Expert Review of Medical Devices

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Endoscopic transforaminal lumbar interbody

fusion: a comprehensive review

Yong Ahn, Myung Soo Youn & Dong Hwa Heo

To cite this article: Yong Ahn, Myung Soo Youn & Dong Hwa Heo (2019): Endoscopic
transforaminal lumbar interbody fusion: a comprehensive review, Expert Review of Medical
Devices, DOI: 10.1080/17434440.2019.1610388

To link to this article: https://doi.org/10.1080/17434440.2019.1610388

Published online: 02 May 2019.

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EXPERT REVIEW OF MEDICAL DEVICES
https://doi.org/10.1080/17434440.2019.1610388

REVIEW

Endoscopic transforaminal lumbar interbody fusion: a comprehensive review

Yong Ahna, Myung Soo Younb and Dong Hwa Heoc
a
Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea; bDepartment of Orthopedic
Surgery, Myungeun Hospital, Busan, South Korea; cDepartment of Neurosurgery, Spine Center, The Leon Wiltse Memorial Hospital, Suwon, South
Korea

ABSTRACT ARTICLE HISTORY

Introduction: Endoscopic spine surgery has been developed as a minimally invasive technique for Received 30 March 2019
decompression in patients with lumbar disc herniation or lumbar stenosis. Recent reports have Accepted 18 April 2019
described the use of endoscopic technology in lumbar fusion surgeries, especially for transforaminal KEYWORDS
lumbar interbody fusion (TLIF). This review aimed to summarize the current techniques of endoscopic Biportal; endoscopic;
TLIF and to discuss the benefits, limitations, and future perspectives of endoscopic lumbar fusion minimally invasive;
surgery. percutaneous;
Areas covered: This review covered the English-language medical literature published in Medline and transforaminal lumbar
focused specifically on endoscopic technologies incorporated into minimally invasive TLIF. The endo- interbody fusion;
scopic TLIF techniques are categorized here according to the properties of the endoscope: percuta- spondylolisthesis; stenosis
neous endoscopic TLIF, biportal endoscopic TLIF, and microendoscopic TLIF. Even though most authors
have reported favorable clinical and radiological outcomes of endoscopic TLIF, such evidence originates
mainly from case series.
Expert opinion: Although the current level of evidence is low and the technical relevance of the
technique is controversial, the key concept and early results of endoscopic TLIF are promising. Technical
advancements to improve safety and reduce technical complexity, as well as comparative cohort
studies and randomized clinical trials with long-term follow-up are required to promote the adoption
of endoscopic TLIF in clinical practice.

1. Introduction fusion rate [21–24]. In MIS-TLIF, the endoscopic approach

helps improve minimalism (i.e., the minimal invasive nature),
As quality of life and longevity have become key aims of
as suggested by very recent reports summarizing clinical
health care, there is an increasing and critical need for the
experience, clinical case series, and cohort studies [25–34].
development of minimally invasive spine surgery (MISS) tech-
However, no resource has provided an up-to-date summary
niques. MISS has many advantages including minimal tissue
of the current state-of-art in endoscopic TLIF, and the level of
damage, reduced incidence of perioperative complications,
evidence supporting the use of endoscopic TLIF remains
early recovery, and higher cost-effectiveness. Among MISS
unclear.
approaches, endoscopic spine surgery has received substantial
The objective of this review was to evaluate the available
attention. Having been originally introduced for the treatment
literature and summarize the current evidence on endoscopic
of lumbar pain and radiculopathy stemming from lumbar disc
TLIF for the treatment of back pain and radicular pain asso-
herniation [1,2], over the past 45 years, percutaneous endo-
ciated with lumbar degenerative diseases.
scopic lumbar discectomy techniques have evolved into effec-
tive strategies for the management of a wide range of
degenerative disc diseases. In particular, transforaminal percu- 2. Methods
taneous endoscopic lumbar discectomy and related techni-
This review consisted of a systematic search of Medline for
ques have been employed for the management of lumbar
articles reporting on endoscopic TLIF. The following free-text
disc herniation and lumbar stenosis [3–8]. The effectiveness
terms were used as search terms: ‘endoscopic transforaminal
of endoscopic spinal surgery techniques has been proven in
lumbar interbody fusion,’ ‘endoscopic,’ ‘arthroscopic,’ ‘transfor-
several randomized trials [9–12] and meta-analyses [13–17].
aminal,’ ‘lumbar,’ ‘interbody fusion,’ and combinations of these
Transforaminal lumbar interbody fusion (TLIF) is considered
with terms describing spine pathology and affected site. The
a standard lumbar fusion technique, providing effective
search was limited to English-language articles describing
decompression of the neural tissue while avoiding neural
studies with human subjects. All abstracts and the full text of
injury [18–20]. Recently developed techniques of minimally
relevant articles were reviewed. Articles describing animal
invasive TLIF (MIS-TLIF) are associated with minimal tissue
studies, reviews, letters, comments, or studies on combined
trauma, satisfactory clinical improvement, and adequate

