The Evolution and Global Impact of Uniportal Endoscopic Spine Surgery : A Korean Perspective and Historical Legacy

Uniportal full-endoscopic spine surgery (FESS) has expanded over three decades from percutaneous discectomy to include multilevel decompression, endoscopic interbody fusion (Endo-LIF), spinal infection management, and tumor surgery. The Republic of Korea is a leading contributor to this field: across bibliometric analyses, six of the world's top ten contributing authors and three of the top five contributing institutions are Korean. This article provides a Korea-centered critical appraisal of uniportal FESS, integrating five domains: Korean academic contributions, Level-I evidence by spinal region, expansion of indications, integration of next-generation technologies (navigation, augmented reality, artificial intelligence, robotics), and structural barriers in health policy and reimbursement. Level-I randomized evidence supports clinical equivalence to microscopic surgery for lumbar disc herniation and lumbar spinal stenosis, with cost-utility data from the Korean National Health Insurance Service showing a cost-per-quality-adjusted-life-year of approximately USD 5,241-well below conventional willingness-to-pay thresholds. Cervical FESS evidence remains limited to two single-center RCTs from 2008-2009, and thoracic FESS data derive from non-randomized multicenter case series showing large perioperative advantages over open surgery. Despite the maturity of the evidence, Korean reimbursement codes have not been updated to reflect modern uniportal techniques, Endo-LIF lacks dedicated coding, and the radiofrequency-related fee schedule still uses 1990s-era valuations. We propose a tiered policy roadmap-short-term code differentiation, mid-term Endo-LIF and navigation-track integration, and long-term registry-based credentialing-to align Korean reimbursement infrastructure with the country's established academic and clinical leadership in this field.