Christoph J. Siepe

Endoscopic spine surgery has advanced from a percutaneous niche technique to a mainstream platform for lumbar decompression. This original study examines the relationship between endoscopic and microscopic platforms across 7 contested domains, using an embedded cross-sectional single-round international survey to map patterns of expert agreement and divergence. Seven contested domains—learning curve, technical feasibility, patient selection, clinical and radiological outcomes, complications, cost-effectiveness, and reoperation—were each argued by a Pro-Microscopic and a Pro-Endoscopic advocate before reconciliation, then complemented by a structured single-round international survey of 105 spine surgeons from 5 world regions. The survey was designed to describe practice patterns and map the distribution of expert opinion, not to determine whether endoscopy can replace microscopy. Statements meeting a prespecified conjunctive threshold of at least 70% agreement overall and within each of 3 practice-profile strata were classified as meeting the consensus standard, with the 70% level adopted on the precedent of the CORE (Convergence of Opinion on Recommendations and Evidence) methodology. Seven statements met this standard: reduced approach-related trauma, lower surgical site infection, primacy of surgeon experience over platform, the training burden of endoscopy, standardized outcome reporting, comparable 1- to 2-year outcomes in selected stenosis, and health-system dependence of cost-effectiveness. Endoscopy-favoring distributions were modal in all 7 domains, reaching a majority for complications, outcomes, and patient selection; learning curve and cost-effectiveness remained areas of mixed opinion, and reoperation showed the widest divergence of views. Although 75.2% judged that endoscopy is ready to replace the microscope as the default platform, this fell to 38.5% (95% confidence interval, 13.9%–68.4%) among microscopically oriented surgeons and failed stratification. Endoscopy has demonstrated comparable outcomes for selected pathology and perioperative advantages in specific domains, but not durable long-term superiority. The evidence supports coexistence rather than replacement, with platform selection matched to pathology, patient phenotype, endoscopic platform, and surgeon expertise. The survey illustrates where expert practice patterns align with, diverge from, or run ahead of published comparative evidence.

Objective: Endoscopic spine surgery (ESS) has expanded rapidly, but existing spine registries do not consistently capture ESS-specific technical variables, ultra-early recovery trajectories, selective imaging validation, or dissemination-related learning-curve effects. This review synthesizes established spine registry models, contemporary consensus initiatives, and digital follow-up approaches to propose a candidate ESS-specific registry framework and preliminary Minimum Data Set (MDS) for future validation.Methods: A structured narrative review was conducted on national and multinational spine registries, relevant consensus initiatives, and digital follow-up models. Sources were reviewed with emphasis on governance, data architecture, workflow design, patient-reported outcome measures (PROMs) integration, follow-up structure, data linkage, validation strategies, and implementation feasibility.Results: Established registries provide a methodological foundation for benchmarking, complication surveillance, longitudinal PROM capture, and real-world evidence generation. However, ESS requires modular augmentation of existing registry infrastructures to capture approach-specific operative details, early recovery, selective imaging phenotypes, and governance-controlled maturity indicators. The proposed candidate MDS is organized into 4 domains: (1) baseline case-mix and phenotyping, (2) procedure-specific technical and perioperative variables, (3) selective quantitative imaging and morphometric validation, and (4) structured longitudinal outcome surveillance. The framework prioritizes an essential core dataset while separating recommended, optional, research-oriented, and governance-controlled modules, including digitally enabled early follow-up, opioid-related outcomes, radiation exposure, advanced imaging, and learning-curve variables.Conclusion: A candidate ESS-specific registry framework may support harmonized data capture, real-world evidence generation, quality feedback, and future registry-based research. Formal Delphi consensus, multicenter feasibility testing, and staged integration into existing spine registry infrastructures are required before broader implementation.

