Endoscopic Decompression Versus Fusion for Degenerative Lumbar Spondylolisthesis: A Structured Debate and International Practice Patterns

Abstract

Degenerative lumbar spondylolisthesis (DLS) combines neural compression with a variable mechanical phenotype, creating uncertainty over whether decompression alone is sufficient or fusion is required. Over the last few decades, endoscopic spine surgery (ESS) has opened new avenues for ultra-minimally invasive decompression with minimal bony resection, reducing the risk of iatrogenic destabilization. Against this background, the emergence of ESS has added a new dimension to the debate over surgical decision-making in DLS. This debate-style review compares endoscopic decompression versus fusion for DLS across 7 domains: learning curve and training, technical feasibility and surgical nuances, patient selection and indications, clinical and radiological outcomes, complication profile and management, cost-effectiveness and economic analysis, and reoperation/revision rates. The literature supports endoscopic decompression as a tissue-preserving option for carefully selected patients with stable, low-grade DLS and predominant leg symptoms, whereas fusion remains appropriate when objective instability, mechanical pain, or destabilizing decompression makes reconstruction necessary. Clinical outcomes may be similar in selected stable disease phenotypes, but fusion provides more predictable radiographic correction, with the durability of DLS-specific endoscopic outcomes remaining less certain in the longer term. Additionally, endoscopic decompression and fusion have different risk profiles: the former concentrates concerns around technical execution, incomplete decompression, and delayed conversion to revision or later fusion, while the latter introduces potential approach-, implant-, pseudarthrosis-, and adjacent segment-related complications. An international survey of 63 ESS-experienced spine surgeons supported endoscopic decompression for stable single-level disease (60 of 63, 95.2%) and fusion in case of instability (49 of 63, 77.8%), while intermediate scenarios remained divided. Respondents strongly endorsed long-term multicenter randomized comparisons (62 of 63, 98.4%). Because the panel consisted of ESSexperienced surgeons who predominantly favored decompression-only procedures, its results quantify structured expert opinion rather than treatment preferences in the wider spine community. The aggregate evidence therefore supports equipoise rather than a universal winner. The clinically relevant question is which strategy best matches the patient’s symptom generator, mechanical phenotype, operative risk, local resources, and surgeon expertise.