Abstract
The field of endoscopic spine surgery currently stands at a critical crossroads, marked by an ongoing and substantial debate between uniportal full-endoscopy (FE) and unilateral biportal endoscopy/biportal endoscopic spine surgery (UBE/BESS). This discussion transcends mere technical differences, such as the number of skin incisions, and instead focuses on surgical philosophy, ergonomics, and the optimal pathways for patient recovery. 1
In the three years since the end of the COVID-19 pandemic, as academic activities resumed their previous vitality, I have been repeatedly asked at international conferences: “When should one choose full-endoscopic surgery, and when is biportal endoscopic surgery preferable? How do the indications differ between these two approaches?” With 19 years of experience in FE and 10 years in UBE, having directly navigated the distinct learning curves of both techniques as an ambidextrous spine surgeon, I have consistently explained that, while there is considerable overlap in indications, each technique presents distinct advantages in specific scenarios.2-5 I have drawn on concrete clinical examples to illustrate these differences.
Current discourse within the community often veers toward polarization. FE offers exceptional magnification at the site of pathology, while UBE allows for greater surgical maneuverability and panoramic visualization. 5 Meta-analyses have suggested that the primary clinical outcomes are largely comparable between the two techniques, with some findings indicating that UBE may achieve more thorough decompression.6-8 FE, on the other hand, is associated with a steeper learning curve and may pose higher risks in complex cases, particularly for less experienced surgeons. 9 However, closer inspection of these meta-analyses reveals that most rely on low-level retrospective evidence, with minimal absolute numerical differences and broad ranges of statistical variation, which limits the interpretability of many findings as conclusive or meaningful.
These observations highlight the need for the debate to evolve. The conversation is already shifting from a competitive “versus” mentality to a more cooperative, synergistic paradigm, with the shared objective of providing patient-centered solutions. Pioneering clinicians have begun to explore hybrid surgical methods that leverage the strengths of both FE and UBE, employing strategies such as beginning a case endoscopically and converting as indicated to optimize outcomes. Furthermore, the discussion has expanded beyond clinical efficacy alone, encompassing practicality, cost-effectiveness, worldwide accessibility, and the influence of a surgeon’s training background on technical preference.10-12
Yet, as I have observed in many academic discussions, a critical limitation remains: the majority of endoscopic spine surgeons possess experience in only one technique, with little to no exposure to alternative methods. In clinical practice, it is common for surgeons to start with FE, accumulate only limited experience before surmounting the steep learning curve, and then transition to UBE, subsequently developing a bias that UBE is superior and underestimating the value of FE. Conversely, surgeons who have reached a master level in FE often dismiss UBE as not representing true endoscopic surgery and see little reason to adopt or learn the technique.
Thus, at this pivotal moment, it is imperative to seek balanced and broadly applicable opinions by assembling the perspectives of genuinely ambidextrous endoscopic spine surgeons—those rare experts worldwide who have attained proficiency in both techniques through at least five years of direct clinical experience with each modality. This editorial therefore proposes an initial pathology-driven framework to help surgeons choose the appropriate endoscopic technique based on clinical context, and, more importantly, calls for the establishment of the first international consensus on this topic through a structured Delphi survey process involving these dual-experienced experts.
As leaders in a field defined by innovation, we bear the responsibility to advance the specialty through rigor and collaboration. Achieving consensus will facilitate standardized training, optimize patient outcomes, and ensure the safe and effective global dissemination of endoscopic spine surgery. Now is the time to transcend the paradigm of competition and unite in the mission of advancing spine care for all patients.
