evolution of Endoscopic Techniques for Spine Surgery

Table 1. Historical review of endoscopic technique.

3. Lumbar Spine Endoscopy

3.1. Microendoscopic Discectomy and Decompression

Microendoscopic discectomy is a minimally invasive surgery technique that was initially described in 1997 [14]. It allows surgeons to work with two hands through a small-diameter, operating table–mounted tubular retractor and a 25 degree endoscope. [14,15]. Compared to conventional open discectomy, microendoscopic discectomy(MED) has several advantages such as lesser blood loss, cosmesis, shorter hospital stay, and early return to work [15]. A study of 150 consecutive patients treated with MED in 2005 confirmed these findings [27]. MED technique has been used not only for paracentral disc herniations, but also for all types including far lateral, cephalad, caudal migrated, and recurrent disc herniations [28,29].

Due to the advantages of MED, in 2002, Khoo and Fessler modified the MED technique and used it to treat 25 patients with LSS [30]. Compared to the open technique, microendoscopic decompression group had statistical decrease in operative blood loss, postoperative narcotic requirement, and length of hospital stay (42 hr versus 94 hr) [30]. Even today, Microendoscopic discectomy and decompression are one of the most commonly performed techniques for treatment of lumbar disc herniations and lumbar spinal stenosis.

Figure 1. MED, A: METRx system C: Scope and attachment, D: Endoscopy image.

Figure 1. MED, A: METRx system C: Scope and attachment, D: Endoscopy image.

Table 2. Surgical results of microendoscopic discectomy and decompression.

Table 2. Surgical results of microendoscopic discectomy and decompression.

Author	Sample	Approach	Follow up	Outcomes	Complication
Perez-Cruet 2002 [27]	150	Paramedian	12 months	Mean operative time (min) 97 Mean hospital stay (hours) 7.7 (range, 2–24) Mean time to return to work (days) 17	Dural tears 8/150 (5%) recurrence 4/150 Pseudomeningocoele 1/150 (0.7%) Surgical site infection 1/150 (0.7%)
Khoo 2002 [30]	25 vs 25 open	Paramedian	12 months	Lesser blood loss 44ml for med vs 193 ml Shorter hospital stay 42 hours vs 94 hours	Additional fusion surgery 0% vs. 12% Transfusion 0% vs. 8% Dural tear 16% vs. 8%
Ikuta 2005 [31]	47 vs 29 microdiscectony	Paramedian	22 months	Rate of recovery 72% (improvement in JOA score) (38/47)	Higher complication rate compared to microdiscectomy
Wu 2006 [32]	873 Vs 358 open	Not specified	28 months vs 31 months for open	Earlier return to work Shorter hospital stay Shorter operation time Lesser blood loss Lesser analgesic need	35/873 for MED vs 19/358
Fukushi 2015 [33]	58 vs 39 open	Midline	42 months	Similar improvement in JOA and similar patient satisfaction	Higher rate of infection,
Wu 2020 [34]	82 vs. 52 Full endoscopy	Paramedian	20 months	Similar improvement in VAS for leg pain Higher VAS for low back pain and ODI	Dysesthesia 0% vs. 1.9%, Dural tear 2.4%vs. 1.9%, Urinary retention 1.2% vs. 0%, Total 3.85% vs. 3.66%
Iwai 2020 [35]	60 vs. 54Microendoscopic	Paramedian	3 months	Shorter operating time but longer hospital stay compared to biportal endoscopy. Similar VAS/NRS in both groups	Dural tear 5.6% vs. 1.8% Hematoma 3.3% vs. 13.0%
Ito 2021 [36]	139 vs. 42 Biportal Endoscopy	Paramedian	6 months	Similar improvement in VAS for low back pain and leg pain, OD	Dural tear 5.8% vs. 4.7%, Hematoma 3.6% vs. 0%, Re-operation1.4% vs. 0%

3.2. Destandau’s Endospine Technique:

This technique requires use of a specialized system called the Destandau Endospine System (Karl Storz, Tuttlingen, Germany), which comprises an endospine tube, trocar, and working insert. The working insert comprises four ports—4-mm endoscope (0°), 4-mm suction cannula, 8-mm for the working instrument, and nerve root retractor [37]There are numerous applications of the Destandau system ranging from degenerative spinal conditions to intradural tumor surgery [21]

Figure 2. instruments of Destandau’s endospine technique.

