Endoscopic Techniques for Spinal Oncology: A Systematic Literature Review.

History of endoscopic spine surgery: where did it all begin? Development of indications and techniques.

A case report. Presentation of transpedicular approach for endoscopic spine surgery (ESS) in a patient with thoracic spine metastases from lung cancer with incomplete paralysis. The spine is the most colonized site for tumor bone metastases, and approximately 5-10% of patients develop symptoms of nerve and spinal cord compression. Traditional open surgery is the best management strategy to address patients' neurological symptoms, but its demanding physical status and low clinical benefit in end-stage patients limit its application in spinal metastases. With the accumulation of experience and technological breakthroughs in ESS, this technology has become an ideal choice for palliative treatment of patients with end-stage spinal metastases. A patient with thoracic spine metastasis from lung cancer with incomplete paralysis was treated with ESS using a transpedicular approach. A patient with lung cancer thoracic spine metastasis with incomplete paralysis was unable to tolerate traditional open surgery due to her physical condition, so our team used the strategy of spinal endoscopic decompression with tumor resection via transpedicular approach to treat him. After the operation, the patient's pain and neurological symptoms were significantly relieved, and he regained the ability to walk on himself within two months. Moreover, the technique prolonged his survival while safeguarding his quality of life. ESS is ideal for patients with end-stage spinal metastases.

This review aims to explore the evolution, techniques, and outcomes of minimally invasive spine surgery (MISS) within the field of neurosurgery. We sought to address the increasing burden of spine degeneration in a rapidly aging population and the need for optimizing surgical management. This review explores various techniques in MISS, drawing upon evidence from retrospective studies, case series, systematic reviews, and technological advancements in neurosurgical spine treatment. Various approaches, including endonasal cervical, transoral cervical, transcervical, mini-open/percutaneous, tubular, and endoscopic techniques, provide alternatives for current approaches to a range of spinal pathologies. The main findings of this review highlight potential advantages of MISS over traditional open surgery, including reduced complications, shorter hospital stays, and improved patient outcomes. Our research underscores the importance of adopting MISS techniques to optimize patient care in neurosurgical spine treatment.

What's New in Spine Surgery.

Bleeding is a commonly encountered problem in spine surgery. The increasing popularity of endoscopic spine surgery poses new challenges to spine surgeons, especially those who are embarking on the learning curve. Hemostasis in endoscopic spine surgery can be difficult due to the narrow working channel and bleeding obscuring the endoscopic view, which hinders hemostasis and effective continuation of the operation. To minimize the risk of bleeding and improve hemostasis, a multimodal approach should be employed, including appropriate strategies for perioperative prevention, intraoperative surgical techniques, and postoperative correction/care. In this technical review article, we discuss several hemostatic techniques that are commonly used in endoscopic spine surgery. We also describe a new bone wax application technique in endoscopic spine surgery—called the “bone wax on pattie” technique—to avoid bone wax sticking onto the working channel/endoscope lens, while enabling easier application of bone wax onto the bleeding bone surface. We share some of our experiences with hemostasis in endoscopic spine surgery, and we hope to gather feedback from fellow spine surgeons around the world, so that we can contribute to further developments in the field together.