CONTACT Yong Ahn ns-ay@hanmail.net Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774
beon-gil, Namdong-gu, Incheon 21565, Republic of Korea (South Korea)
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 Y. AHN ET AL.

3.2. Categories of endoscopic TLIF

Article highlights
● Transforaminal lumbar interbody fusion (TLIF) is regarded as
a standard technique for lumbar fusion surgery.
● Due to remarkable advancements in endoscopic technologies, mini-
mally invasive TLIF (MIS-TLIF) techniques can now employ a surgical
endoscope.
● Endoscopic TLIF techniques can be classified according to the proper-
ties of the endoscopic system used: percutaneous endoscopic, bipor-
tal endoscopic, and microendoscopic TLIF.
● Percutaneous endoscopic TLIF uses a working-channel endoscopic
system and represents the most commonly used endoscopic TLIF
technique in clinical practice.
● Biportal endoscopic TLIF uses a biportal endoscopic or arthroscopic
system with a larger surgical field.
● Microendoscopic TLIF uses a microendoscope attached to the tubular
retractor system and is similar to the traditional MIS-TLIF.
● This review of endoscopic TLIF identified only ten studies published
in English to date, of which nine are case series and one is a technical
note, indicating that the level of evidence is low.
● Further development of endoscopic instruments will help improve
the safety of endoscopic TLIF and reduce the learning curve.
surgery were excluded. Studies describing other interbody
fusion techniques such as posterior lumbar interbody fusion
(PLIF), anterior lumbar interbody fusion (ALIF), oblique lumbar
interbody fusion (OLIF), and direct lateral interbody fusion
(DLIF) were also excluded from the review.
The basic concept of endoscopic TLIF is to perform a lumbar
lateral decompression and interbody fusion via the transfor-
aminal approach, using thin tubular devices under endoscopic
visualization. The surgical techniques can be distinguished
into three categories according to the type of endoscopic
system employed (Figure 1).
3.2.1. Percutaneous endoscopic (or full-endoscopic) TLIF
This is the most commonly used endoscopic fusion technique
in clinical practice and is usually characterized by the follow-
ing [35,36]: use of a working-channel endoscope containing
the optical system and the working channel within the same
thin tubular device; complete percutaneous access with a stab
incision; and monoportal approach with constant saline
irrigation.
3.2.2. Biportal endoscopic TLIF
This technique is characterized by the use of an endoscopic
system with separate optical and working channels [30,37].
The basic concept of biportal endoscopic TLIF is similar to
that of arthroscopic joint surgery, wherein two portals are
required: the endoscopic portal and the instrumental portal.
The endoscopic portal is used for continuous irrigation and
viewing of the surgical field, while the instrumental portal is
used for instrument manipulation.

