A 76-year-old patient with L3–4 stenosis was operated on under general anesthesia in the prone position, supported on pads for optimal exposure. An interlaminar endoscopic approach (Maxmore system) was used to treat the stenosis. During the procedure, a dural tear occurred, requiring immediate repair. The technique involved the use of Prolene 6.0 sutures, passed through the dura’s margins with the assistance of delicate instruments, and completed through the endoscopic system without conversion to open surgery. The video demonstration illustrates the step-by-step approach, highlighting the effectiveness of this minimally invasive technique.

In recent years, the advent of endoscopic spinal surgery has brought numerous advancements in minimally invasive techniques, particularly for managing degenerative conditions of the lumbar spine.

We believe that a delicate technique, primarily utilizing high-performance drilling with an interchange of cutting and diamond burrs, combined with continuous saline irrigation to ensure optimal visualization of anatomical structures, is essential for safe decompression. Additionally, meticulous dissection of the ligamentum flavum and dural sac is crucial in preventing unintended dural injuries. Ultimately, prevention through meticulous surgical technique should remain the primary objective in lumbar stenosis surgeries to minimize complications and enhance patient outcomes.

However, with these advancements comes the challenge of dealing with dural tears, a common complication during such procedures. Repairing dural tears via endoscopy remains a relatively new and evolving concept, with various approaches being explored by different authors, each offering distinct solutions to this complex problem.

Müller et al. [1] undertook a comprehensive review of the literature to examine the management of dural tears in endoscopic lumbar spinal surgery. Their findings highlighted that the incidence of dural tears is notably higher in endoscopic procedures compared to traditional open surgeries, especially in cases involving lumbar stenosis. This complication presents a significant challenge, particularly as the limited working space in endoscopy makes primary closure via suturing technically demanding. Müller et al. [1] emphasized that there is no consensus on the ideal technique for endoscopic dural repair, but they noted that the use of autologous muscle or fat grafts in combination with fibrin glue or collagen sponges appears to be a safe and effective method. These materials create a seal over the dural defect, allowing for cerebrospinal fluid (CSF) containment without the need for open conversion [1].

Building on this, Shin et al. [2] introduced a novel solution through their development of a full-endoscopic dural suture repair technique, known as Youn's technique. Unlike traditional approaches, which often require conversion to open surgery to achieve direct repair under microscopic visualization, this method allows for direct suturing of the dura using an endoscopic approach. The authors acknowledged that the need to convert to open surgery can be particularly problematic when patients are under local anesthesia, as is common in many endoscopic procedures. By avoiding this conversion, Youn's technique provides a minimally invasive alternative, offering a promising approach to maintaining the benefits of endoscopy while managing dural tears effectively.

Further expanding on the theme of endoscopic dural repair, Zhao et al. [3] presented the case of a patient with a dural injury and cauda equina herniation during percutaneous endoscopic lumbar discectomy. Their innovative approach involved the use of a double-line suture technique, performed entirely through the endoscope. The procedure successfully prevented CSF leakage and maintained dural integrity, with no complications observed during a one-year follow-up period. This case report underscores the potential for endoscopic techniques to evolve beyond the limitations of nonsuturing methods and demonstrates that, with the right techniques, full repair of dural tears is achievable without abandoning the endoscopic approach [3].

A different approach is highlighted by Pruttikul et al. [4], who addressed the challenges of dural closure following interlaminar endoscopic lumbar surgery. Instead of focusing on suturing, the authors proposed a technique using autologous fat grafts combined with Gelfoam to seal the dural tear. This method proved highly effective, with no reported cases of CSF leakage or wound complications in their series. The simplicity and reliability of this approach make it an attractive option, especially in cases where suturing is not feasible due to anatomical or technical constraints [4].

Finally, Bergamaschi et al. [5] contributed to the evolving landscape of endoscopic dural repair by describing a full-endoscopic transforaminal approach for treating dural injuries. Their report demonstrated that primary dural repair could be successfully performed using an endoscope, offering an alternative to the widely accepted practice of converting to open surgery. This technique not only represents a significant advancement in the management of one of the most common complications in spinal surgery, but it also broadens the possibilities for treating such injuries in a minimally invasive manner. By proving that suturing via endoscopy is feasible, Bergamaschi et al. [5] have paved the way for further innovations in endoscopic spine surgery.

In conclusion, dural tears are a relatively common complication in lumbar spine surgery, but there is still no standardized approach for suturing these tears endoscopically. The concept of endoscopic dural suturing is relatively new, and various authors have proposed different solutions for managing this complex issue. Some favor direct suturing techniques, such as Youn's method and the double-line suture, while others advocate for nonsuturing alternatives like the use of autologous grafts and sealing materials. These varied approaches highlight the ongoing evolution of endoscopic techniques, reflecting both the challenges and opportunities in this field. With advancements in instrumentation and increased training, endoscopic dural repair could become a more viable and effective solution, reducing the need for surgical conversion and improving patient outcomes. However, further research and consensus are needed to optimize the management of dural tears in minimally invasive spine surgery.