A 66-year-old male presented with progressive neurogenic claudication and bilateral lower extremity radiculopathy over the past 12 months. His symptoms were exacerbated by walking and relieved by sitting or leaning forward. He had failed conservative management including physical therapy, epidural steroid injections, and pharmacologic treatment.

Radiographs of his lumbar spine showed disc degeneration in lumbar spine (Figure 1). Preoperative magnetic resonance imaging revealed lumbar spinal stenosis at L3–4 and L4–5, primarily involving the lateral recesses, with associated mild central canal narrowing due to hypertrophy of the ligamentum flavum and facet joints (Figure 2). There was no evidence of spondylolisthesis, instability, or notable scoliosis. The decision was made to proceed with surgical decompression. Written informed consent for publication was obtained from the patient before submission of this case report.

Multilevel decompression was planned due to the severity of stenosis and bilateral symptoms. L3–4 and L4–5 decompression was required, with simultaneous endoscopic surgery by 2 surgeons utilizing a slalom approach: a left-sided interlaminar approach at L3–4 and a right-sided interlaminar approach at L4–5.

The surgical team comprised 2 spine surgeons, both trained in endoscopic techniques, and a scrub nurse specialized in endoscopic spinal interventions. For the procedure, the operating room was equipped with 2 independent endoscopic towers, separate monitors, and duplicated instrument sets (Figures 3 and 4). The patient was positioned prone on a radiolucent Jackson table, allowing for dual C-arm access. General anesthesia was administered without neuromonitoring. Standard uniportal endoscopic tools were used, specifically the Elliquence stenosis instrument set (Elliquence LLC, USA), which is designed for endoscopic spinal decompression. Irrigation was performed exclusively by gravity (free-flow), without the use of pressurized pump systems.

Two 1-cm skin incisions were made: one on the left at the L3–4 level and another on the right at L4–5. Sequential dilation and working channel placement were performed simultaneously.

Using a high-speed burr and Kerrison rongeurs, partial laminotomy and undercutting of the contralateral lamina was achieved at each level. The ligamentum flavum was resected in a piecemeal fashion. The thecal sac and traversing nerve roots were visualized and decompressed bilaterally.

Continuous communication was maintained between surgeons to avoid vibration-induced interference during drilling. Hemostasis was ensured using bipolar cautery under endoscopic visualization. No dural tears or nerve injuries occurred.

The total operative time for the entire intervention was 75 minutes, reflecting the time efficiency of the simultaneous dual-surgeon approach. Intraoperative blood loss was minimal. The patient was able to begin walking independently within 6 hours after surgery and was discharged home the following day, indicating a rapid postoperative recovery.

Pain levels, evaluated using the visual analogue scale (VAS), showed a notable reduction from a preoperative score of 9 to a postoperative score of 2 at the 6-week follow-up. Additionally, axial VAS scores improved from 3 to 1. Functional improvement was also substantial, with the Oswestry Disability Index improving from 62% preoperatively to 16% postoperatively.

No intraoperative complications were observed. However, the immediate postoperative period was complicated by a urinary tract infection, which was successfully treated with oral antibiotic therapy without further sequelae. No neurological deficits were noted during the postoperative course.

This novel approach offers distinct advantages beyond those commonly associated with single-surgeon endoscopic spinal surgery. Crucially, it leads to a substantial reduction in total operative time. Our recorded operative time for 2-level decompression in this inaugural case was 75 minutes. This efficiency is notably superior to other reported endoscopic approaches for multilevel stenosis; for instance, a recent meta-analysis on endoscopic multilevel stenosis reported a mean surgical time of 91.5 minutes [7], which represents an approximate 18% reduction in operative time with our simultaneous technique. Furthermore, published data for single-level endoscopic lumbar decompression typically range from 105 to 144 minutes [8-10], implying that a sequential 2-level decompression performed by a single surgeon would theoretically require approximately 210 to 288 minutes. In comparison to this theoretical sequential approach, our simultaneous dual-surgeon technique achieved a remarkable time saving of approximately 65% to 74%. This significant reduction in operative time is critical in elderly or comorbid patients, minimizing anesthetic exposure and consequently lowering the risk of morbidity associated with prolonged surgical interventions, such as deep vein thrombosis or complications related to prolonged anesthesia. As this represents our first reported experience with this simultaneous dual-surgeon technique, we anticipate further reductions in operative time as proficiency and workflow optimization advance. Furthermore, by leveraging 2 distinct interlaminar entry points—for instance, a left-sided approach for L3–4 and a right-sided approach for L4–5—this method enables highly precise and localized decompression at each level. This meticulous targeting significantly reduces the need for extensive lateral retraction and broad dissection typically seen with single, larger accesses, thereby promoting maximal preservation of muscle and ligamentous structures at each segment and potentially mitigating iatrogenic trauma. Ultimately, the simultaneous approach streamlines the management of 2 distinct pathological levels, eliminating the need for patient repositioning or for intricate changes in a single surgeon's working angle that would be necessary in sequential procedures, thus ensuring a more direct and efficient decompression process.