3. Results 3.2.3. Microendoscopic TLIF

3.1. Search results and surgical indications
Ten articles were retrieved using the above-described search
strategy, including nine case series and one technical note.
The characteristics of these studies are summarized in Table 1.
No randomized controlled trial or prospective comparative
cohort study was found.
Common indications for endoscopic TLIF include the following:
(i) lumbar foraminal stenosis with segmental instability, (ii) lumbar
lateral recess stenosis with segmental instability, (iii) lumbar disc
herniation with segmental instability, (iv) grade 1 lumbar degen-
erative/isthmic spondylolisthesis, and (v) postoperative instability
or failed back surgery syndrome. Contraindications to endoscopic
TLIF include the following: (i) severe lumbar central stenosis, high-
grade spondylolisthesis (grade >2), (iii) severe disc space narrow-
ing, and (iv) any condition potentially decreasing the safety and
effectiveness of a spinal implant, such as osteoporosis, vertebral
fracture, infection, or congenital abnormality.
This technique involves using a rigid endoscope (microendo-
scope) attached to a tube system with tissue dilators, which
helps minimize the skin incision and muscle retraction [35,38].
The most commonly used microendoscopic system is the
METRx System. Constant saline irrigation is not used. The
microendoscopic TLIF helps reduce the access trauma by
applying muscle dilation rather than muscle retraction. In
real clinical practice, the term ‘tubular approach’ is used as
a synonym of ‘minimally invasive approach.’
3.3. Surgical technique
3.3.1. Percutaneous endoscopic TLIF
Although certain aspects of the technique differ across
reports, the following represent typical procedures of endo-
scopic TLIF: (i) conventional transforaminal percutaneous
endoscopic approach; (ii) full-endoscopic decompression
using endoscopic burrs and instruments; (iii) insertion of

Table 1. Characteristics of included studies.

No. Study Year of publication No. of patients Study design Surgery type Anesthesia FU (m)
1 Zhou et al. [25] 2008 42 Case series Microendoscopic General 6–24
2 Osman [26] 2012 60 Case series Percutaneous endoscopic General 12
3 Jacquot et al. [27] 2013 57 Case series Percutaneous endoscopic Local 24
4 Lee et al. [28] 2017 18 Case series Percutaneous endoscopic Local 46
5 He et al. [29] 2017 42 Case series Microendoscopic General 27.6
6 Heo et al. [30] 2017 69 Case series Biportal endoscopic General or epidural 13.5
7 Youn et al. [31] 2018 NA Technical note Percutaneous endoscopic Local NA
8 Kim et al. [32] 2018 14 Case series Biportal endoscopic General 2
9 Wu et al. [33] 2018 7 Case series Percutaneous endoscopic General 24
10 Kamson et al. [34] 2019 85 Case series Percutaneous endoscopic Epidural 12
NA = not applicable, FU = follow-up period in months
 EXPERT REVIEW OF MEDICAL DEVICES 3

Figure 1. Categories of endoscopic systems for transforaminal lumbar interbody fusion. (a). Working-channel endoscopic system containing the optical device and
working channel in a single portal. The surgery is performed under constant saline irrigation. (b). Biportal endoscopic system with separate endoscopic and working
channels. The surgery is also performed under constant saline irrigation. (c). Microendoscopic system with the optical device attached to the tubular retractor.
Continuous saline irrigation is not generally used.

a lumbar interbody fusion cage with or without percutaneous
instrumentation (Figure 2). The procedure can be performed
under local, epidural, or general anesthesia. With the patient
placed in prone position on a radiolucent operating table, the
skin entry point is identified at the lateral edge of the para-
vertebral muscle, which typically lays 8–13 cm laterally from
the midline, depending on the patient’s body size. Local anes-
thetics are injected into the paravertebral muscle and facet
joint. The target point of the approach needle is the surface of
the superior articular process (SAP) or facet joint, confirmed in
the lateral fluoroscopic view. As the needle engages the facet
joint firmly, it is replaced by a guidewire over which a tapered
obturator is advanced to the SAP surface or intervertebral
foramen, with care to avoid the exiting nerve root.
Afterwards, a bevel-ended working cannula is introduced
over the obturator placed securely onto the facet joint or
the intervertebral foramen. The guidewire and obturator are
now withdrawn, and a working-channel endoscope is
advanced to the foraminal structures.
The initial endoscopic field provides adequate visualization
of the surface of the SAP and foraminal structures. After
removing the soft tissues using bipolar radiofrequency, the
facet joint including the SAP can be removed using endo-
scopic burrs, punches, and osteotomes. Bone removal should
be continued until the ligamentum flavum is exposed. After
foraminal unroofing, the intraforaminal structures such as the
ligamentum flavum, foraminal ligament, and perineural fat can
be distinguished clearly. The soft ligamentous structures are
removed using endoscopic punches and forceps to expose the
dural sac and exiting nerve root. This step is essential to
achieve complete epidural decompression and make space
for interbody fusion. Further decompression is then performed
on the ventral and dorsal side of the dura.
Discectomy and endplate preparation for interbody fusion
are performed after adequate transforaminal decompression.
Initial discectomy can be performed using endoscopic forceps,
and a specially designed endoscopic reamer is inserted into
the disc space under fluoroscopic and endoscopic control. The