Introduction: The history and development of endoscopic spine surgery (PELD) in China is reviewed. Its significance and effect is predicted to have great implications for advancing spine care in China’s working and aging population. Percutaneous spine technology was introduced simultaneously from Japan and the United states by Hijikata and Kambin in the early 1980s. It was called Arthroscopic Microdiscectomy (AMD). The access portal was called “Kambin’s Triangle, with the discectomy technique through a “safe” puncture portal through an anatomical triangular zone in the foramen bordered by the facet and foraminal ligament dorsally, the exiting nerve ventrally, and the endplate of the caudal margin of the triangle. Method: An expanded indication for the transforaminal Kambin technique was introduced to China by Anthony Yeung in 1998, and its evolution and contribution to modern minimally invasive spine care, called the Yeung Endoscopic Spine System (YESSTM) technique, is reviewed. The percutaneous technique has been adopted by surgeons as well as non-surgeons who also undergo surgical training in their rehabilitation programs who integrate the technique through their various affiliations in China for painful degenerative conditions of the spine. Results: The efficacy of the endoscopic technique has evolved significantly since Kambin, with additional contributions by Chinese surgeons and key opinion leaders of surgical and non-surgical Chinese associations that have co-existed, but are focused on providing treatment options for the Chinese population for centuries. Western Medicine has provided great influence on Chinese medicine, but a significant percentage of the Chinese population still cling to traditional treatment, embracing both Old and New methods. With respect to modern surgical techniques, surgeons and no surgeons are cooperative, and focus on results while working together. They recognize that with endoscopic spine surgery, it is important to maintain a success rate comparable to traditional western open surgery with less surgical morbidity utilizing the endoscope. Peer reviewed papers are emerging from China, using the EBM guidelines of Western Journals. Conclusion: A rapidly increasing number of surgeries along with improving results will continue to drive this minimally invasive surgical method to China that bridges the gap between non-surgical pain management, physical medicine, and surgical intervention that focuses on the patho-anatomy and patho-physiology of spinal conditions of pain. This will be known as “surgical pain management, a term coined by Dr Anthony Yeung. Future developments will continue to drive the adoption of endoscopic surgery as a significant advancement for Chinese medicine and surgery.

Background: Surgical intervention may become necessary for chronic pain secondary to Lumbar Spinal Stenosis (LSS). It can be effectively achieved by using Conventional Decompression Surgery (CDS) or Minimally Invasive Spine Surgery (MISS). This study aimed to compare the functional outcome and complications associated with these two techniques. Methods: Online database sources (PMC and Cochrane Library) were utilized to identify 1,050 publications, which were narrowed down to 18 studies included in this systematic review. The mean postoperative improvement in Oswestry Disability Index (ODI) and Visual Analog Scale/ Numeric Pain Rating Scale (VAS/NPRS) scores was statistically evaluated by using SPSS-23 and compared for the two techniques through independent t-test. A p-value <0.05 was considered significant. Results: A total of 1,724 patients [CDS=705; MISS=1019] were included in the study. MISS cases had a significantly greater mean ODI preoperatively and the mean ODI improvement was significantly better in this cohort. The patients undergoing MISS also had a significant decline in the VAS/NPRS scores for Low Back Pain (LBP) and Leg Pain (LP). A significantly higher rate of operative complications and reoperation were seen in CDS patients. Conclusion: In cases of LSS, this review suggests that MISS carries a lower risk of complications and appears to yield better functional outcomes when compared to CDS.

Objective : So called “minimally invasive procedures”have evolved from chemonucleolysis, automated percutaneous discectomy, arthroscopic microdiscectomy that are mainly working within the confines of intradiscal space to transforaminal endoscopic technique to remove herniated epidural disc materials directly. The purpose of this study is to assess the result of endoscopic spinal surgery and favorable indications in the thoracolumbar spine. Methods : The records of 71 patients, 73 endoscopic procedures, were retrospectively analysed. Yeung Endoscopic Spine Surgery system with 7 mm working sleeve and 25°viewing angle was used. The mean follow up period was 6 months (range,3-9). Results : Operated levels were from T12-L1 disc down to L5-L6 or S1 disc. Of 71 cases, 2 patients underwent transforaminal endoscopic surgery twice due to recurrence after initial operation. MacNab’s criteria was used to assess the outcome. Favorable outcome, excellent or good, was seen in 78% (57 procedures) of the patients. Among 11 fair outcomes, only 1 procedure was followed by secondary open procedure, laminectomy with discectomy. Two of 5 poor outcomes were operated again by same procedure which resulted in fair outcomes. One patient with aggravated cauda equina syndrome remained poor and a lumbar fusion procedure was performed in other patient with poor outcome. There were 2 postoperative discitis that were treated with conservative care in one and anterior lumbar interbody fusion in the other. Conclusion : Evolving technology of mechanical, visual instrument enables minimal invasive procedure possible and effective. The transforaminal endoscopic spinal surgery can reach as high as T12-L1 disc level. The rate of favorable outcome is mid-range among reported endoscopic lumbar surgery series. Authors believe that the outcome will be better as cases accumulate and will be able to reach the rate of standard open microsurgery.

