Blog & research

Endoscopic spine surgery (ESS) has recently captured the attention of the Australian spine community and patients alike. Often marketed as ‘keyhole’ or ‘band-aid’ back surgery, it is frequently presented as a cure-all for spinal conditions.

Although ESS offers some short-term benefits over traditional minimally invasive spine surgery (MISS), these are not clinically significant for the average person with a common back problem, nor is ESS superior in providing long-term pain relief. Consequently, MISS approaches, like microdiscectomy and decompression, remain the gold standard, backed by decades of solid evidence.

Here is a look at how ESS actually works and why the reliability of MISS often outweighs the novelty of endoscopy.

What is the difference between ESS and traditional minimally invasive surgery?

ESS involves different technology and technique compared with the established MISS. Here is a quick comparison of the two minimally invasive techniques:

How endoscopic spine surgery works

To make a fair comparison, it helps to understand the mechanics of ESS.

The central piece of technology is the endoscope itself, which functions like a telescope with a light and camera on the end.

In traditional spine surgery, surgeons make a small incision and move muscle aside to reach the spine. In contrast, ESS allows surgeons to slide a thin tube through a stab incision. The camera sends a brightly lit, high-definition and magnified view of the spine and nerves to a large screen in the operating theatre.

This system uses a water channel that constantly flushes the area with sterile saline. This washes away blood or debris, keeping the view clear.

Because the tube is narrow, surgeons use very slender instruments, one at a time, to operate. These include grasping forceps that can swivel, tiny shavers to remove bone, or radiofrequency probes that use heat energy to shrink disc material and seal blood vessels.

Australian surgeons generally use one of two techniques to achieve this:

• Uniportal endoscopy: A single tube is used for the camera, water and instruments.
• Biportal endoscopy: Two separate tiny incisions are made, one for the camera and one for the instruments, giving the surgeon more angles to work with.

Evolution, not revolution

There is no doubt this technology is impressive. However, modern tubular and micro-endoscopic techniques, which form the foundation of traditional minimally invasive surgery (MISS), have already delivered the vast majority of these benefits.

Techniques like microdiscectomy already allow for small incisions and reduced muscle disruption. Therefore, moving to endoscopy does not represent a complete shift in surgical philosophy, but rather a different way to look at the same problem.

Do the short-term advantages of ESS matter?

Proponents of ESS often highlight short-term metrics, such as the small size of the skin incision,  potentially shorter hospital stay and less blood loss. While true, these advantages are often overstated when compared to a modern, well-performed microdiscectomy for the average, healthy person. Current microdiscectomy techniques preserve tissue and blood much better than older ‘wide open’ surgeries. Consequently, the advantage of ESS over a standard MISS procedure is often only marginal.

Regarding the metrics that matter to most – pain relief and daily function – ESS is considered broadly ‘non-inferior’ to microdiscectomy. This means it works just as well, but it is not statistically better in the long term. Both techniques provide similar durable relief.

Why does traditional MISS remain the benchmark?

While ESS is gaining popularity, traditional minimally invasive decompression remains the proven benchmark for several reasons.

Versatility for complex cases

Endoscopy forces the surgeon to work through a very narrow channel using one instrument at a time. This works well for straightforward soft disc herniations. However, for more complicated problems, the familiar field of view provided by a standard microsurgery as well as the ability to use both hands (and therefore two instruments at the same time) is often safer.

Complex issues, such as large disc fragments that have moved far from their original spot, hard calcified discs or severe narrowing of the spinal canal (stenosis), are easier to manage with the direct approach of a microdiscectomy.

Decades of proven data

Traditional MISS is backed by decades of data showing consistent and lasting improvements. Surgeons have well-established statistics regarding risks, reoperation and recurrence rates. Because ESS is newer to widespread adoption, people should be cautious of narratives that imply it is superior when the evidence suggests the outcomes are similar.

Widespread safety and reproducibility

Microdiscectomy is widely taught and mastered by the vast majority of neurosurgeons and spine surgeons. The instruments are robust and available in most hospitals, ensuring high-quality surgery is not restricted to a few specialised centres.

In contrast, the learning curve for ESS is steep, meaning the safety of the procedure can rely heavily on the specific experience of the surgeon.

Choose the surgeon, not the gadget

Endoscopic surgery has a valid place in medicine. It is particularly useful for niche cases, such as herniations located far to the side of the spine, or for medically frail people where minimising soft-tissue damage and blood loss is important.

However, for the average person with a standard herniated disc or spinal stenosis, a well-performed microdiscectomy remains an outstanding and highly reliable operation. It represents the most predictable balance of benefit and risk.

The most important question is not “Can I have the endoscopic operation?” but “Which approach offers the most reliable outcome for my specific problem?”

As always, the quality of the nerve decompression and the judgment of the surgeon matter far more than the size of the incision.

Disclaimer: This article is written based on established neurosurgical and spine literature. It is for informational purposes only and does not substitute for personalised medical advice.

References

American Academy of Orthopaedic Surgeons, Endoscopic discectomy

American Association of Neurological Surgeons, Minimally invasive spine surgery

Johns Hopkins Medicine, Minimally invasive spine surgery

Journal of Minimally Invasive Spine Surgery and Technique

Neurosurgical Society of Australasia, Patient information