Endoscopic Lumbar Interbody Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Structured Debate and International Practice Patterns
Win Boonsirikamchai, Khanathip Jitpakdee, Don Young Park, Zubair Khalid, Rizwan Akram, Ariel Kaen, Christoph J. Laux, Ahmed Ibrahim, Akarawit Asawasaksakul, John Choi, Avelino Parajón, Asrafi Rizki Gatam, Xavier A. Santander, José M. Spirig, Koichi Sairyo, Alberto Gotfryd, Mazda Farshad, Cheol-Wung Park, Vit Kotheeranurak, Xuexiao Ma, Roger Härtl, Jin-Sung Kim,Lumbar fusion has evolved from open transforaminal lumbar interbody fusion (TLIF) to minimally invasive TLIF (MIS-TLIF), the current minimally invasive benchmark. Endoscopic techniques, proven in discectomy and decompression, have been extended to fusion (uniportal endoscopic TLIF and biportal endoscopic TLIF), offering an alternative to MIS-TLIF. This structured debate-style review critically compares both techniques across 7 domains to clarify their respective roles in lumbar degenerative disease. It combined independent advocacy drafts with an international survey of 106 respondents across 35 countries, capturing procedural preferences and case-based reasoning. Using a prespecified 70% agreement threshold, domains were classified as domains with ≥70% panel agreement, whereas domains falling below this threshold were categorized as domains below the prespecified agreement threshold. This represents structured international survey agreement, not a formal Delphi process. Endoscopic fusion offers advantages in decreased blood loss, soft-tissue preservation, early postoperative back pain, and early recovery, with comparable mid-term clinical outcomes (long-term insufficiently established) to MIS-TLIF, which remains more reproducible and familiar. Complication rates are similar but technique-sensitive for endoscopic fusion. Panel responses favored endoscopic approaches for morbidity-related domains (soft-tissue preservation 89.6%, visualization 81.1%, recovery 74.5%), while fusion stability, short- to mid-term clinical outcomes, complications, and revision remained context-dependent without clear agreement. Endoscopic fusion is a credible option for selected single-level lumbar degenerative disease, offering perioperative advantages with comparable mid-term outcomes to MIS-TLIF; core endpoints, including fusion rate and revision rate, did not reach 70% panel agreement, even among endoscopy-favorable panelists. MIS-TLIF retains reproducibility advantages. The debate has shifted from feasibility to implementation, training standardization, cost-effectiveness, and long-term durability.