A narrative review of endoscopic vs. tube-based decompressive surgery: contrasting indications and clinical outcomes

Introduction

Background

Low back pain (LBP) is a common musculoskeletal condition that affects a large portion of the population. While chronic LBP most frequently affects adults over the age of 60, its prevalence is rising among younger populations (1,2). Globally, LBP is the leading musculoskeletal cause of disability, contributing to a substantial socioeconomic burden (3). In the United States, it is one of the most common reasons for primary care visits and has accounted for the highest healthcare spending among medical conditions since 1996 (4,5).

Common structural etiologies of LBP include lumbar spinal stenosis (LSS) and lumbar disc herniation (LDH) (6). LSS, often seen in the elderly, results from age-related changes such as facet joint hypertrophy, disc degeneration, and ligamentum flavum thickening (7). In contrast, LDH, characterized by focal displacement of disc material beyond the intervertebral disc space, is the most common indication for lumbar spine surgery in working-age adults (8,9).

Conservative management for both conditions typically include activity modification, physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. For patients unresponsive to conservative measures, targeted epidural steroid injections may offer temporary relief, though long-term benefits have not been clearly demonstrated (10,11). For patients with refractory symptoms, surgical decompression often becomes necessary to improve pain, function, and quality of life.

Historically, open laminectomy and discectomy have been the standard surgical treatments, offering an expansive field of view and direct visualization of structures, but with substantial soft tissue disruption (12-14) (Figure 1). These procedures are associated with longer operative times, greater blood loss, higher infection risk, and prolonged recovery (15,16).

Figure 1 Representative sketch of a multilevel open spinal surgery.

Rationale and knowledge gap

Recent adoption of minimally invasive techniques, originally developed for intracranial procedures, marked a crucial shift in the practice of spine surgery (13,15,17). Minimally invasive spine surgery (MISS) has emerged as the preferred approach for LSS and LDH, leveraging smaller incisions, reduced muscle dissection, and improved postoperative recovery (16,18). A 2018 survey revealed that 80% of patients preferred MISS over traditional open surgery, citing reduced pain, cost, and recovery time (19). Specifically, endoscopic decompression (ED) and tubal decompression (TD) are two different MISS techniques that have been widely adopted and shown to have favorable patient outcomes (20-22). Despite the body of existing literature on these MISS techniques, the authors of this review were unable to find any published reviews to broadly compare and contrast them.

Objective

Despite their demonstrated efficacy, both of the aforementioned techniques have their relative advantages and complication profiles, which have received much attention and debate amongst spine surgeons. To the best of the authors knowledge, this is also the first narrative review to broadly compare and contrast these surgical techniques. This review aims to compare ED and TD across multiple domains, including surgical indications, clinical outcomes, complication profiles, technical challenges, and cost-effectiveness, to guide patient selection and institutional decision-making. We present this article in accordance with the Narrative Review reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-66/rc).

Methods

This narrative review focuses on literature published between 2002 and 2025, with the majority of studies being published in the period of 2018–2025 to capture current established and emerging uses of the surgical techniques. Robust studies that focused on the aims laid out above were included in the review, while qualitative studies and other studies with low numbers of participants were excluded. Studies were identified through keyword searches via PubMed, Embase and Google Scholar, as well as through manual searches of reference lists of articles found on database searches. Keywords used in the searches included “minimally invasive spine surgery”, “tube-based”, “endoscopic”, “decompression”, “uniportal”, and “biportal” (Table 1). Studies that were used exclusively in the introduction and background sections may fall outside of the above time period.

Overview of techniques

Tube-based decompression

Tube-based decompression is a well-established MISS technique that utilizes tubular retractors to create a working corridor through a small midline or paramedian incision. These incisions are typically about 1 inch in length, significantly smaller than the ~3-inch incisions used in traditional open single-level decompressions (Figure 2A). For multilevel or offset pathology, retractors can be placed contralaterally (Figure 2B), in tandem, or angled to access multiple levels of the spine (Figure 2C) (22).