Figure 2. Percutaneous endoscopic (full-endoscopic) transforaminal lumbar interbody fusion. (a). Full-endoscopic decompression with a working-channel endo-
scope. After removal of superior articular process, the dural sac and nerve roots are decompressed. (b). Note the exposed dural sac and ipsilateral nerve root (NR).
(c). Thorough discectomy and endplate preparation are performed under endoscopic visualization. (d). Interbody fusion with bone chips and an interbody fusion
cage is then performed under fluoroscopic and endoscopic visualization. Supplementary percutaneous pedicle screw fixation can be conducted under fluoroscopic
control.
4 Y. AHN ET AL.
reamer is expanded within the disc space and rotated back
and forth in the plane of the disc space, to excise the fibro-
cartilage. Adequate endplate preparation can be ensured
under full-endoscopic guidance. After fusion site preparation,
the anterior disc space is filled with allograft bone chips. The
working cannula is then replaced with a larger working can-
nula that facilitates delivery and placement of the interbody
fusion cage under fluoroscopic and full-endoscopic guidance.
Supplementary percutaneous pedicle screws or facet screws
are then inserted. Upon completing the instrumentation pro-
cedures, direct closure of the skin incision is performed, and
the patient is monitored for complications.
3.3.2. Biportal endoscopic TLIF
These operations are performed under general or epidural
anesthesia. All decompression and interbody fusion procedures
are performed with a biportal endoscopic system (Figure 3). With
the patient placed in prone position on a radiolucent operating
table, waterproof drapes are installed and the portal sites are
established under fluoroscopic guidance. Two ipsilateral skin inci-
sions are made in the paramedian region, at 1 cm above and 1 cm
below the midpoint of the disc space in the lateral fluoroscopic
view, and on the ipsilateral medial border of the pedicle in the
anteroposterior view. In the left-sided approach, the upper hole
acts as the endoscopic portal, and the lower hole is used as the
working portal. After making two small incisions in the skin and
fascia, serial dilators are inserted to create adequate portals. The
lamina is then dissected using a specialized lamina dissector
inserted through the working portal. An endoscopic irrigation
system is used during the procedure, and the irrigation fluid is
drained from the endoscopic portal to the working portal. The
irrigation fluid can be drained naturally, without the aid of
a retractor or tube. If the irrigation flow is poor, a small endoscopic
retractor can be used to improve the flow and ensure adequate
visibility, as well as to reduce the swelling of soft tissues. Additional
bony dissection and bleeding control are performed using
a radiofrequency coagulator. The surgical technique of biportal
endoscopic TLIF is similar to that of MIS-TLIF using a tubular
retractor and a microscope. Ipsilateral hemilaminectomy is per-
formed using endoscopic burrs and Kerrison punches. After ade-
quate ipsilateral decompression, the contralateral sublaminar
Figure 3. Biportal endoscopic transforaminal lumbar interbody fusion. (a). Overview of the Biportal endoscopic surgery. (b). Ipsilateral facetectomy and bilateral
hemilaminectomy can be performed under the biportal endoscope. Note the decompressed dural sac and nerve root (NR). (c). Complete discectomy and endplate
preparation are performed under fluoroscopic and endoscopic visualization. (d). Interbody fusion with bone chips and an interbody fusion cage is then performed
under fluoroscopic and endoscopic visualization. Supplementary percutaneous pedicle screw fixation can be conducted under fluoroscopic control.
portion is decompressed by sublaminar drilling to remove the
ligamentum flavum. Unilateral facetectomy is then performed
using endoscopic burrs and osteotomes to harvest autograft
bone. Complete exposure of the ipsilateral and contralateral
nerve roots is confirmed. After complete dorsal decompression,
the disc is radically removed using pituitary forceps and reamers.
The cartilaginous endplate is completely removed using curettes
under endoscopic visualization. Autologous bone chips from the
lamina and facet are impacted into the disc space, and an inter-
body fusion cage packed with bone chips and fusion material is
inserted under fluoroscopic guidance. Finally, additional percuta-
neous pedicle screws are inserted and a drain catheter is placed to
prevent epidural hematoma.
3.3.3. Microendoscopic TLIF
This type of operation is performed under general anesthesia.
A rigid endoscope placed on the tubular retractor is mainly used
for the decompression and interbody fusion procedures (Figure 4).
Lateral and anteroposterior fluoroscopic images are obtained with
the patient placed in prone position on a radiolucent operating
table. The location of the skin incision is established between the
centers of the upper and lower pedicles, along the lateral pedicular
lines. Therefore, the skin incision is 3.2–3.5 cm long and lies
3.5–4.5 cm laterally to the midline, typically on the side with
worse symptoms. To identify the bony anatomy, a spinal needle
is inserted laterally to the midline at an angle of 10°–15°. To expose
the lateral lamina and lateral facet, a periosteum detacher is
inserted along the needle. A series of dilators ranging from small
to large are inserted through the paraspinal muscle to enlarge the
surgical field. Finally, a suitable tubular retractor or X-tube endo-
scopic retractor is placed over the last dilator. The optimal position
of the retractor can be achieved under fluoroscopic guidance.
A flexible arm is then attached to the retractor to hold it firmly in
place. After removing the soft tissues on the bone surface using
electrical cautery, a 25-degree rigid endoscope is placed using the
locking arm on the ring attachment. The position of the endoscope
is adjusted to identify the anatomical structures under appropriate
visualization. Resection of the facet joint, together with laminect-
omy and removal of the ligamentum flavum are performed to
achieve canal and foraminal decompression. If contralateral
decompression is required, the tubular retractor is tilted to the

