The Fluoroscopy Paradox: Radiation Exposure, Dose Optimization, and Occupational Risk in Full-Endoscopic and Biportal Spine Surgery—A Narrative Review

Endoscopic spine surgery (ESS)—including full-endoscopic transforaminal and interlaminar techniques, and unilateral biportal endoscopy (UBE)—offers patients smaller incisions, preserved paraspinal muscle, and faster recovery. Because the working corridor is narrow, intraoperative fluoroscopy plays a larger role than in open or microscopic approaches, making radiation exposure worthy of attention for both patients and surgeons. This narrative review aims to be a practical resource for the endoscopic spine surgeon. We synthesize the available literature on typical radiation doses across the main ESS techniques, compare them with minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open alternatives, review the factors that drive exposure, and walk through the full menu of dose-optimization options—from simple measures such as collimation, pulsed fluoroscopy, and leaded eyewear, through navigation platforms, to robotic guidance. A consistent practical observation is that the simplest, least expensive interventions often deliver the largest dose reductions. Capital-intensive technologies add real value, particularly for endoscopic interbody fusion, and work best alongside rather than in place of these basics. With routine dosimetry and straightforward as-low-as-reasonably-achievable (ALARA) practices, surgeons can continue to build on the already favourable profile of ESS while keeping radiation exposure low. Conclusions are tempered by the largely retrospective and heterogeneous nature of the underlying evidence.