Figure 2. instruments of Destandau’s endospine technique.

3.3. Transforaminal Endoscopy

Transforaminal approach was the first approach which was used by the pioneers of full endoscopic spine surgery techniques[38] The key transforaminalecompression is safe docking of the endoscope, which requires careful analysis of preoperative radiologic imaging to evaluate the angle of approach required to retrieve fragment and understand the anatomic constrains in the transforaminal approach.(38)two popular techniques are the “inside out technique” [20] by Yeung and the “outside in technique” described by Hoogland. (21) Although it was initially believed that transforaminal approach has several limitations , literature suggests that this technique can be applied successfully to treat migrated disc herniations and foraminal pathology such as foraminal disc herniations and foraminal stenosis. (39,40) Literature suggests that challenging cases like highly migrated disc herniations can be operated by using the transformational endoscopic lumbar discectomy (TELD) by performing partial resection of the pedicle and enlargement of the foramen. (41) TELF can be used to treat foraminal stenosis while maintaining favorable long-term outcomes without the need for fusion in the vast majority of patients. (42) Several cadaveric studies also showed confirmed feasibility and efficacy of percutaneous endoscopic lumbar foraminoplasty/ TELF.(43,44)

When used for revision spine surgery, TELF and TELD are associated with minimal blood loss, lesser scar tissue formation and similar operating time compared to primary spine surgeries (45,46 In addition to other advantages of this technique such as shorter operation time, minimal blood loss and less muscle trauma, there are several published reports of transforaminal endoscopic spine surgery performed in awake patients under local anesthesia (47,48). Therefore, transforaminal endoscopic spine surgery is a viable surgical treatment option for patients with severe medical co-morbidities who are medically unfit to undergo surgery under general anesthesia.

Figure 3. Three kinds of endoscopic approaches, A: Inside out approach - Starts from the disc to the epidural space、B : Outside in approach - Starts from the epidural space, with or without foraminoplasty、C: Interlaminar approach.

Figure 3. Three kinds of endoscopic approaches, A: Inside out approach - Starts from the disc to the epidural space、B : Outside in approach - Starts from the epidural space, with or without foraminoplasty、C: Interlaminar approach.

3.4. Interlaminar Endoscopy :

3.4.1. Interlaminar Endoscopic Lumbar Discectomy (IELD)

Due to technical difficult of using the transforaminal approach at L5-S1 level due to anatomical constraints, the inter laminar approach was advocated (24). Due to similar orientation compared to conventional posterior decompression techniques, the inter laminar approach though initially described for L5-S1 level was popularized for surgical treatment of lumbar canal stenosis (LCS) even at higher lumbar levels.

The patients undergoing IELD have significant advantages such as lower immediate postoperative back pain, shorter operation time, and rapid return to work.(49) Reuten et al followed up 178 patients who underwent either interlaminar endoscopic lumbar discectomy (IELD) or microsurgical discectomy and concluded that Full-endoscopic surgery is a sufficient and safe alternative to microsurgical procedures with minimal soft tissue trauma. (50)

The Interlaminar approach can also be used to treat Lumbar spinal stenosis. Lumbar endoscopic - unilateral laminotomy and bilateral decompression (LE-ULBD) when compared to microscopic ULBD showed comparable clinical and radiological outcomes. The endoscopic approach might further minimize tissue injury and enhance post-operative recovery. (51,52) McGrath et al in a similar study found that Lumbar endoscopic unilateral laminotomy for bilateral decompression is a safe and effective surgical procedure with favorable complication profile and patient outcomes.(53).

