The Rape of the Spine: Endoscopic Innovation and the Imperative of Restraint

INTRODUCTION

In 1993, James T. Robertson published a provocative editorial titled “The Rape of the Spine,” warning the neurosurgical community about the overuse of spinal fusion driven by financial incentives rather than sound clinical judgment [1]. Twenty-two years later, Richard J. Nelson revisited the same title, lamenting that little had changed [2]. Now, as endoscopic spine surgery enters its era of rapid expansion, I find myself compelled to ask: are we destined to repeat history? Rajaee et al. [3] documented a 137% increase in spinal fusion procedures from 1998 to 2008, far outpacing increases in laminectomy and hip replacement.

THE RISE OF ENDOSCOPIC SPINE SURGERY

Endoscopic spine surgery has emerged as one of the most significant innovations in minimally invasive spine surgery. What was once considered a niche technique in the 1990s has now become a dominant force. A PubMed search for “endoscopic lumbar interbody fusion” yields 537 papers in 2024, a nearly 4-fold increase from 148 papers in 2019. South Korea leads global research output with an h-index of 23, followed by the United States, Germany, and China. Several pioneering studies have demonstrated the technical feasibility of biportal endoscopic techniques for both decompression and fusion [4,5].

The benefits are undeniable: reduced muscle damage, shorter hospital stays, faster recovery, and excellent visualization. For decompression surgery, endoscopic techniques have proven their worth. I believe endoscopic spine surgery represents the best of minimally invasive surgery at this moment.

THE PRESERVATION PARADIGM: DEGENERATIVE SPONDYLOLISTHESIS AS A CASE STUDY

Perhaps nowhere is the tension between innovation and restraint more evident than in the management of degenerative spondylolisthesis (DS). For decades, the landmark study by Herkowitz and Kurz [6] established fusion as the standard of care, demonstrating superior outcomes compared to decompression alone. However, recent high-level evidence has challenged this paradigm [7-10].

The NORDSTEN-DS trial, a multicenter randomized controlled trial comparing decompression alone versus decompression with fusion in patients with grade 1 DS, found no significant difference in clinical outcomes at 2 years [8]. Long-term follow-up confirmed these findings, with no advantage for fusion at 5 years [9]. Similarly, Ghogawala et al. [10] demonstrated that while fusion provided modest short-term benefits, these advantages diminished over time.

More recently, Bayram and Karataş [11] reported outcomes of endoscopic decompression for DS, demonstrating that slip percentage remained essentially unchanged (13.4% to 13.8%) while achieving 90.6% excellent or good clinical outcomes. These findings suggest that for patients with stable, grade 1 DS—what I term the “borderline stability zone”—decompression alone may be sufficient.

A critical counterpoint must be acknowledged. Even meticulous decompression carries biomechanical risks: resection of the ligamentum flavum, facet joint capsule, and portions of the facet complex can compromise the posterior tension band, which is essential for segmental stability. In patients with borderline biomechanical competence, this may unmask latent instability, potentially leading to progressive slip, recurrent stenosis, or delayed fusion [7]. This concern emphasizes the need for meticulous technique that preserves the posterior tension band as much as possible—a goal for which endoscopic approaches are particularly well suited when performed judiciously.

THE HIDDEN THREAT OF INDICATION CREEP

Yet beneath this success lies a concerning trend. As endoscopic techniques expand from decompression to fusion, I observe a troubling pattern—one that echoes Robertson’s warnings from 3 decades ago. The allure of “minimally invasive fusion” has led some surgeons to push indications beyond what evidence supports [12].

I recently encountered a patient who underwent endoscopic transforaminal lumbar interbody fusion (TLIF) at another institution. The back muscles were pristine. The spinal canal was well decompressed. But the intervertebral disc space told a different story: fusion failure. Twenty months of severe mechanical pain. Countless sessions of alternative treatments. Eventually, revision surgery with oblique lateral interbody fusion was required.

