Response to the letter to the editor: Interpreting meta-analyses of biportal endoscopic decompression for lumbar spinal stenosis

Article information

Asian Spine J. 2026;20(2):409-410

Publication date (electronic) : 2026 April 29

doi : https://doi.org/10.31616/asj.2026.0074.r2

Alexander Yu¹, Mark Kurapatti¹, Ryan Hoang¹, James Hong¹, Nancy Shrestha², Ryan Stadler³, Peter Campbell¹, Junho Song¹, Joshua Lee¹, Samuel K. Cho^,1

¹Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

²Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA

³Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA

Corresponding author: Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 787 11th Avenue, 7th Floor, New York, NY 10019, USA Tel: +1-212-636-8250, Fax: +1-212-636-3102, E-mail: samuel.cho@mountsinai.org

Received 2026 February 2; Accepted 2026 February 13.

To the Editor,

We thank the correspondents for their insightful comments regarding our article, “Comparison of biportal versus uniportal endoscopic decompression for the treatment of lumbar degenerative disease: a systematic review and meta-analysis.” We appreciate the opportunity to discuss further the methodological nuances distinguishing our respective meta-analyses.

We agree that the distinction between pathologies is crucial for interpreting the current literature. Our primary objective was to evaluate the comparative effectiveness of biportal versus uniportal techniques as general modalities for lumbar decompression. By including both lumbar disc herniation (LDH) and lumbar spinal stenosis (LSS), we aimed to maximize the statistical power of our analysis and provide a comprehensive overview of the techniques’ safety and efficacy profiles across the range of conditions a spine surgeon typically encounters. Our findings, that biportal endoscopy is associated with similar long-term outcomes to uniportal endoscopy, support the viability of the biportal approach for degenerative practice [1].

However, we acknowledge the validity of the correspondents’ argument that the surgical demands of LSS differ significantly from those of LDH (primarily discectomy). It is biologically plausible that the advantages of the biportal technique, specifically the independent viewing portal and wider range of motion, may be more pronounced in cases requiring complex bony decompression (LSS) than in simple discectomies. This likely explains why Lobo et al. [2] observed superior operative efficiency and long-term functional outcomes in their stenosis-specific analysis, whereas our broader analysis found equivalent clinical outcomes.

Importantly, we must highlight a significant difference in the literature synthesized. Our literature search concluded in December 2023, whereas the search by Lobo et al. [2] extended to November 2024. Consequently, their meta-analysis incorporates several studies published in 2024 (e.g., Guo, Han, Hwang, Tang) that were unavailable at the time of our review. The inclusion of these recent high-quality studies strengthens the statistical power of their analysis and provides a more current assessment of the biportal technique’s efficacy for stenosis.

We view the two studies as complementary rather than contradictory. Our analysis confirms that biportal endoscopy is a safe and effective alternative to uniportal endoscopy for lumbar degenerative disease broadly. The work by Lobo et al. [2] refines this by suggesting that, for spinal stenosis specifically, the biportal technique may offer distinct advantages as reported in the most recent literature.

Sincerely,

Alexander Yu and Samuel K. Cho, on behalf of the authors Department of Orthopaedic Surgery Icahn School of Medicine at Mount Sinai New York, NY, USA