3.4.2. Percutaneous Biportal Endoscopic Discectomy and Decompression (PBED)

The PBED technique, involves using one portal for the endoscope and the other for introduction of instruments for performing decompression. In recent years, this technique of spinal surgery has gained tremendous popularity due to the advantages of familiarity of surgeons to posterior approach, free dexterity and use of conventional instruments used for open spine surgery. (54,55,56). It is generally believed that UBE surgery has the advantages of a wider field of vision, minimal muscle damage and faster recovery. (57) The learning curve of this technique is relatively shorter than that of uniportal full endoscopic surgery, which is another advantage of the UBE technique. (58)

UBE discectomy is a good treatment choice for lumbar disc herniation.(59) The Biportal endoscopic technique can also be used to treat foraminal pathology such as foraminal stenosis and far lateral disc herniation by using the extraforaminal technique described by Ann.(52)

A number of studies have compared the intra-operative and post-operative outcomes following PBED. Compared to ILED, PBED has superior results such as shorter operation time, better central canal decompression.(60) and less violation of the facet joints. (61) PBED has also demonstrated favorable clinical outcomes for revision surgery such as lower postoperative pain and has outcomes comparable to primary PBED, thus suggesting advantage of PBED for revision spine surgeries. (62)

Figure 4. Unilateral Biportal Endoscopic Transforaminal Lumbar Interbody Fusion. A:Scopic and Instrument portals. B:Endoscopic view after soft tissue dissection. C:osteotomy of inferior articular process (IAP) D:Resection of tip of superior articular process (SAP) E&F:removal of disc and preparation of disc space. G: Endoscopic view showing insertion of cage.H:Final position of cage. This step is followed by insertion of Percutaneous Pedicle screws under fluoroscopic guidance.

Figure 4. Unilateral Biportal Endoscopic Transforaminal Lumbar Interbody Fusion. A:Scopic and Instrument portals. B:Endoscopic view after soft tissue dissection. C:osteotomy of inferior articular process (IAP) D:Resection of tip of superior articular process (SAP) E&F:removal of disc and preparation of disc space. G: Endoscopic view showing insertion of cage.H:Final position of cage. This step is followed by insertion of Percutaneous Pedicle screws under fluoroscopic guidance.

Table 3. Clinical Results of Unilateral Biportal Endoscopy.

Table 3. Clinical Results of Unilateral Biportal Endoscopy.

Author	Study type	Sample	Diagnosis	Follow up(Months)	Operation time (minutes)	Complications
Eum et al(2016) [26]	Retrospective	58	LSS	13.8	68.9 ± 16.1	13.8%; post-op headache(3),dural tear (2),transient numbness (2), epidural hepatoma (1)
Choi et al (2016) [63]	Retrospective	68	LDH(25),revision(3) stenosis(39),synovial cyst(1)	NR	68.2±23.7	10.3%;dural tear(2),nerve root injury(1),incomplete decompression(4)
Kim et al(2018)[64]	Retrospective	60	LDH	12.6	70.15 ± 22.0	5%, incomplete decompression (3)
Ahn et al (2018)[55]	Retrospective	21	Foraminal stenosis (11), foraminal LDH(9),ASD(1)	14.8	96.7	4.8%;dural tear (1)
Kim and Choi (2018)[65]	Retrospective	105	LSS	14	53 ± 13.5	2.9%;dural tear (2), epidural hematoma(1)
Akbary et al (2018)[66]	Retrospective	30	Lateral recess+foraminal stenosis	5.67	102.5 ± 43.66	0%
Pao et al (2019)[67]	Retrospective	81	LSS	8.6	NR	8.6%;dural tear(4), transient motor weakness (1), inadequate decompression (1),epidural hematoma(1)
Wang et al (2023)[68]	Prospective	70	LDH	24	NR	0%