Figure 4. Microendoscopic transforaminal lumbar interbody fusion. (a). Endoscopic decompression can be performed with a 25-degree rigid endoscope attached to
the tubular retractor. (b). Hemilaminectomy and facetectomy can be performed using standard surgical instruments, under endoscopic visualization. Radical
discectomy and endplate preparation are performed. (c). Interbody fusion with bone chips and an interbody fusion cage is then conducted under fluoroscopic and
endoscopic visualization. (d). Supplementary percutaneous pedicle screw fixation can be conducted under fluoroscopic control.
medial side, and further removal of the inner layer of the lamina
and ligamentum flavum is performed. After adequate discectomy
and preparation of endplates, the previously resected autologous
bone chips are mixed with allograft bone chips and then packed
into the disc space via a specialized cannula. Finally, an interbody
fusion cage packed with bone chips is inserted into the disc space
under endoscopic monitoring, with care not to injure the nerves.
Supplementary percutaneous pedicle screws are then inserted
under fluoroscopic guidance. After completing the instrumenta-
tion procedures, direct closure of the skin is performed and the
patient is monitored for complications.
3.4. Clinical and radiological outcomes
Previous studies on endoscopic TLIF reported good or excellent
relief of radiculopathy and low-back pain. The most common out-
come measures were the pain score on the visual analog scale
(VAS), the Oswestry Disability Index (ODI) score, and outcome
rating on a four-point scale (excellent, good, fair, poor). The
mean preoperative VAS scores ranged from 5.33 to 8.3 for leg
pain and from 6.17 to 7.85 for back pain, whereas the mean post-
operative VAS scores at the final follow-up ranged from 0.17 to 2.2
for leg pain and from 0.67 to 3.0 for back pain. The mean pre-
operative ODI score ranged from 42.3% to 69.4%, whereas the
postoperative ODI score at the final follow-up ranged from 15% to
34.3%. As a reduction of more than 2 points in the VAS score and
more than 20% in the ODI score are considered as clinically rele-
vant [39,40], the above-listed data demonstrate that endoscopic
TLIF achieves clinically relevant improvement in symptoms.
According to the overall outcome rating on the four-point scale,
excellent or good outcomes were obtained in 76%–95.2% of
patients. The overall rate of complications was 13.2% (range, 0%–
38.6%), which included residual pain, postoperative dysesthesia,
motor weakness, dural tear, hematoma, infection, and hardware
failure. The overall rate of reoperation was 6.09% (range, 0%–
26.32%). Fusion rate varied substantially across studies, ranging
from 53.8% to 100%. We could not find significant differences
among the three endoscopic TLIF techniques regarding clinical
outcomes, fusion rate, or complication rate. The operative data and
clinical outcomes are summarized in Table 2.
EXPERT REVIEW OF MEDICAL DEVICES 5
4. Discussion
4.1. Advantages of endoscopic TLIF
4.1.1. Minimal tissue injury
Regardless of the approach, endoscopic spine surgery is associated
with minimal injury to the connective tissue because it employs
minimally invasive muscle splitting without excessive bone resec-
tion. Therefore, the primary advantages of endoscopic TLIF are
expected to include reduced blood loss, very low risk of deep vein
thrombosis or pulmonary embolism, early recovery, and lower risk
of postoperative fibrotic scar formation. The key advantage of the
transforaminal approach under full-endoscopic visualization is that
it facilitates direct yet safe decompression around the dural sac and
nerve roots.
4.1.2. Local or epidural anesthesia
Endoscopic TLIF procedures can be performed without general
anesthesia. In particular, percutaneous endoscopic TLIF is usually
performed under local anesthesia. Use of conscious sedation
reduces the risks associated with general anesthesia and facilitates
real-time neurological feedback from the patient. Therefore, per-
cutaneous endoscopic TLIF is particularly useful in elderly or medi-
cally compromised patients.
4.1.3. Endplate preparation
From a technical perspective, endplate preparation should be
superior for endoscopic TLIF than for standard open TLIF,
which does not provide direct visualization during endplate
preparation using a reamer or curette. Moreover, the range of
endplate preparation accessible in open TLIF may be insuffi-
cient to facilitate fusion in some patients. Subchondral bone
injury or incomplete endplate preparation may result in cage
subsidence or fusion failure following open TLIF [41,42]. In
contrast, the use of endoscopic visualization during endplate
trimming facilitates visual confirmation of the adequacy of
endplate preparation and a more extensive range of endplate
preparation. Finally, endoscopic visualization helps reduce the
risk of injury to major vessels, which sometimes occurs during
blind endplate preparation procedures [43].
6 Y. AHN ET AL.