Figure 2 Representations of tube-based spinal procedures. (A) A single level paraspinal approach, (B) a contralateral multilevel approach, and (C) a demonstration of how a single insertion site can facilitate multilevel procedures through tube angulation.

After the posterior incision is made, sequential dilation through the paraspinal musculature is performed with progressively larger tubes, culminating in placement of a fixed-diameter working channel, typically 18–22 mm. This corridor provides access to the lamina, ligamentum flavum, facet joints, and disc space while minimizing disruption to surrounding tissues. Visualization is achieved using loupes or a surgical microscope, offering a broad operative field. A hybrid variant, microendoscopy, incorporates a collinear endoscope within the tube, enhancing visualization without the need for continuous irrigation, as required in traditional endoscopic systems (22).

These techniques are primarily performed via posterior or posterolateral approaches, as tubular systems are best suited for short working distances and offer limited anterior access. General anesthesia is required due to the procedural duration, positioning demands, and incision size (22).

ED

ED is a minimally invasive spinal surgery technique that provides neural decompression through small incisions, typically 7–10 mm in length. Several systems are available, including collinear (full-endoscopic), traditional endoscopic (biportal), and multiportal configurations. Collinear systems use a single working channel with a long insertion tube specifically adapted for spinal procedures, allowing for simultaneous visualization and instrumentation (Figure 3A). This technique offers a unique view that may be unfamiliar to surgeons trained in traditional arthroscopy, which often utilize two or more ports for separate camera and instrument access. In the collinear approach, instruments are attached to the camera and move together as the surgeon manipulates the device within the port. In contrast, traditional endoscopic and multiportal systems separate the camera and instruments, a method commonly utilized in other orthopedic procedures, which offers greater flexibility and instrument maneuverability (Figure 3B). This view is analogous to microscopic surgery, with the added advantage of visualizing the operative field through a screen rather than through eyepieces. Given these differences, the collinear (full-endoscopic) technique of ED remains the most specific and tailored method for minimally invasive spinal surgery and is therefore the most widely adopted (23,24).

Figure 3 Representations of the endoscopic spinal surgery platforms. (A) A collinear endoscopic approach, and (B) a traditional endoscopic approach.

Access routes vary based on pathology location and spinal region, with the lumbar and thoracic spine most commonly approached posteriorly. The two primary approaches are interlaminar and transforaminal. In the interlaminar approach, a dilator and working sheath are inserted under fluoroscopic guidance, followed by decompression under continuous irrigation using endoscopic instruments such as burrs and punches (25-27). In the transforaminal approach, the entry point is typically 10–14 cm lateral to midline, allowing access to the posterior annulus and ligamentous structures. After needle placement and guidewire insertion, sequential dilation is performed, and a working sheath is introduced to facilitate decompression under endoscopic visualization (27,28). Anterior approaches are also possible but are more commonly reserved for cervical pathology (26).

Due to the smaller profile of endoscopic instruments, decompression procedures using uniportal endoscopy can often be performed under local anesthesia. In contrast, biportal endoscopic procedures typically require general anesthesia. This difference in anesthetic approach is primarily attributed to the greater complexity and broader surgical scope associated with biportal techniques. Ongoing advancements in optics and instrumentation continue to expand the indications and utility of endoscopic spine surgery (26).

Indications and patient selection

Tube-based decompression

The wide field of view and ability to use traditional microsurgical instruments allows tube-based decompression techniques to be well-suited for a broad range of spinal pathology, including multilevel degenerative stenosis, disc herniations, and even select cases of intradural tumors and recurrent disease. Retractors placed in contralateral configurations enables treatment of multilevel and bilateral pathology through minimal incisions, as each entry site can be used to access 2–3 levels by angling the tube (29,30).

Patients with significant anatomical variation or loss of conventional landmarks (commonly encountered in older adults or revision cases) may be more safely and effectively treated with tube-based systems, which provide a wider operative field and direct anatomical visualization. In such cases, the extent of decompression or need for broader exposure often favors the tube-based approach (30).

