Endoscopic spine surgery has rapidly evolved as a minimally invasive technique for treating various spinal pathologies. However, its use in removing epidural metastatic tumors remains insufficiently explored. This video article presents 2 cases utilizing unilateral biportal endoscopic spine surgery for resection of epidural metastatic tumors causing spinal cord compression. The first case involved a 63-year-old woman with metastatic non-small cell lung cancer at T4–5, and the second case an 86-year-old man with prostate cancer metastases at T6–9. Both patients presented with motor weakness (American Spinal Injury Association [ASIA] grade C) and potential spinal instability (SINS [Spinal Instability Neoplastic Scale] score 7). The surgical techniques emphasized precise identification and dissection of the tumor–dura interface to minimize dural injury and bleeding—an essential consideration when managing vascular lesions, particularly under antiplatelet therapy. Both cases achieved complete tumor resection with minimal blood loss (60–90 mL) and operative times of 71 and 109 minutes, respectively. Postoperatively, both patients improved to ASIA grade D and began early radiotherapy, underscoring the advantages of this minimally invasive approach in enabling prompt adjuvant treatment. Endoscopic epidural tumor removal represents a safe and less invasive alternative to open surgery for selected patients, though further long-term evaluation is warranted.

Ultrasonic bone-cutting instruments have gained traction in open and minimally invasive spine surgery because of their selective bone-cutting capability while preserving adjacent soft-tissue structures. However, their use in uniportal endoscopic spine surgery has not been reported in the peer-reviewed literature. This technical note describes a uniportal endoscopic surgical technique that uses an ultrasonic osteotome for uniportal endoscopic lumbar interbody fusion (U-ELIF) and reports preliminary outcomes. Specifically, we describe the technical nuances of ultrasonic osteotome use in U-ELIF and evaluate its feasibility and safety, with an emphasis on minimizing complications.

Objective: This study characterizes the demographic and clinical profiles of patients undergoing unilateral biportal endoscopic spine surgery (UBE ESS) for lumbar decompression/discectomy at a tertiary hospital in Singapore. It examines service implementation across multiple senior surgeons, evaluates preliminary clinical outcomes, and describes the learning curve observed during early adoption among surgeons already experienced in minimally invasive spine surgery, benchmarked against international standards. In the context of increasing global uptake of endoscopic techniques, this work provides evidence to inform institutional adoption and surgeon training. This analysis forms part of a multi-paper series comparing surgeon experience and patient outcomes between conventional minimally invasive approaches and UBE ESS for lumbar decompression/discectomy. Methods: We conducted a retrospective review of 111 patients who underwent UBE lumbar decompression/discectomy at a public tertiary hospital between October 2022 and April 2024. Data on patient demographics, comorbidities, presenting symptoms, operative details, and clinical outcomes, including visual analogue scale (VAS) scores and 36-Item Short Form Health Survey (SF-36) health domains, were analyzed using appropriate statistical methods. Results: The mean patient age was 56.8 years, with a slight female predominance (54.1%). Statistically significant improvements were observed in VAS scores for both back and leg pain (p<0.05), alongside significant gains in SF-36 domains including physical functioning, bodily pain, vitality, and social functioning. Operative times decreased progressively with increasing case volume, consistent with the presence of a procedural learning curve. Conclusion UBE ESS for lumbar decompression/discectomy is a safe and efficacious technique that can be successfully adopted by spinal surgeons with prior minimally invasive surgical experience. Operative time demonstrates a meaningful reduction once the initial learning curve has been overcome. ESS provides a reproducible option for the treatment of degenerative lumbar spine disease in the tertiary hospital setting in Singapore, with outcomes comparable to established international benchmarks. Future work will include long-term follow-up of this patient cohort and direct comparison with conventional minimally invasive techniques in subsequent studies.