3.4.3. Endoscopic Lumbar Interbody Fusion

Current literature in endoscopic fusion can be broadly divided into transforaminal lumbar interbody fusion by the Kambin triangle ventral to the facet joint with or without foraminoplasty, transforaminal lumbar interbody fusion through posterolateral approach by uniportal or biportal endoscopy, through the resected facet joint and endoscopic-assisted lateral lumbar interbody fusion.(7) The technique of transforaminal lumbar inter body fusion via the Kambin’s triangle can be used as an alternative technique for spinal fusion in patients with severe medical comorbidities as it can be done under local anesthesia. (69) The technique is based on the principle of indirect decompression and has several advantages such as short operative time, minimal blood loss and ability to perform visualized preparation of the end plates. However, the disadvantages are possibility of injuring the exiting nerve root and radiation exposure.(70)

Full endoscopic lumbar interbody fusion (FELIF) has the advantage that it allows direct decompression of pathology with minimal invasive technique.(70) FE-PLIF via the inter laminar approach is known to have outcomes compared to other popular minimally invasive techniques like MIS TLIF with minimal surgical trauma.(71).

Endoscopic lumbar interbody fusion using percutaneous unilateral biportal endoscopic technique can achieve direct neural decompression similar to conventional open surgery and can be an alternative to minimally invasive LIF surgery for treating degenerative lumbar disease. However, long-term follow-up and larger clinical studies are needed to validate the clinical and radiological results of this surgery.(54)

According to a recent meta-analysis, UBE-TLIF was superior to MIS-TLIF in terms of intraoperative blood loss, duration of hospital stay, VAS score for low back pain and ODI score, but the operative time was longer than MIS-TLIF group. There were no significant differences between the two groups in terms of total complication rate, modified Macnab grading criteria, fusion rate, VAS score of leg pain, lumbar lordosis, intervertebral disk height.(72)

4. Thoracic Spine Endoscopy

5. Cervical Spine Endoscopy

5.2. Endoscopic Aterior Cevical Dscectomy and Fusion

Ahn et al reported 5-year follow-up outcomes of anterior full endoscopic discectomy for soft disc herniation and showed comparable results with conventional ACDF(95). Recently Endoscopic ACDF has also been performed but no concrete data is currently available proving its efficacy.

Figure 5. Endoscopic Aterior Cevical Dscectomy and Fusion, A: Intra-operative level marking . B&C: Docking over C6-C7 disc space D&E: Endoscopic view showing removal of disc and preparation of disc space. F: Endoscopic view showing complete removal of disc and adequate endplate preparation. G: Introduction of cage F: final position of cage.

Figure 5. Endoscopic Aterior Cevical Dscectomy and Fusion, A: Intra-operative level marking . B&C: Docking over C6-C7 disc space D&E: Endoscopic view showing removal of disc and preparation of disc space. F: Endoscopic view showing complete removal of disc and adequate endplate preparation. G: Introduction of cage F: final position of cage.

5.3. UBE Cervical Foraminotomy and Laminectomy

Some studies have demonstrated that UBE laminectomy may be considered an excellent surgical alternative to treat cervical stenosis without the development of iatrogenic kyphosis(77). It represents an effective method with excellent neurological and radiological outcomes with less soft tissue invasion, which translates into dramatically less postoperative axial pain and maintained postoperative cervical lordosis(77). Wang et al concluded in their study that UBE and PE (percutaneous posterior endoscopic discectomy) were both safe and effective in the treatment of cervical spondylotic radiculopathy and were characterized by minimal trauma, no adverse impact on cervical stability and few complications(78). It is safe to say that cervical endoscopic surgeries have evolved and are no longer limited to dealing with just single level disc disease.

Figure 6. UBE Cervical foraminotomy and Laminectomy, A: Axial section through C5-C6 disc showing left sided disc osteophyte complex with impingement of left C6 nerve root. B: Intra-operative surgical view. C: Intra-operative fluoroscopic view showing targeting of V point i.e. junction of inferior articular process (IAP) with superior articular process (SAP) D. Endoscopic view showing identification of V point. E: Beginning of decompression by burring of IAP F,G: Resection of IAP and SAP with kerrison Ronguers H. Final image showing adequate decompression of the nerve root.

