Endoscopic Versus Microscopic Decompression for Lumbar Spinal Stenosis: A Structured Debate and International Practice Patterns

Endoscopic spine surgery has advanced from a percutaneous niche technique to a mainstream platform for lumbar decompression. This original study examines the relationship between endoscopic and microscopic platforms across 7 contested domains, using an embedded cross-sectional single-round international survey to map patterns of expert agreement and divergence. Seven contested domains-learning curve, technical feasibility, patient selection, clinical and radiological outcomes, complications, cost-effectiveness, and reoperation-were each argued by a Pro-Microscopic and a Pro-Endoscopic advocate before reconciliation, then complemented by a structured single-round international survey of 105 spine surgeons from 5 world regions. The survey was designed to describe practice patterns and map the distribution of expert opinion, not to determine whether endoscopy can replace microscopy. Statements meeting a prespecified conjunctive threshold of at least 70% agreement overall and within each of 3 practice-profile strata were classified as meeting the consensus standard, with the 70% level adopted on the precedent of the CORE (Convergence of Opinion on Recommendations and Evidence) methodology. Seven statements met this standard: reduced approach-related trauma, lower surgical site infection, primacy of surgeon experience over platform, the training burden of endoscopy, standardized outcome reporting, comparable 1- to 2-year outcomes in selected stenosis, and health-system dependence of cost-effectiveness. Endoscopy-favoring distributions were modal in all 7 domains, reaching a majority for complications, outcomes, and patient selection; learning curve and cost-effectiveness remained areas of mixed opinion, and reoperation showed the widest divergence of views. Although 75.2% judged that endoscopy is ready to replace the microscope as the default platform, this fell to 38.5% (95% confidence interval, 13.9%-68.4%) among microscopically oriented surgeons and failed stratification. Endoscopy has demonstrated comparable outcomes for selected pathology and perioperative advantages in specific domains, but not durable long-term superiority. The evidence supports coexistence rather than replacement, with platform selection matched to pathology, patient phenotype, endoscopic platform, and surgeon expertise. The survey illustrates where expert practice patterns align with, diverge from, or run ahead of published comparative evidence.