Robotic-assisted pedicle screw placement and full-endoscopic transforaminal lumbar interbody fusion (FE-TLIF) are established minimally invasive spine techniques. Their integration has the potential to combine navigation accuracy with the muscle-preserving advantages of uniportal endoscopy. This technical note describes a hybrid approach using the Mazor X Stealth edition robotic system to enhance workflow, safety, and efficiency during FE-TLIF. A 74-year-old patient with metabolic syndrome presented with severe back and radicular leg pain that was refractory to conservative treatment. Magnetic resonance imaging demonstrated bilateral lateral recess stenosis, disc height loss, and facet arthropathy at L4–5, with dynamic instability observed on flexion-extension radiographs. Preoperative computed tomography imaging was uploaded to the robotic system for trajectory planning. Following registration, the robotic arm guided percutaneous pedicle screw placement via Wiltse incisions. Uniportal endoscopic access enabled hemilaminotomy, facetectomy, discectomy, endplate preparation, and insertion of an expandable L4–5 interbody cage under direct visualization. Robotic guidance facilitated precise screw trajectory placement without repeated fluoroscopic localization, reduced intraoperative radiation exposure, and avoided muscle disruption associated with open approaches. Endoscopic visualization enabled controlled facet resection and preservation of neural elements during cage placement. Postoperative radiographs confirmed appropriate implant positioning. The combined workflow improved surgical ergonomics and minimized tissue trauma while maintaining fusion stability. Robotic-assisted FE-TLIF represents a safe and feasible hybrid minimally invasive surgery technique that enhances pedicle screw accuracy and complements endoscopic fusion. Despite a steep learning curve, this approach may reduce perioperative morbidity, improve procedural efficiency, and enhance postoperative recovery. Further comparative studies are required to evaluate long-term clinical and radiographic outcomes.

Objective: Degenerative lumbar spine disease affects millions worldwide, substantially diminishing quality of life. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has emerged as a preferred alternative to open TLIF, offering reduced morbidity and improved cosmetic and functional outcomes. This study investigated the long-term outcomes of MIS-TLIF in patients with lumbar degenerative disease. Methods: We conducted a retrospective analysis of 180 patients who underwent MIS-TLIF between 2009 and 2014. Inclusion criteria comprised persistent back and leg pain unresponsive to conservative management, single- or double-level lumbar stenosis or spondylolisthesis, and at least 5-year follow-up. Patients with prior spinal instrumentation, trauma, or multilevel disease were excluded. All procedures were performed using tubular retractors and a microscope, with pedicle screws inserted over guidewires. Parameters assessed included estimated blood loss, operative time, hospital stay, complications, and revisions. Functional outcomes were evaluated using the visual analogue scale (VAS) and Oswestry Disability Index (ODI). Long-term complications and fusion rates were also analysed. Results: MIS-TLIF resulted in significant improvement in VAS and ODI scores at final follow-up (p<0.05). The overall complication rate was 5%, and the incidence of adjacent segment disease was 8.8%, both comparable to or better than rates reported in the literature. The technique preserved pelvic incidence and lumbar lordosis while reducing tissue injury, blood loss, and length of hospitalisation compared to open TLIF. Conclusion MIS-TLIF is a safe and effective technique for lumbar degenerative disease, offering superior long-term functional outcomes, lower complication rates, and expedited recovery in well-selected patients.

Chiari malformation, when accompanied by progressive neurological symptoms or syringomyelia, often necessitates surgical decompression. Although endoscopic spinal surgery continues to advance, its application in foramen magnum decompression remains limited. This video article demonstrates the biportal endoscopic foramen magnum decompression technique for Chiari type I malformation. We present the case of a 19-year-old female patient with progressive headache, motor weakness, and radiological evidence of 7-mm tonsillar descent with C2–7 syringomyelia. She successfully underwent biportal endoscopic foramen magnum decompression with C1 laminectomy. The procedure employed a triportal approach with safe docking on the C2 spinous process, allowing a minimally invasive C1 laminectomy and foramen magnum decompression extended to the suboccipital area. Postoperatively, computed tomography confirmed adequate decompression, and magnetic resonance imaging revealed expansion of the posterior fossa with resolution of tonsillar herniation. The patient experienced no complications or symptom recurrence at the 3-month follow-up. Despite a minor intraoperative–postoperative measurement discrepancy, which highlights the anatomical considerations required to achieve sufficient decompression, this video supports the feasibility of biportal endoscopic surgery. This approach may provide comparable clinical outcomes to conventional open surgery while offering minimally invasive advantages, though long-term follow-up remains essential.

