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

Endoscopic spine surgery began as a minimally invasive treatment for lumbar disc herniation. Over time, significant advances in optical technology, surgical instruments, and imaging systems have expanded its applications to a wide spectrum of spinal diseases, including stenosis, instability, and deformities across the lumbar, cervical, and thoracic regions.

This review aims to summarize the historical evolution, technical development, and expanding indications of endoscopic spine surgery, focusing on both full endoscopic (uniportal) and biportal approaches.

A narrative literature review.

The authors performed an extensive review of historical and recent literature on endoscopic spine surgery, covering major milestones in technique development, key innovations in instrumentation, and published outcomes of different endoscopic approaches. The review systematically categorizes the evolution of full endoscopic transforaminal and interlaminar procedures, endoscopic lumbar interbody fusion, cervical and thoracic techniques, and the development of biportal endoscopic spine surgery, including its generational progression and safety considerations.

Full endoscopic techniques have progressed from early transforaminal discectomy to interlaminar decompression and lumbar interbody fusion. In cervical and thoracic spine, endoscopic posterior foraminotomy and laminotomy have shown promising results. Biportal endoscopic spine surgery, developed primarily in South Korea, has gained popularity due to its similarity to arthroscopic and microsurgical procedures. It allows clear visualization and handling of conventional instruments while maintaining minimally invasive principles. Biportal techniques have been successfully applied to decompression, interbody fusion, and complex cervical and thoracic conditions. Furthermore, recent innovations such as large working channels, expandable cages, and 3D endoscopy have enhanced surgical precision and expanded indications. Studies indicate that with proper technique and low-pressure saline irrigation, biportal endoscopy is safe, including the use of radiofrequency devices.

Endoscopic spine surgery has evolved into a versatile and effective approach for treating various spinal disorders. Continuous refinement of tools, visualization technologies, and operative methods will further improve outcomes and broaden clinical applications. Understanding this historical development is essential for appreciating current practices and guiding future advances in minimally invasive spine surgery.