Ahmed Ibrahim

This structured debate integrates a narrative evidence synthesis with an international practice-pattern survey comparing uniportal endoscopic cervical foraminotomy (PECF), unilateral biportal endoscopic cervical foraminotomy (UBE-CF), and microscopic/tubular posterior cervical foraminotomy. The literature search covered January 1990 to July 5, 2026. Comparative evidence was predominantly retrospective, single-center, and heterogeneous. Background and expertise data were available for 75 respondents, including 74 with endoscopic expertise, and 73 completed all 4 clinical scenarios. Uniportal-only respondents predominantly selected PECF, whereas biportal-only respondents favored UBE-CF. Treatment choices differed across the predefined clinical scenarios, with anterior cervical discectomy and fusion (ACDF) selected by 19 of 73 (26.0%), 35 of 73 (47.9%), 19 of 73 (26.0%), and 49 of 73 respondents (67.1%) in cases 1–4, respectively. These scenarios changed several clinical features simultaneously and do not establish the independent influence of any single feature. Available comparative studies have not established durable superiority of one posterior technique over another. ACDF was the most frequently selected single procedure in the scenario combining retrolisthesis, asymptomatic central stenosis, and motor weakness (case 2) and in the revision scenario (case 4). Platform selection should reflect surgeon expertise, anatomy, and available resources. Multicenter randomized or expertise-based comparative trials with standardized outcomes and long-term follow-up are needed.

Lumbar fusion has evolved from open transforaminal lumbar interbody fusion (TLIF) to minimally invasive TLIF (MIS-TLIF), the current minimally invasive benchmark. Endoscopic techniques, proven in discectomy and decompression, have been extended to fusion (uniportal endoscopic TLIF and biportal endoscopic TLIF), offering an alternative to MIS-TLIF. This structured debate-style review critically compares both techniques across 7 domains to clarify their respective roles in lumbar degenerative disease. It combined independent advocacy drafts with an international survey of 106 respondents across 35 countries, capturing procedural preferences and case-based reasoning. Using a prespecified 70% agreement threshold, domains were classified as domains with ≥70% panel agreement, whereas domains falling below this threshold were categorized as domains below the prespecified agreement threshold. This represents structured international survey agreement, not a formal Delphi process. Endoscopic fusion offers advantages in decreased blood loss, soft-tissue preservation, early postoperative back pain, and early recovery, with comparable mid-term clinical outcomes (long-term insufficiently established) to MIS-TLIF, which remains more reproducible and familiar. Complication rates are similar but technique-sensitive for endoscopic fusion. Panel responses favored endoscopic approaches for morbidity-related domains (soft-tissue preservation 89.6%, visualization 81.1%, recovery 74.5%), while fusion stability, short- to mid-term clinical outcomes, complications, and revision remained context-dependent without clear agreement. Endoscopic fusion is a credible option for selected single-level lumbar degenerative disease, offering perioperative advantages with comparable mid-term outcomes to MIS-TLIF; core endpoints, including fusion rate and revision rate, did not reach 70% panel agreement, even among endoscopy-favorable panelists. MIS-TLIF retains reproducibility advantages. The debate has shifted from feasibility to implementation, training standardization, cost-effectiveness, and long-term durability.