Table 2. Summary of outcome data.

No. Study Operative time (min) EBL (mL) Clinical outcomes Fusion (%) Revision (%) Complication (%)
1 Zhou et al. [25] 240 180 VAS back 6.5 to 2.1 100 4.76 11.9
VAS leg 8.3 to 2.1
ODI 56 to 15
E 62.2, G 29.2, F 8.6%
2 Osman [26] 174 57.6 VAS back 7.5 to 2 95.8 3.33 20
VAS leg 7.0 to 1.7
RMDQ 21.2 to 17.5
3 Jacquot et al. [27] 60 NA VAS back 7.76 to 2.45 NA 26.32 38.6
VAS leg 7.22 to 2
ODI 69.4 to 34.3
4 Lee et al. [28] 77 NA VAS back 6.5 to 3 88.9 5.56 11.1
VAS leg 7.8 to 2.2
ODI 69.9 to 22.3
E 41, G 35, F 18, P 6%
5 He et al. [29] 133.9 221.8 VAS 7.2 to 1.5 92.9 2.38 4.76
ODI 42.3 to 28.6
E 76.2, G 19.0, F 4.8%
6 Heo et al. [30] 165.8 85.5 VAS 8.12 to 2.79 NA 0 7.25
ODI 45.65 to 15.41
7 Youn et al. [31] NA NA NA NA NA NA
8 Kim et al. [32] 169 74 VAS 7.4 to 2.7 NA 0 14.29
9 Wu et al. [33] 167.5 70 VAS back 6.17 to 0.67 100 0 0
VAS leg 5.33 to 0.17
ODI 44.83 to 11.17
SF-36 PCS 38.3 to 55.67
SF-36 MCS 43.83 to 57.50
10 Kamson et al. [34] 247 NA VAS leg 7 to 2 NA 3 2.35
VAS back 7 to 2
Satisfied: 92.31%
NA = not applicable, EBL = estimated blood loss, VAS = visual analog scale, ODI = Oswestry Disability Index, E = excellent, G = good, F = fair, P = poor,
RMDQ = Roland-Morris questionnaire, SF-36 = Short Form-36 health survey questionnaire, PCS = Physical Component Summary, MCS = Mental Component
Summary