Figure 6. UBE Cervical foraminotomy and Laminectomy, A: Axial section through C5-C6 disc showing left sided disc osteophyte complex with impingement of left C6 nerve root. B: Intra-operative surgical view. C: Intra-operative fluoroscopic view showing targeting of V point i.e. junction of inferior articular process (IAP) with superior articular process (SAP) D. Endoscopic view showing identification of V point. E: Beginning of decompression by burring of IAP F,G: Resection of IAP and SAP with kerrison Ronguers H. Final image showing adequate decompression of the nerve root.

Table 4. Clinical Rsult of Cervical Spine Endoscopy.

Table 4. Clinical Rsult of Cervical Spine Endoscopy.

Author	Sample	Approach	Follow up	Outcome	Complication
Fontanella (1999)[96]	296 (273 anterior,23 posterior)	Anterior, posterior	12 months	97% success at 1 year; average surgical time 25 min	Nil
Ahn (2005)[97]	111	Anterior	49 months	Excellent/ good outcome in 80%	Persistent radicular pain in 1 patient 1 patient required ACDF
Lee (2007)[98]	116	Anterior	36 months	87 % had good outcomes	2 patients ACDF 2 patients repeat endoscopy 1 patient - posterior fixation
Reutten (2009)[99]	60	Anterior	24 months	96% - good clinical outcome	2 patients - progressive neck pain 2 patients - radicular pain 4 patients - ACDF
Yang (2014)[100]	84	Anterior 42 Posterior 42	18 months	Shorter operating time for anterior approach Shorter hospital stay for posterior approach	1 Neurological deterioration 1 Hematoma - 1 Re-operation -1 post-operative headache -
Oertel (2016)[101]	43	Posterior	6 months	82% regained full arm strength; mean one level operation time 77 min	1 haematoma, 1 triceps paresis

6. Latest Advances

6.1. Navigation

Debilitating consequences for patients can occur to damage to important structures such as nerves and blood vessels . Navigation systems that use real-time images improve surgical accuracy [103,104]Using O-arm, a high-quality computed tomography (CT) scan can be performed. Surgeons can perform intraoperative three-dimensional (3D) anatomical mapping in real time by integrating it with a real-time anatomical tracking tool[105]. Spine surgeons initially use navigation systems for percutaneous pedicle screw fixation, but nowadays, navigation systems can be used for various surgical procedures.

[106] Some examples of such applications in the field of endoscopic spine surgery are shown in the figures below.

Figure 7. C arm free MED posterolateral, A: Intraoperative image, B: Navigated high speed burr, C: Navigation monitor, D: Preoperative MRI, A white arrow shows left L5/S1 lateral lumbar disc herniation.

Figure 7. C arm free MED posterolateral, A: Intraoperative image, B: Navigated high speed burr, C: Navigation monitor, D: Preoperative MRI, A white arrow shows left L5/S1 lateral lumbar disc herniation.

Figure 8. C arm free cervical endoscopic keyhole foraminotomy, A: Endoscopy image, B: Neuromonitouring, C: Navigation monitor, D: MRI. A white arrow shows cervical disc herniation.

Figure 8. C arm free cervical endoscopic keyhole foraminotomy, A: Endoscopy image, B: Neuromonitouring, C: Navigation monitor, D: MRI. A white arrow shows cervical disc herniation.

Figure 9. C arm free lumbar transforaminal discectomy, A: Endoscopy image, B: Foraminoplasty with a navigated high speed burr, C: Navigated approach to the disc, D: Endoscopy image.

Figure 9. C arm free lumbar transforaminal discectomy, A: Endoscopy image, B: Foraminoplasty with a navigated high speed burr, C: Navigated approach to the disc, D: Endoscopy image.

Figure 10. C arm free UBE, A: O arm, B: Intraoperative image, C: Navigation monitor, D: endoscopy image.

Figure 10. C arm free UBE, A: O arm, B: Intraoperative image, C: Navigation monitor, D: endoscopy image.

7. Conclusion

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