ED

Patient selection for ED is primarily driven by lesion location, pathology type, and anatomical constraints. When compared to tube-based decompression, endoscopic technique is ideal for single-level pathology including contained disc herniation, isolated foraminal stenosis, and lateral recess stenosis, particularly in the lumbar spine. In other regions of the spine, anatomic restrictions, such as vasculature in the neck and scapula/rib cage in the thorax, are important to consider when planning interlaminar or transforaminal approaches using endoscopic technique (31,32).

While segmental instability can be managed using both endoscopic and tube-based techniques, the rationale for an endoscopic approach is more limited in this context compared to tube-based or open surgery. Degenerative spinal conditions such as isolated foraminal or lateral recess stenosis, as well as contained disc herniations, are well-suited for endoscopic techniques (31,32). While large bony pathologies have generally been considered contraindications, the use of endoscopic burrs and bone reamers permits the removal of smaller osteophytes and facilitates the expansion of the foraminal space, allowing for an expanded range of applications in recent years (29). Tumors are typically unsuitable for endoscopic approaches due to the need for extensive exposure and reliable hemostasis to achieve adequate surgical margins and thorough debridement. Conversely, spinal infections such as discitis are considered favorable indications, as continuous saline irrigation aids in pathogen clearance while minimizing anesthetic risk (29,33).

Patient-specific factors are also important. Younger patients with preserved anatomical landmarks are often better candidates for ED, as distorted or degenerative anatomy in older patients can complicate endoscopic access (29). Obese patients may particularly benefit from endoscopic techniques, as studies have shown equivalent outcomes and complication rates in obese versus non-obese cohorts (34). Traditional endoscopic systems may be preferred over collinear systems for multilevel disease, due to improved maneuverability and independent instrument access (21,25).

Clinical outcomes

Pain relief & functional outcomes

Individually, both tube-based and endoscopic techniques reliably improve pain and other symptoms of stenosis and disc herniation. Across multiple studies, over 90% of patients report postoperative pain improvement, with many experiencing resolution of radicular symptoms (27,35,36).

In a prospective randomized controlled trial by Ruetten et al. [2008] comparing collinear interlaminar and transforaminal discectomy with conventional microsurgical discectomy, 178 patients were followed and both groups demonstrated significant reductions in leg pain visual analog score (VAS) and improvements in functional status, with no statistically significant difference between techniques (20).

Similarly, Kotheeranurak et al. [2023] conducted a randomized controlled trial of 60 patients comparing collinear ED versus tubular-based decompression. Patients undergoing collinear ED demonstrated greater improvement in VAS leg pain scores during the first postoperative year; however, this difference diminished by 24-month follow-up, with comparable outcomes [VAS and Oswestry Disability Index (ODI)] observed between groups (36).

A systematic review by Komp et al. [2015] evaluating ED found that >70% of patients achieved complete or near-complete leg pain relief, and that collinear ED had similar functional outcomes to microscopic decompression (35).

Interestingly, several studies, including a prospective cohort study by Tang et al. [2018], suggest that ED may result in earlier “pain-free” status after surgery when compared to tube-based techniques, although no differences in leg pain relief were observed at any follow-up interval (28).

Complication rates

MISS techniques have generally been shown to have fewer complications when compared to open surgical techniques. A systematic review by Weiss et al. [2019] analyzed complication rates across multiple MISS studies, including transforaminal lumbar interbody fusion (TLIF), and found that tube-based decompression had higher complication rates than endoscopy, but still significantly fewer complications than open decompression. Total blood loss, risk of cerebrospinal fluid leaks, and length of hospital stay were all decreased when comparing the MISS to open cohorts. In lumbar laminectomies specifically, complication rates improved from 16.1% (open) to 7.9% (MISS overall). Lower rates of infection were also seen in minimally invasive lumbar discectomies when compared to open, though open procedures carried a lower risk of reoperation (37).

In a prospective cohort study by Komp et al. [2015] involving 71 patients, the complication rate for bilateral ED was 5%, compared to 12.5% in the microscopic laminectomy group. Reported complications included dural tears, transient foot dorsiflexion paresis, and delayed wound healing (35).

