Targeting the Symptom-Driving Level in Multilevel Lumbar Stenosis Using Unilateral Biportal Endoscopy: A Strategy Reappraisal

Background/Objectives: Multilevel lumbar spinal stenosis (MLSS) is frequently encountered in patients undergoing surgery for lumbar spinal stenosis, yet the optimal extent of decompression remains debated. While multilevel decompression (MLD) may address all radiological stenotic levels, it may also increase surgical invasiveness and operative time. Minimally invasive endoscopic techniques such as unilateral biportal endoscopy (UBE) allow for targeted decompression and facilitate staged surgical strategies. The aim of this study was to evaluate the clinical outcomes of selective single-level decompression (SLD) using UBE in patients presenting with MLSS. Methods: This retrospective monocentric observational study included consecutive adult patients with MLSS who underwent decompression using UBE between December 2022 and July 2025. MLSS was defined as the presence of at least two lumbar levels with Schizas grade B or higher stenosis. Patients undergoing prior lumbar surgery or presenting with non-degenerative pathology were excluded. Patients underwent either SLD targeting the symptom-driving level or MLD, depending on the surgical strategy. Patient-reported outcomes included the Oswestry Disability Index (ODI), lumbar visual analog scale (LVAS), and radicular visual analog scale (RVAS). Results: Among 305 patients operated on for lumbar spinal stenosis, 83 (27%) presented with MLSS and were included in the study. Seventy-four patients (89%) underwent initial SLD and nine (11%) underwent MLD. Among patients treated with SLD, 9 (12%) required a second decompression during follow-up, whereas 65 patients (88%) achieved favorable outcomes without further surgery. Across the entire cohort, ODI, LVAS, and RVAS improved significantly after surgery. Operative time was significantly longer in the MLD group (122 ± 28.1 min vs. 58.1 ± 12.0 min; p < 0.001). These findings support the feasibility of a symptom-driven selective decompression strategy for MLSS using UBE. In our cohort, most patients experienced meaningful functional improvement after SLD without requiring additional surgery. Although a staged approach may necessitate secondary intervention in a minority of patients, selective decompression may help limit surgical extent in carefully selected patients while preserving favorable clinical outcomes. Conclusions: Selective SLD using UBE was associated with significant clinical improvement in most patients with MLSS while reducing operative time and surgical extent. A stepwise strategy targeting the dominant symptomatic level may represent a feasible minimally invasive approach for selected patients with MLSS. Prospective studies are needed to confirm these findings.