Full Endoscopic Fusion

A lumbar interbody fusion removes a worn or unstable disc and replaces it with a cage — a spacer that restores height and holds the two vertebrae until they fuse solidly into one. Traditionally this is done through an open or tubular approach with screws and rods added for support. In a full-endoscopic fusion, the disc is cleared and the cage placed through the endoscope, under continuous saline irrigation and magnified vision, working through very small portals rather than stripping the muscles off the spine. Small percutaneous screws and rods are added through separate stab incisions to hold the segment while it fuses. The goal is exactly the same as any fusion — a solid, stable, well-aligned union — achieved with far less collateral damage.

This appeals to me because it carries the low-demand, low-insult principle into fusion. The nerves can be decompressed endoscopically and the disc prepared and fused through the same tissue-sparing corridors, sparing the paraspinal muscles that a traditional fusion disrupts. It is not the right operation for every fusion — larger deformities, multi-level reconstructions and certain complex revisions still call for open or minimally invasive open techniques — but for the right, lower-demand problem, such as a single unstable or degenerate segment causing nerve compression, it offers a way to achieve stability and fusion with less muscle injury, less blood loss and a quicker recovery. Choosing the right case for it is central to using it well.

I am candid that endoscopic fusion is a demanding, technically advanced operation with a real learning curve — placing a cage accurately and preparing the disc for solid fusion through a keyhole asks a great deal of the surgeon. It is precisely the kind of frontier technique that belongs in a subspecialty endoscopic practice, and it is one I follow and apply carefully rather than universally. As with any fusion, I still treat alignment as central — restoring the height and the natural curve of the segment — and I select patients for whom the tissue-sparing benefits genuinely outweigh the demands of the technique.

The evidence for endoscopic fusion is maturing quickly and is encouraging. Systematic reviews and meta-analyses comparing full-endoscopic interbody fusion with minimally invasive open TLIF find comparable fusion rates and clinical outcomes, with the endoscopic approach showing less blood loss, shorter hospital stays and faster early recovery, at the cost of longer operating time and a steep learning curve. A large network meta-analysis comparing minimally invasive, full-endoscopic and biportal fusion supports this picture of equivalent fusion and outcomes with reduced surgical insult. This is exactly the evidence base I draw on in offering it selectively — good fusion and relief, achieved more gently, in the right hands and the right case.

Because the muscles are largely spared, recovery from a full-endoscopic fusion is often quicker than from a traditional fusion — many people are up and moving soon afterwards and home within a few days. There is still a period of weeks to months during which the bone is knitting and heavy activity is limited, with physiotherapy supporting a graded return. The fused level is now stiff because it is joined, while the rest of the spine continues to move. The spine is followed up over the longer term to confirm the fusion is solid.

• —Relvas-Silva M, et al. Endoscopic lumbar interbody fusion: systematic review and meta-analysis. (PMID 38828975 / PMC11195334)
• —Zhu L, et al. Percutaneous endoscopic versus MIS-TLIF for degenerative lumbar disease: systematic review and meta-analysis. (PMID 34554684)
• —Heo DH, et al. Clinical results and complications of endoscopic lumbar interbody fusion: meta-analysis. (PMID 33065349)
• —Sousa JM, et al. Endoscopic-assisted intraforaminal lumbar interbody fusion versus MI-TLIF: systematic review and meta-analysis. (PMID 35136081 / PMC8825843)
• —Comparative efficacy of minimally invasive, full-endoscopic and biportal TLIF: network meta-analysis. (PMID 41420307)
• —Heo DH, et al. Fully endoscopic lumbar interbody fusion: technical note and preliminary results. (PMID 28760038)
• —Tan R, et al. Learning curve of full-endoscopic posterior lumbar interbody fusion. (PMID 35574552 / PMC9096087)