Endoscopic spine surgery has long been synonymous with lumbar discectomy, according to Jang Yoon, MD, director of minimally invasive spine surgery at the University of California San Francisco — but he doesn’t see it that way.
“I don’t see endoscopic surgery as a specific procedure. I see it as more of a visualization tool,” Dr. Yoon said.
He said that once endoscopy is treated as a platform, it opens the door to cases far beyond decompression, including some that used to require the biggest, most morbid open approaches in the spine surgeon’s toolkit.
From decompression to reconstruction
Dr. Yoon is now performing endoscopic lumbar decompressions paired with interbody fusion, a combination that used to mean an open midline incision with significant muscle stripping to place a cage and screws. He has published techniques for single-level endoscopic TLIF and, more recently, multilevel cases.
“Endoscopic allows the visualization of all those anatomies beautifully while preserving everything that’s superficial to the bones and the nerves,” Dr. Yoon said. The appeal, in his view, isn’t just a smaller incision. It’s doing a genuine reconstruction, not just a decompression, that keeps the visualization advantage intact.
The most striking extension of the technique is in spinal oncology. Patients with metastatic disease that has compressed the spinal cord traditionally need separation surgery: removing tumor from around the cord and reconstructing the spine so it doesn’t collapse. Done open, that often means taking down ribs to reach the thoracic spine, a significant procedure for patients who are already critically ill with stage 4 cancer.
Dr. Yoon has performed these separation surgeries endoscopically. So far, he said, none of his endoscopic oncology patients have developed a postoperative infection, a stark contrast to open separation surgery, where wound complications run from 10% to 20%.
The bigger clinical payoff may be speed to systemic treatment. Metastatic spine patients typically need chemotherapy and radiation for disease elsewhere in the body, but an open spine wound can force weeks of delays to protect against breakdown. In the case Dr. Yoon published, the patient started chemotherapy and radiation four days after surgery.
“When you do it endoscopically, there’s a lot of preservation of the soft tissue … so I can transition these patients quicker to the chemo and radiation,” Dr. Yoon said.Dr. Yoon was direct that endoscopy has limits. It works best, he said, when a problem can be localized to one or two levels and approached without disrupting a lot of surrounding anatomy, particularly in frailer patients who can’t tolerate a bigger operation. Long-segment, multilevel circumferential compression is often better served open, where a surgeon can reach everything more quickly.
“It’s not a fool with a tool,” Dr. Yoon said. “You can’t apply this technology to everything.” He said he weighs the patient’s overall health, the anatomic region involved and whether the pathology is focal or continuous before deciding on an approach.
A learning curve, especially in the thoracic spine
Surgeons typically need 20 to 30 lumbar cases before they’re comfortable moving to cervical work, Dr. Yoon said, with thoracic cases saved for last, given how little room for error exists around the cord. The biggest early hurdles are managing bleeding and triangulating instruments, particularly with biportal techniques that put the camera and surgical tools on separate trajectories.
Surgeons with prior arthroscopic experience, including some orthopedic trainees, tend to pick up the triangulation faster, he said, as do neurosurgeons already familiar with endoscopic transsphenoidal approaches.
Dr. Yoon sees endoscopy as one iteration in a longer evolution of minimally invasive spine surgery, following the tubular retractor systems that emerged in the early 2000s. He expects it to eventually converge with navigation, robotics and AI rather than stand alone as a discrete technique.
“I do think that nationally there’s a way to scale this up, make it reproducible, teachable, sort of widespread, so that people can learn it from coming out of residency,” Dr. Yoon said. He added that UCSF is actively training residents and fellows in the technique.
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