4.2. Limitations of endoscopic TLIF 4.3. Technical considerations

4.2.1. Limited indications
Despite the benefits mentioned above, endoscopic TLIF remains
a challenging and technically complex procedure with limited
indications and unique complications associated with the trans-
foraminal endoscopic approach [33]. In patients with disc space
narrowing or very narrow Kambin’s triangle, it may be difficult to
achieve sufficient disc preparation for safe cage insertion, result-
ing in non-union, delayed cage subsidence, or migration and
injury to the exiting nerve root. Although severe central stenosis
is often noted in real clinical practice, patients with this condi-
tion may be not indicated for endoscopic TLIF due to consider-
able risk of incomplete decompression.
4.2.2. Long learning curve
Another limitation of endoscopic TLIF lies in the long learning
curve required to ensure that each step of the procedure is safe
and effective: safe transforaminal approach, thorough endoscopic
decompression, and sufficient interbody fusion under the endo-
scopic visual field.
4.2.3. Limited interbody fusion
It may be difficult to achieve sufficient interbody fusion if very
little amount of autograft is available or if a fusion cage of
adequate size cannot be delivered or positioned properly due
to limited working space.
4.2.4. Radiation exposure
Several steps of endoscopic TLIF require fluoroscopic gui-
dance. Excessive radiation exposure may increase the risk of
health problems for the patients and the surgical team.
Some characteristics are common across the three reported
techniques. First, all strategies generally involve a posterolateral
transforaminal approach with either total or partial
facetectomy. Second, visualization is obtained through an endo-
scopic system rather than through an operating microscope.
Third, the decompression procedure is similar to that used in
MIS-TLIF, regardless of the type of endoscope used. However,
endoscopic TLIF and MIS-TLIF differ in terms of some key fea-
tures. First, endoscopic TLIF requires a smaller skin incision with
less muscle dilation, though there is no evidence that this actu-
ally results in less pronounced muscle trauma. Second, endo-
scopic TLIF allows more flexibility in terms of the method of
anesthesia. Unlike MIS-TLIF, endoscopic TLIF can be performed
under local anesthesia or conscious sedation, which is a unique
benefit of endoscopic TLIF. Third, despite these advantages, the
indication of endoscopic TLIF may be limited to degenerative
stenosis with low-grade spondylolisthesis, whereas MIS-TLIF is
more appropriate for deformity correction or reduction of ver-
tebral slippage in high-grade spondylolisthesis. Finally, the opti-
mal instrumentation technique to accomplish solid fusion or
stabilization of the vertebral segment in endoscopic TLIF has
yet to be established.
Several categories of endoscopic TLIF can be distinguished
based on the type of endoscope used: percutaneous endoscopic
TLIF, biportal endoscopic TLIF, and microendoscopic TLIF.
Unfortunately, a direct comparison among these categories can-
not be conducted based on the evidence available to date.
Moreover, the choice of endoscopic system is not standardized
yet, and is generally left to the surgeon’s discretion. Well-designed
studies with long-term follow-up and large sample size are