Endoscopic procedures have unique risks, including fluid-related complications. A case series and international survey by Vargas et al. [2023] documented rare but serious events such as elevated intracranial pressure and hydrocephalus related to irrigation fluid entering the thecal sac during endoscopic surgery (38). Further studies expand on the risk of irrigation-induced epidural hematomas in both collinear and traditional endoscopic approaches. Traditional endoscopic technique offer better control of the irrigation and epidural pressure if there is adequate inflow and outflow through the two ports. The use of infusion pumps during surgery may serve as a risk factor for increased rates of epidural pressure from continuous saline irrigation. A study by Kim et al. found radiographic evidence of epidural hematoma in the immediate postoperative magnetic resonance imaging (MRI) in 23.6% of patients who underwent lumbar decompression via traditional endoscopy. Collinear approaches, however, use an integrated inflow and outflow channel within the endoscopic system controlling the pressure. Given this advantage, the collinear approach limits the incidence of epidural hematomas to as low as 0.4% for patients undergoing LSS (39-41).

Reoperation rates

Minimally invasive decompression techniques demonstrate similar reoperation rates between endoscopic and tube-based approaches and lower rates compared to open surgery. Patient factors continue to play a substantial role, as open techniques remain preferred for complex pathology and decompressions in patients with greater body mass index (BMI), both situations which carry a higher probability of reoperation (42). In a retrospective study of 2,130 patients by Ramanathan et al. [2023], endoscopic and tube-based decompression each had a 14% reoperation rate at 5 years, with longer time to reoperation compared to open techniques, which they attributed to reduced disruption of posterior elements and minimized risk of iatrogenic instability (43).

Paradoxically, younger patients have been shown to experience greater risks of reoperation, regardless of MISS technique. Wang et al. [2023], in a retrospective cohort study of 417 patients undergoing percutaneous endoscopic transforaminal decompression, reported a reoperation rate of 13.7% at 3 years. Risk factors included younger age, longer preoperative symptom duration, and higher preoperative VAS scores (44).

Technical considerations and learning curve

General considerations and learning curve of MISS

With the increasing demand for MISS from both patients and hospital systems, specialized training and surgical familiarity with these new techniques has become paramount. As MISS becomes more widely adopted, surgical trainees are increasingly exposed to these techniques during residency and fellowship, resulting in greater baseline competency and shorter independent learning curves. Nevertheless, surgical experience remains a critical factor influencing operative times, complication rates, and overall outcomes (45).

Tube-based decompression

Tube-based decompression benefits from a shorter and more accessible learning curve, particularly for trainees and attending surgeons with prior experience in open approaches to the lumbar spine. The larger field of view, familiar tactile feedback, and usage of standard microsurgical instruments all reduce the cognitive and technical demands of the transition to MISS (45).

Although the working corridor is more restricted compared to open technique, tandem or contralateral retractors during tube-based decompression may significantly aid the surgeon with visualization and access. Most surgeons can become proficient with fewer cases compared to endoscopic techniques. In a study by Ahn et al. [2016], tube-based decompression was associated with faster early proficiency acquisition, and surgeons reported greater comfort within the first 10–15 cases (45). The relative ease of setup, lack of irrigation systems, and minimal need for specialized navigation tools further lower the barrier to widespread implementation, especially in resource-limited or community hospital settings (46).

ED

Endoscopic spine surgery is technically demanding and is associated with a steeper learning curve compared to tube-based or open techniques. One of the primary challenges is transitioning from direct to indirect visualization, as surgeons must operate using 2D endoscopic imaging rather than line-of-sight views. Additionally, the limited tactile feedback, precise working angles, and need for accurate sheath placement require considerable skill and experience. Data show that despite the challenges in initial training, most surgeons become proficient in the techniques through the course of their training (47). A narrative review by Mayer [2019] and others suggests that case volume thresholds for proficiency vary by approach, with collinear techniques requiring 30–50 cases and traditional endoscopic systems potentially requiring more due to increased instrument independence and fluid management complexity (45).

