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.

The authors' abstract, as published at the source. Neurospine, 2026 · DOI ↗