Purpose Clear intraoperative visualization is essential for safe and effective endoscopic spine surgery, yet existing assessments remain subjective and lack standardization. The Visualization in Endoscopic Workspace (VIEW) Score was developed to provide an objective, reproducible grading system for evaluating intraoperative visualization quality. This study aimed to validate the VIEW Score as a standardized and reliable tool for assessing visualization during endoscopic spine surgery. Methods The VIEW Score is a 4-point ordinal scale (0 = Excellent, defined as no bleeding observed, to 3 = Poor) developed through expert consensus to evaluate bleeding, clarity of anatomical structures, and impact on surgical progress. Five experienced endoscopic spine surgeons independently rated 40 de-identified, 5-second video clips of interlaminar endoscopic lumbar spine surgery. After a 4-week washout period, the raters re-evaluated the same clips in a randomized order. Inter- and intra-rater reliability were analyzed using the Intraclass Correlation Coefficient (ICC) with a two-way random effects model for absolute agreement. Results The VIEW Score demonstrated excellent inter-rater reliability for mean ratings (ICC(2,5) = 0.963; 95% CI 0.940–0.979) and good single-rater reliability (ICC(2,1) = 0.839; 95% CI 0.758–0.902). Intra-rater reliability was also high (mean ICC 0.889 ± 0.04; range 0.840–0.943). Reliability remained consistently strong across approach (ICC(2,5) = 0.965) and decompression phases (ICC(2,5) = 0.945). Conclusions The VIEW Score is a reliable and objective grading system for assessing intraoperative visualization during endoscopic lumbar decompression. Its strong reproducibility supports its use for standardized communication, surgical training evaluation, quality assessment, and future research examining visualization, hemostasis, and surgical workflow.

Nach initial offener Durchführung stellt der Einsatz des Operationsmikroskops heutzutage im Rahmen dekomprimierender Verfahren wie der operativen Behandlung von Bandscheibenvorfällen oder der Dekompression einer Spinalkanalstenose den Gold-Standard dar. Mit Einführung der vollendoskopischen Eingriffe in uniportalen Technik konnte die Invasivität der Eingriffe mit den bekannten Vorteilen der MIS-Chirurgie nochmals reduziert werden. Microsurgical techniques significantly reduced the invasiveness of lumbar decompression surgeries in comparison to previous open techniques since their introduction in the 1980´s and nowadays represent the “gold standard” for the surgical treatment of pathologies such as lumbar disc herniations and/or spinal canal stenosis. The advantages of minimally invasive surgery (MIS) are multifold and include reduced access related tissue trauma, less postoperative wound pain, early patient mobilisation and return to daily living activities, reduced blood loss and others. Full-endoscopic techniques performed through a uniportal approach through a single 6–8mm skin achieved a further reduction of the surgical access related invasiveness. The risk of surgical site infection/wound healing problems is minimal, and surgeries can be performed almost independently of the patient´s weight. A considerable learning curve is required to fully acquire the surgical skills to master the endoscopic technique which is considered one of the drawbacks of the technique. Article published online: 21 October 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Decompression of spinal stenosis represents one of the most commonly performed procedures in spine surgery. With constantly increasing patient age and changing demographics, reducing the invasiveness of surgical procedures has become increasingly important. Over the past decades, microsurgical decompression has been established as a gold standard technique for the surgical treatment of spinal stenosis. In comparison with open techniques or surgeries that were performed with loop lenses, which required larger skin incisions, and which consecutively raised the access-related collateral damage, the microscope served to significantly reduce the invasiveness of the decompression interventions. Advantages included smaller skin incisions, reduced collateral tissue damage, less blood loss, lower infection rates and wound healing problems, shorter hospital stay, and multiple others, as widely known across various MIS techniques. For the same reasons as outlined above, the introduction of full-endoscopic surgical techniques aims to further reduce the invasiveness of surgical interventions. The present manuscript provides a delineation of the surgical technique of LE-ULBD (Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression), gives an overview on the current state of literature, and aims to put this surgery into context with other currently available decompression techniques.