Endoscopic Spine Surgery - What, How, Why and Where?

By Dr Leonie Bell

MBChB- Spinal assistant and interventional pain practitioner

Endoscopic Spine Surgery: What, How, Why and Where? — A Primer for Spinal Surgeons

As Endoscopic Spine Surgery continues to gain traction globally, many spine surgeons are seeking clarity on where it fits into their clinical practice. Globally, ESS is no longer viewed as experimental; in many regions, it is now part of standard spinal care pathways. Our goal as SAESS is to assist the integration of endoscopic spine surgery into everyday practice in a safe, step-wise manner that flattens the steep learning curve.

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What Is Endoscopic Spine Surgery?

Endoscopic Spine Surgery is an advanced minimally invasive technique that utilizes a high-definition endoscope, continuous irrigation, and either one (monoportal) or two (unilateral biportal endoscopy) portals to visualise and treat spinal pathologies. The indications for ESS are vast and include degenerative and infective pathologies. The focus of endoscopic spine surgery is still on neural decompression and symptom relief, whilst also keeping in mind a goal of maximal tissue preservation and minimal collateral damage.

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How Is Endoscopic Spine Surgery Performed?

ESS typically involves a transforaminal or interlaminar approach, guided by fluoroscopy or navigation systems, using either one (monoportal) or two (unilateral biportal endoscopy) portals.

Monoportal ESS uses a single working channel that houses both the endoscope and surgical instruments. It offers a compact approach, but requires careful handling within a confined space.

Unilateral Biportal Endoscopy (UBE) utilises two separate portals—one for the endoscope and one for instruments—providing greater freedom of movement and a wider working field, particularly useful for decompressions involving larger areas.

Both techniques use specialised endoscopic instruments including a light source, camera, arthroscope, burrs, punches, osteotomes and radiofrequency probes.

While the technique offers clear advantages in terms of reduced postoperative pain and recovery time, it requires deliberate training. Familiarity with the endoscopic view and tactile nuances are essential for safe and effective outcomes.

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Why Consider Endoscopic Spine Surgery?

The driving reasons to adopt ESS are both patient-centered and practice-focused:

• Less tissue trauma: Muscle-sparing and bone-preserving techniques minimise collateral damage compared to open surgery.

• Reduced postoperative pain: Often eliminating or significantly reducing the need for opioids postoperatively.

• Faster recovery times: Many patients resume normal activities sooner, supporting modern expectations around surgical recovery.

• Cost-efficiency potential: Shorter hospital stays and the possibility of outpatient procedures align with value-based care models.

Ultimately, ESS represents not just a surgical technique, but a shift toward less invasive, patient-friendly spinal care.

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Where can you learn how to perform Endoscopic Spine Surgery?

The South African Endoscopic Spine Society (SAESS) is committed to advancing the field of spinal endoscopy in South Africa. Our goal is to serve orthopaedic surgeons and neurosurgeons practicing or wanting to practice endoscopic spine surgery.

Aligning with international standards, we hope to provide training, online webinars, resources and access to mentors to empower those wishing to learn the techniques as well as refine the techniques of those already practicing.

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For spine surgeons, understanding the strategic role of endoscopic techniques is increasingly important. ESS does not replace other, well established techniques, but rather complements them, offering a patient-centered alternative in appropriate cases.

As adoption grows, SAESS is committed to supporting surgeon education, skill development, and ongoing dialogue around best practices. For those ready to explore ESS for the very first time, browse through out blog posts, join our society, and look out for our step-wise training programs to get you started.

Looking forward to starting this journey with you,

Dr Lee Bell

Treasurer, SAESS