Thoracolumbar junction pathologies can be treated through various anterior and posterior approaches. In recent decades, minimally invasive endoscopic procedures, including percutaneous endoscopic transforaminal discectomy (PETD), have emerged to reduce tissue disruption and iatrogenic instability. This surgical video describes the steps required to perform PETD and highlights the importance of optimal preoperative planning. A 47-year-old male patient with a T12–L1 disc herniation in the left paracentral and foraminal region, compressing the spinal cord, was treated with PETD. Under fluoroscopic guidance, precise skin markings were made, followed by sequential placement of the needle, guidewire, dilator, and working cannula using an inside-outside technique. The advantages and limitations of this approach were described. Successful removal of the herniated fragment and associated osteophyte was achieved using PETD. The patient’s pain decreased abruptly after surgery and fully resolved in the medium term. The patient ambulated independently 1 month after the procedure. PETD is a safe and efficient alternative for treating thoracolumbar junction pathologies in patients with disc herniation and/or myelopathy caused by neural compression. This fully endoscopic technique can achieve ventral decompression even under sedation.

Uniportal full-endoscopic posterior cervical foraminotomy and discectomy (PECF/D) has emerged as a promising minimally invasive technique for treating cervical radiculopathy caused by soft foraminal disc herniations. We report the case of a 42-year-old woman who presented with persistent neck and right arm pain unresponsive to conservative treatment. Neurological examination revealed weakness in wrist extension and hypoesthesia in the C6 dermatome. Magnetic resonance imaging demonstrated a right-sided C5–6 soft disc herniation compressing the C6 nerve root. Given the absence of bony stenosis and the foraminal location of the herniation, PECF/D was selected to achieve neural decompression while preserving cervical motion. The procedure was performed under general anesthesia with the patient in the prone position. A 1-cm incision was made, and a working cannula was introduced via a uniportal approach. Under continuous endoscopic visualization, a keyhole foraminotomy was performed with partial undercutting of the facet joint, and the herniated disc material was removed with minimal manipulation of the nerve root. The total operative time was 45 minutes, and no intraoperative complications occurred. The patient experienced immediate postoperative relief of radicular symptoms and was discharged the following day without neurological deficits. This case demonstrates the technical feasibility, safety, and efficacy of uniportal PECF/D in appropriately selected patients. The technique provides targeted decompression with minimal tissue disruption, avoids fusion, and preserves segmental motion, potentially reducing the risk of adjacent segment disease. As endoscopic spine surgery continues to advance, PECF/D represents a valuable alternative to anterior cervical approaches for soft, foraminal disc herniations.

Objective: Revision surgery for recurrent cervical radiculopathy or myelopathy after posterior decompression is technically challenging because of epidural adhesions, altered anatomy, and the risk of postoperative instability. Although anterior cervical discectomy and fusion is commonly performed, it sacrifices segmental motion and is associated with fusion-related morbidity. This technical report describes the surgical technique and early clinical outcomes of unilateral biportal endoscopic (UBE) posterior cervical revision as a motion-preserving alternative. Methods: Five patients underwent UBE-assisted posterior cervical revision surgery for recurrent cervical disc herniation, foraminal stenosis, or central canal stenosis. Procedures included inclinatory foraminotomy or unilateral laminotomy with bilateral decompression, depending on pathology. Clinical outcomes were evaluated using visual analogue scale (VAS) scores for neck and arm pain, motor strength assessment, radiographic evaluation, and modified MacNab criteria. All patients were followed for at least 1 year. Results: All procedures were completed without conversion to open surgery or the need for fusion. Adequate neural decompression was achieved in all cases, with preservation of facet joint integrity and cervical alignment. Neck pain VAS scores improved from 4–8 preoperatively to 0–1 at 1 year postoperatively, while arm pain VAS scores improved from 7–9 to 0–2. Motor weakness improved in all patients who presented with preoperative deficits. No intraoperative or postoperative complications were observed during the follow-up period. Conclusion UBE-assisted posterior cervical revision surgery appears to be a feasible and effective minimally invasive option for selected patients. This technique allows sufficient decompression while preserving cervical motion and avoiding fusion-related morbidity.