Uniportal Versus Biportal Endoscopic Unilateral Laminotomy for Bilateral Decompression in Lumbar Spinal Stenosis: A Structured Debate and International Practice Patterns
Abstract
Lumbar spinal stenosis is a common degenerative disorder that may cause neural compression, neurogenic claudication, radicular pain, and disability, particularly in the elderly; surgical decompression is established when conservative care fails. Endoscopic unilateral laminotomy for bilateral decompression (ULBD) is widely performed by 2 techniques: uniportal (UE-ULBD), 1 incision carrying a single channel for visualization and instrumentation, and biportal (BE-ULBD), separating viewing and working portals across 2 incisions. Superiority remains actively debated. This debate-style article presents advocacy for each technique across 7 contested domains: learning curve and training, technical feasibility, patient selection, clinical and radiological outcomes, complications, cost-effectiveness and reoperation, each prepared independently by the co-first authors. We surveyed 140 endoscopic spine surgeons in 39 countries across 6 continents (July 4–21, 2026), applying an a priori 70% agreement threshold overall, by platform-expertise subgroup and in sensitivity analyses restricted to dual-platform respondents. This was a single-round opinion survey, not a Delphi consensus; the literature component is a nonsystematic expert narrative debate. No clinically meaningful difference between techniques was demonstrated in patient-reported outcomes across validated instruments; a statistically significant 12-month Oswestry Disability Index difference favoring BE-ULBD in one meta-analysis fell below the minimal clinically important difference. Eight ULBD-related items were reported as survey agreement points (one only among respondents with comparative experience), with one additional agreement item concerning a separate foraminal decompression scenario; 9 items remained Points of Persistent Debate. Agreement on training, cost and research priorities held in every exposure stratum, whereas 2 platform-specific items fell below threshold among dual-platform surgeons performing 26 or more annual cases on both platforms. Disagreement persisted over operative efficiency, instrument versatility, decompression adequacy, and long-term economic sustainability; neither technique demonstrated superiority. Preference tracked the respondent’s own platform more than the pathology.
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Authors: Kandarpkumar K. Patel, Catrina Scherrer, Jae‐Joong Kim, Vincent Hagel, Hussam Essam Jabri, Akaworn Mahatthanatrakul, Ian Bustorff Freire, Dimas Rahman Setiawan, Ariel Matias Kaen, Jin Young Lee, Young San Ko, Moritz C. Deml, Ki-Eun Chang, Guang‐Xun Lin, José Miguel Sousa, Kajetan Łątka, Georgios Vastardis, Elsa González Pérez, Asrafi Rizki Gatam, Qingbing Meng, Hyun‐Jin Park, Dhawi A Alotaibi, Richard Assaker, Christoph Paul Hofstetter, Javier Quillo-Olvera
Institutions: University of Washington, Shanghai Jiao Tong University, Catholic University of Korea, Xiamen University, First Affiliated Hospital of Xiamen University, Kyungpook National University, University of Indonesia, Hospital Universitario Virgen del Rocío, University of Sharjah, University Hospital of Bern, Centre Hospitalier Universitaire de Lille, Administração Regional de Saúde de Lisboa e Vale do Tejo, Riyadh Armed Forces Hospital, The Catholic University of Korea Seoul St. Mary's Hospital, Rumah Sakit Umum Pusat Nasional Dr. Cipto Mangunkusumo, King Fahd Medical City, Naresuan University, Harborview Medical Center, Kyungpook National University Hospital, Shanghai First People's Hospital, Fatmawati Hospital, Centro Hospitalar de Lisboa Ocidental, Kantonsspital Baden, Asklepios, Hallym University Kangnam Sacred Heart Hospital, Hôpital Roger Salengro, Hospital Estadual Mário Covas, Naval Medical Center San Diego, IASO General Hospital