Despite the longer training curve, outcomes improve significantly with experience. In a study by Ahn et al. [2016], procedural times and complication rates declined significantly after the first 20–30 endoscopic cases, underscoring the value of early experience and mentorship (46). As spine surgeons gain more experience, they are more likely to employ endoscopic techniques in a greater percentage of their operations, including more complex and emerging indications that require the use of burrs, bone reamers, and other advanced endoscopic instruments (29,47).

Cost analysis

General considerations

Cost is a critical factor in the selection of MISS techniques. While both endoscopic and tube-based decompression offer lower complications rates, improved function/pain, and shorter hospital stays, their upfront costs and reimbursement dynamics occupy a dynamic landscape. Facility-specific factors such as capital investment, staff training, and available technology all influence the choice of technique for each patient.

Tube-based decompression

Tube-based decompression provides cost advantages over open surgery, though the magnitude of savings may be more modest compared to endoscopic approaches. Unlike endoscopic techniques, upfront cost for tube-based procedures are generally lower, as they utilize standard surgical instruments and do not require continuous irrigation or navigation platforms.

Additionally, tube-based decompressions are shown to have comparable direct hospital costs, but lower two-year total healthcare costs compared to open decompressions Facilities may experience delayed financial benefits, as direct hospital costs and 2-year direct healthcare costs have not shown significant differences in patients undergoing tube-based versus open approaches. Despite these similarities, tube-based approaches display significantly lower total 2-year costs and higher quality-adjusted life years (QALYs) compared to open surgery. Similar to endoscopic approaches, tube-based procedures display shorter operating room times, minimal blood loss, and shorter hospital stays; however, minimal differences in complications rates have been detected between tube-based and open techniques. While tube-based procedures may display lower initial investment than endoscopic approaches, they are relatively cost-neutral compared to traditional open approaches (48).

ED

ED incurs higher initial cost, requiring specialized instruments, high-resolution endoscopes, and often navigation/robotic adjuncts. However, these investments may be offset by downstream savings related to improved recovery metrics (49).

Choi et al. [2019] conducted a cost-effectiveness analysis comparing endoscopic discectomy to microdiscectomy and found that transforaminal endoscopic lumbar discectomy (TELD) incurred the lowest total cost when compared to microdiscectomy. This cost reduction was largely due to the ability to conduct TELD under local anesthesia, which reduced overall anesthetic and recovery expenses compared to other procedures (50). When comparing collinear and traditional endoscopic approaches, the traditional method presents a lower cost barrier to entry. This is largely because it utilizes equipment that overlaps with open spine surgery and other arthroscopic procedures. Additionally, traditional endoscopy often relies on pre-existing arthroscopic towers for visualization, whereas the collinear approach requires a specialized endoscopic tower, resulting in a higher initial investment. These lower upfront costs make traditional endoscopic systems more cost-effective for implementation in hospitals and outpatient surgery centers (24).

Additionally, McGrath et al. [2019] demonstrated that endoscopic approaches resulted in fewer readmissions, shorter length of stay, and lower overall resource utilization compared to traditional open laminotomy in matched cohorts (48). Similarly, a meta-analysis by Kwon and Park [2023] reported higher QALYs and lower indirect costs with ED due to faster return to work and improved short-term pain relief (51).

Nonetheless, the initial equipment acquisition, ongoing maintenance, and the cost of training staff remain barriers to widespread adoption, especially in smaller or community-based institutions.

Future directions

Technological advancements

Emerging imaging and visualization technologies continue to enhance MISS. Recent advancements in medical imaging, such as co-registration of rapid-scanning MRI and low radiation dosage computed tomography (CT) scans, expedite development of three-dimensional (3D) models for patient-specific pre-operative planning. Compared to conventional fluoroscopy, these technologies can improve surgical precision and potentially reduce intraoperative radiation exposure (52).