7 - Navigation in Non-Instrumented Spine Surgery

Minimally invasive spine surgery (MISS) has transformed spinal surgery by minimizing tissue disruption, reducing recovery times, and lowering complication rates compared with traditional open procedures. MISS uses smaller incisions, specialized tools, and advanced imaging to treat conditions such as degenerative disk disease, trauma, and tumors. Techniques such as endoscopic spine surgery and tubular retractors have expanded its applications, enabling effective treatment with less postoperative pain and faster mobilization. Patient selection is crucial to the success of MISS, requiring detailed imaging analysis and consideration of overall health and pathology. Although MISS provides significant benefits, it is less effective for complex spinal deformities that require extensive sagittal or coronal corrections. Technological advancements, including robotic assistance and augmented reality, are enhancing surgical precision and expanding the scope of MISS. Enhanced recovery after surgery protocols, when combined with MISS, improve outcomes by reducing hospital stays and postoperative pain. Complications such as dural tears and hardware misplacement, although less common than in open surgery, require careful management, with techniques such as intraoperative imaging and robotic navigation aiding in complication prevention. Continued innovation in MISS will broaden its application and improve safety and patient outcomes across various spinal pathologies.

Background and ObjectiveAugmented reality (AR) is being increasingly integrated into spine surgery. However, most existing reviews predominantly focus on its use in instrumentation-based procedures. The broader role of AR in of non-instrumentation minimally invasive spine surgery (MISS), including decompression, endoscopic, and tubular techniques, has not been fully synthesized. This narrative review aims to bring together the current evidence on AR applications across the full range of MISS, with a particular focus on visualization- and workflow-critical non-instrumentation procedures, an area that has been underrepresented in prior reviews.MethodsA comprehensive literature search was conducted in PubMed, Embase, and the Cochrane Library for articles published between 2010 and 2025. Search terms included Medical Subject Headings (MeSH) and free-text keywords related to augmented reality, minimally invasive spine surgery, decompression, and navigation. Only peer-reviewed English-language articles were included. Study selection was performed independently by three reviewers, with discrepancies resolved by consensus.Key Content and FindingsThe review synthesizes AR applications across percutaneous procedures, tubular surgery, endoscopic spine surgery (ESS), microscopic surgery, and lateral approaches. The literature indicates that AR can enhance intraoperative visualization through in-situ image overlays, reduce visual attention shifts and cognitive workload, improve workflow efficiency, and lower radiation exposure. However, current evidence is largely derived from small-sample, single-center feasibility studies (levels IV–V evidence). Comparative analyses suggest AR is most valuable as a complementary visualization layer within multimodal navigation ecosystems rather than a standalone replacement.ConclusionsAR represents a promising adjunct in MISS, particularly for non-instrumentation procedures in which visualization is limited. To define its definitive clinical value, future research must prioritize workflow standardization, validation of performance metrics, and adequately powered multicenter trials that assess clinically meaningful outcomes. Integration with artificial intelligence (AI) and robotic platforms may further enhance surgical precision and efficiency, shaping the next phase of MISS.

Advancement in medical treatment leads to increase life expectancy and population ageing.The corresponding increase in the incidence of degenerative spinal conditions are top 10 causes of disabilities worldwide. 1As science advances with new procedures, there is a demand for more advanced technology and surgical techniques in spinal surgery to minimise collateral soft tissue damages to provide improved clinical outcomes with less perioperative morbidities for our patients.This demand gives rise to the evolution of endoscopic spine surgery. 2 Despite the many benefits of spinal endoscopy, there is a steep learning curve in spinal endoscopy. 3Surgeons who are practicising the art of spinal endoscopy should be familiar with open surgical techniques and spinal anatomy.As endoscopic spine surgery is a fast evolving field, it is important for practicing endosocpic surgeon to keep current with the latest literature and updates.Since the previous special edition of Endoscopic Spine Surgery in Neurospine in 2020, there is continual development of technology in spinal endoscope in terms of lens clarity, variety of angulation, light transmission, radiofrequency energy systems, spinal endoscopic instruments, and further refinement of surgical techniques by worldwide endoscopic surgeons.This leads to an expansion of clinical indications for endoscopic spine surgery. [4][5]5][6][7][8] In this special edition, we have articles from uniportal full endoscopic and unilateral biportal endoscopy addressing various conditions in spine with advanced endoscopic techniques involving cervical and thoracic decompression as well as endoscopic spinal fusion techniques.We are confident this current special issue of Endoscopic Spine Surgery in Neurospine will become a core forum for spine scholars who are interested in endoscopic spine surgery.We wish you success in your academic, clinical and endoscopic spine surgical career.