required to compare the clinical characteristics among the surgery
types.
4.4. The current level of evidence
The current level of evidence regarding the clinical safety and
effectiveness of endoscopic TLIF is very low. Very few studies
have been published on this topic since the late 2000s, and
most published studies are retrospective case series (level 4
studies) or technical notes with a relatively small sample size.
Therefore, at present, there is insufficient clinical evidence to
support the effectiveness of endoscopic TLIF. Furthermore,
although three surgical techniques can be distinguished
based on the type of endoscope used (percutaneous endo-
scopic TLIF with a working-channel endoscope; biportal endo-
scopic TLIF; and microendoscopic TLIF), no studies have
examined the impact of endoscope type or other technical
differences on procedural or clinical outcomes.
5. Conclusion
Endoscopic TLIF is an emerging technique in the field of MISS,
promising benefits in terms of minimal tissue damage and low rate
of complications. However, the current level of evidence is low and
limited to case series and a technical note. Therefore, well-
designed prospective randomized trials are required to confirm
the safety, effectiveness, and clinical relevance of endoscopic TLIF.
6. Expert opinion
Due to substantial technological advancements, endoscopic lum-
bar discectomy and decompression for spinal stenosis have
become accessible in clinical practice. Endoscopic lumbar decom-
pression is no longer a minimally effective procedure. For example,
the effectiveness of transforaminal endoscopic lumbar discectomy
has been proven in many randomized trials and systematic
reviews. After some learning period and once the technique is
mastered, endoscopic decompression may serve as a more effec-
tive and less traumatic surgical option. Given the success of endo-
scopic technologies in spine surgery, it is envisioned that such
approaches may be adapted to provide a practical and minimally
invasive solution in spinal fusion surgery. Compared to open TLIF,
MIS-TLIF has been regarded as the standard minimally invasive
lumbar fusion technique. However, endoscopic TLIF may be even
more minimalistic in terms of invasiveness. From a technical per-
spective, endoscopic TLIF is expected to provide key advantages
such as minimal tissue trauma, low rate of complications, reduced
hospitalization, earlier recovery, and better cost-effectiveness. In
particular, endoscopic TLIF may be useful in elderly or medically
compromised patients who represent the high-risk group for
extensive open surgery under general anesthesia.
Two main limitations of endoscopic TLIF prevent its widespread
adoption in fusion surgery, namely the difficulty to achieve defini-
tive, full-scale decompression and adequate interbody fusion in
the limited endoscopic surgical field. Advancements in surgical
instruments and optics will help overcome such hurdles.
Currently, full-scale decompression can be achieved using specially
designed endoscopic instruments, but the optimal fusion techni-
que under endoscopic visualization has not been fully
EXPERT REVIEW OF MEDICAL DEVICES 7
standardized. The reported endoscopic TLIF techniques differ sub-
stantially across the published case series and technical note.
Moreover, only preliminary or early results are reported, and
there has been no effort to compare or standardize the various
endoscopic TLIF techniques described to date.
Although the current evidence is insufficient and the technical
standard is not established, the key concept and early results of
endoscopic TLIF are promising. The major technical hurdles will
soon be overcome. First, the development of articulating or steer-
able instruments may provide a wider range of decompression in
the limited endoscopic surgical field, facilitating faster, broader,
and safer decompression under endoscopic visualization. Second,
extensive discectomy and thorough endplate preparation can
already be obtained under endoscopic visualization, which may
enhance the fusion rate above that associated with open TLIF or
MIS-TLIF. Finally, standardization of the surgical technique and
implementation of adequate training programs may reduce the
learning curve and increase the relevance of the technique in daily
clinical practice.
Due to the benefits of minimally invasive surgery and relevance
of the technique, endoscopic TLIF may soon be fully adopted in
clinical practice and perhaps even become the standard surgical
technique for lumbar degenerative stenosis and instability. It is
expected that the endoscopic TLIF technique will soon be unified
and standardized. Nevertheless, current evidence on the clinical
effectiveness and safety of endoscopic TLIF comes mostly from
level 4 case series or technical notes. Therefore, well-designed
prospective cohort studies or randomized trials with sufficient
sample size and long-term follow-up are warranted. Such studies
will likely be reported in 5–10 years.
Acknowledgments
The authors would like to thank Jin Ah Kim, Jae Min Son, and Ho Kim for
their support and assistance with this review.
Funding
This paper was not funded.
Declaration of interest
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other
relationships to disclose.
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