Virtual reality (VR) and augmented reality (AR) have been integrated into surgical workflows to assist with navigation and surgical planning, which has shown promising results. VR systems enable immersive preoperative planning, allowing surgeons to manipulate 3D patient anatomy interactively. AR systems, which overlay virtual 3D anatomical models onto live surgical views, can facilitate real-time navigation, enhancing surgical accuracy and reducing the risk of intraoperative complications (51,53).

Camera and endoscopic technology also continue to evolve. The shift from standard-definition to 4K ultra-high-definition imaging significantly enhances visualization, allowing surgeons to discern finer anatomical details such as foraminal ligaments and neural structures. Additionally, 3D stereoscopic endoscopes have been developed, which provide depth perception similar to open surgery or the visualization provided by the Da Vinci Robotic system, although these devices may initially require adjustment and/or an acclimation period due to motion sensitivity or visual disorientation that the surgeon may experience (51).

Emerging techniques

Novel intraoperative navigation systems, such as electromagnetic navigation (EMN), are being integrated into MISS, particularly endoscopic procedures. EMN tracks instrument positioning in real-time without fluoroscopy, significantly reducing radiation exposure and improving surgical efficiency. A randomized controlled trial by Wu et al. [2020] demonstrated substantial reductions in cannula placement times, total radiation dose, and intraoperative pain scores using EMN compared to traditional fluoroscopy-based navigation (54). Robotic platforms are increasingly being integrated into MISS, improving accuracy, stabilization, and inter-surgeon variability when instrumenting, particularly in robot-assisted percutaneous endoscopic lumbar discectomies (r-PELD). A study by Wang et al. [2022] reported improvements in operative blood loss and radiation exposure with robotic-assisted PELD (55), although it has also been shown that the initial investment and training requirements remain substantial barriers to widespread adoption (56).

Implementation

Before broader integration into standard clinical practice, these technologies must undergo rigorous evaluation through large-scale randomized controlled trials that demonstrate clear improvements in patient outcomes, safety, and cost-effectiveness. Currently, MISS addresses less than 20% of applicable spinal pathologies; therefore, successful integration of emerging techniques could significantly expand their clinical indications and enhance overall patient care quality (16).

As these approaches gain traction and are applied to a broader range of pathologies, several key considerations are necessary to ensure optimal outcomes. First, additional high-quality studies are needed to validate the efficacy of these techniques, particularly the traditional endoscopic approach, which remains relatively underutilized. Concurrently, structured training and skill development must be prioritized to ensure that surgeons are proficient in these evolving techniques, though increased adoption will likely drive the development of training programs. Finally, careful patient selection remains essential, with factors such as disease pathology, comorbidities, age, and body habitus guiding the choice of surgical approach.

Conclusions

This review synthesizes current evidence comparing endoscopic and tube-based decompression techniques, highlighting key differences in clinical indications, outcomes, technical demands, and associated costs (Table 2). Endoscopic approaches are particularly advantageous for younger patients with fewer degenerative changes, isolated foraminal or lateral recess stenosis, and contained disc herniations. Collinear endoscopy remains effective for focal pathologies, whereas traditional endoscopic systems offer greater versatility despite their steeper learning curve and slower adoption rate.

Tube-based decompression remains an excellent choice for multilevel pathology, tumor resection, and in patients with significant degenerative changes or anatomical complexity. Although tube-based approaches necessitate slightly larger incisions, they allow for more extensive decompression, direct visualization, and easier integration into existing surgical workflows.

Ultimately, both endoscopic and tube-based decompression provide safe, effective, and durable clinical outcomes. Endoscopy is generally associated with less postoperative pain and faster recovery, but tube-based techniques currently offer broader clinical applicability, shorter learning curves, and wider accessibility. As technological advancements continue, both approaches are expected to expand their roles and further improve patient outcomes in MISS.

Acknowledgments

None.

Footnote

Provanence and Peer Review: This article was commissioned by the Guest Editor (Mitchell S. Fourman) for the series “Advances in Minimally Invasive Spine Surgery” published in AME Surgical Journal. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-66/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-66/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-66/coif). The series “Advances in Minimally Invasive Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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