Emerging evidence corroborates these concerns. Although meta-analyses report overall complication rates of approximately 4.9% for endoscopic TLIF—statistically comparable to minimally invasive TLIF—these figures derive predominantly from expert-center case series with substantial selection bias [13]. More concerning is the variability in cage subsidence rates, which range from 0% to 60% depending on technique, cage type, and surgeon experience. Kim et al. [14] demonstrated that uniportal endoscopic TLIF during the early learning phase produced 60% cage subsidence at 1 year, compared to 15.8%–26.3% for biportal approaches. A recent propensity-matched analysis of 47,446 patients found endoscopic fusion associated with 13.5% pseudarthrosis at 1 year versus 6.4% for open fusion—a finding that, while subject to coding-related caveats, cannot be ignored [15]. These data suggest that the complication profile of endoscopic lumbar interbody fusion may be substantially underestimated outside specialized centers, and that the learning curve poses a genuine obstacle to reproducible outcomes.

THE TRUE PROBLEM: DECISION-MAKING, NOT THE TOOL

Let me be clear: the problem is not fusion itself. Fusion is a powerful and necessary tool. When properly indicated, it restores stability, relieves pain, and improves quality of life. The problem lies in our decision-making process. It is the abandonment of proper clinical judgment. It is choosing procedures based on reimbursement rather than indication. As Gawande described, this represents an “avalanche of unnecessary medical care” harming patients physically and financially [16].

We entered this field to help patients. We adopted endoscopy to minimize surgical trauma. These intentions are noble. But noble intentions, unchecked by evidence and unchallenged by honest self-reflection, can lead us astray.

AN HONEST CONFESSION

I must be honest with my colleagues. Every spine surgeon faces an internal conflict between what we know is right and what is financially or technically tempting. Those who claim otherwise are either exceptionally fortunate or not paying close attention to their own decision-making processes.

Which is my true mindset when treating the spine and my patients? This is what I constantly grapple with—for my patients and their lifelong well-being. I see both sides in myself: the surgeon who wants to innovate, to heal, to advance the field; and the one who feels the pull to expand indications, to follow trends,to prioritize volume over value.

I do not write this editorial as someone who has conquered these temptations. I write as someone still navigating them daily.

QUESTIONS WE MUST ASK

In 2015, Moojen and Peul [17] published an editorial in the British Medical Journal assessing minimally invasive surgery for lumbar spinal stenosis. They concluded it was “as good as open laminectomy, but no better.” They posed uncomfortable questions: Is our hunger for new techniques based on little more than a gut feeling that new and smaller is always better? If so, is it ethically justifiable to test these new techniques on patients?

Endoscopic spine surgery is a tool within minimally invasive surgery. It cannot be a panacea for every patient. The complete spine surgeon should be proficient in multiple approaches— microscopic surgery, tubular techniques, endoscopy, lateral interbody fusion, and open procedures. The patient’s pathology should dictate our approach, not our technological preferences or financial incentives.

When evaluating any new technique, including endoscopic fusion, we must ask 3 fundamental questions:

“Can we do it?” — Is it technically feasible?

“Should we do it?” — Does the patient truly need it?

“Will it last?” — Is there evidence to support long-term outcomes?

Only when all three answers are affirmative should we proceed.

THE PATH FORWARD

Despite these concerns, I remain hopeful. Technological advancements— expandable cages, 3-dimensional printed implants, biological materials, and navigation systems—continue to address the current limitations of endoscopic fusion. More importantly, the next generation of spine surgeons has the opportunity to generate the high-level evidence we currently lack.

It is time for prospective, randomized studies comparing endoscopic fusion with established techniques. It is time for honest reporting of complications and failures. It is time for our specialty to hold itself accountable.

I share my struggles openly today—not because I have all the answers, but because I believe transparency is the first step toward progress. My hope is that the next generation will learn from both our achievements and our mistakes, and ultimately surpass us. That is the true measure of our legacy as surgeons and educators.

CONCLUSION

Thirty-three years after Robertson first warned us about the rape of the spine, we stand at another crossroads. Endoscopic spine surgery offers tremendous potential, but only if we resist the temptation to abandon sound clinical judgment for financial gain or technological enthusiasm.

Fusion is not the enemy. Poor decision-making is. Greed is. The absence of evidence is.

The “Rape of the Spine” in 2026 will not be committed by open surgeons, but by those of us in the endoscopic community who fail to recognize when restraint is the wiser choice. This is not an indictment of a technique, but a call for collective selfreflection.

May we have the wisdom to know the difference—and the courage to act accordingly.