Microscopic versus endoscopic pituitary surgery.

To assess and compare the rate of procedure-related complications after intrauterine treatment of spina bifida by endoscopic surgery and by open fetal surgery. Systematic literature searches in PubMed and SCOPUS databases were performed on 20 September 2015 to identify randomized controlled trials and observational studies on treatment of human spina bifida by endoscopic or open fetal surgery techniques. Only studies with ≥ 10 cases that were published in or after 2000 were included in the meta-analysis in order to reduce the risk of bias. Primary outcomes (complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar; preterm delivery < 34 weeks; mean gestational age at delivery) and secondary outcomes (oligohydramnios, prelabor rupture of membranes, placental abruption, chorioamnionitis and perinatal death) were assessed for both techniques. Precision of the estimated proportions was evaluated with 95% CIs. Inconsistency was assessed using the I(2) statistic. The search identified 1080 records that were examined based on title and abstract, of which 28 full-text articles were examined completely for eligibility. Nine records were excluded because cases were also described in other studies, leaving 19 records for analysis. When comparing endoscopic vs open fetal surgery, the rate of complete dehiscence, focal dehiscence and/or markedly thin hysterotomy scar was, respectively, 1% (95% CI, 0-4%) vs 26% (95% CI, 12-42%); preterm delivery < 34 weeks was 80% (95% CI, 41-100%) vs 45% (95% CI, 38-53%); oligohydramnios was 39% (95% CI, 9-75%) vs 14% (95% CI, 7-24%); prelabor rupture of membranes was 67% (95% CI, 12-100%) vs 38% (95% CI, 26-50%); and perinatal death was 14% (95% CI, 1-38%) vs 5% (95% CI, 3-8%). Open fetal surgery for spina bifida seems to show lower rates of procedure-related complications than does endoscopic surgery, but the rate of hysterotomy scar complications is high after open surgery. Because of the low quality of evidence, the conclusions should be interpreted with caution. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Lumbar spinal stenosis is the most common spinal degenerative disease in patients over 60 years, and the unilateral biportal endoscopic (UBE) spine surgery treatment of lumbar spinal stenosis (LSS) has achieved preliminary clinical results. This systematic review and meta-analysis aimed to reveal the clinical efficacy of UBE for LSS and provide evidence for clinical practice. PubMed, Embase, Web of Science, and Cochrane databases were searched for literature. The papers selected were those published from inception till October 2021. The selected pieces of literature were graded for evidence using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). Outcomes measures were operation time, blood loss, complication rate, admission period, Visual Analogue Scale (VAS)-back, VAS-leg, and Oswestry Disability Index (ODI) score, and radiological outcomes. The mean comparisons were based on VAS and ODI scores. A total of 823 patients with a single LSS segment were included from the selected nine studies. There were nine studies comparing UBE clinical outcomes and micro-endoscopic unilateral laminotomy for bilateral decompression (M-ULBD). The meta-analysis revealed that the UBE group had better VAS-leg and -back scores in the first week postoperatively [total: mean difference (MD) = -0.96, 95% confidence interval (CI): -1.19, -0.74, p < 0.00001; total: MD = -1.69, 95% CI: -1.93, -1.45, p < 0.00001], 1st month postoperatively (total: MD = -0.35, 95% CI: -0.61, -0.08, p = 0.01; total: MD = -0.40, 95% CI: -0.68, -0.12, p = 0.005), 6th month postoperatively (total: MD = -0.22, 95% CI: -0.35, -0.08, p = 0.002; total: MD = -0.24, 95% CI: -0.40, -0.07, p = 0.005), and UBE group also performed better in ODI score at 1st month postoperatively (total: MD = -3.36, 95% CI: -4.26, -2.46, p < 0.00001). There was no significant difference in VAS-leg and -back scores between both groups at the 3rd and 12th month postoperatively, and ODI scores did not significantly differ between both groups at 3, 6, and 12 months postoperatively (all p > 0.05). UBE has achieved good preliminary clinical results and may be a minimally invasive alternative surgery for patients with single segmental LSS.