The successful implementation of this dual-surgeon setup depends on meticulous coordination and a profound understanding of its technical intricacies. These critical considerations, which proved essential to the intervention's success, require a carefully coordinated task allocation. It is vital to prevent both surgeons from undertaking identical or conflicting steps concurrently, especially during the delicate phases like ligamentum flavum resection with Kerrison rongeurs. To mitigate the risk of hand collisions and potential complications, one surgeon might focus on the flavectomy while the other provides hemostasis, maneuvers contralateral instruments, or prepares for the subsequent surgical phase, fostering a complementary and organized progression. Ergonomic setup and precise instrument management are equally paramount. The strategic placement of foot pedals for both radiofrequency and motor systems is crucial to avoid accidental dislodgement or tangling; in our practice, pedals were securely taped and oriented according to each surgeon's dominant foot, ensuring uninterrupted control. Moreover, the meticulous organization and secure routing of motor and radiofrequency cables are indispensable for safe, accessible, and efficient handling by the scrub nurse, whose role in managing equipment flow throughout the case is pivotal. A mirrored layout was employed to guarantee ergonomic access for both surgeons and minimize cross-interference. Continuous mutual awareness and verbal communication are nonnegotiable. Surgeons must remain acutely cognizant of potential traction forces transmitted through the patient’s skin during manipulations, which could inadvertently displace the contralateral working cannula or destabilize the operative field. This ongoing dialogue is fundamental for maintaining optimal positioning, preventing instrument collisions, and ensuring stability. Fluoroscopic guidance is consistently utilized for accurate localization of entry points and trajectory alignment, with both surgeons independently verifying their respective levels. Finally, fluid management within a dual-surgeon framework requires careful attention. The simultaneous decompression at 2 levels inherently involves water inflow from 2 distinct portals. While the uniportal endoscopic system incorporates a dedicated outflow channel, meticulous management is essential. We exclusively employed gravity-fed (free-flow) irrigation, eschewing pressurized pump systems, to mitigate the potential risk of increased intrathecal pressure, especially in the rare event of a dural tear. Surgeons must maintain constant vigilance over fluid outflow and the patient's vital signs.

The incidence of dural tears in full-endoscopic lumbar spinal surgery is a recognized complication, with reported rates generally ranging from 1% to 8.6% in the existing literature, often comparable to or even lower than those observed with traditional open or microscopic approaches [7]. While most dural tears are successfully managed intraoperatively, a dual-surgeon simultaneous approach inherently introduces specific challenges beyond those encountered in a single-surgeon procedure. Enhanced spatial awareness is paramount; the concurrent operation in 2 distinct surgical fields demands heightened attention from both surgeons to avert accidental contact between instruments or inadvertent traction on the dura from the contralateral side. A clear and continuous communication protocol is also indispensable. This encompasses confirming the precise location of instruments, reporting real-time changes in visualization, and coordinating delicate maneuvers, such as precise bone removal near the dura or meticulous ligamentum flavum resection with Kerrison rongeurs, to ensure synchronized and safe action. As previously noted, the presence of 2 active working channels leads to increased water inflow, necessitating rigorous monitoring of fluid balance and intrathecal pressure, especially if a dural tear occurs. Our gravity-fed system is designed to minimize this risk, but immediate identification and management of any leakage are crucial. Furthermore, establishing clear protocols for addressing complications like dural tears or bleeding in one field while the other surgeon remains active is vital for a coordinated response and to prevent problem escalation. Finally, while the synchronized efforts can lead to less vibration from drilling—a potential benefit—the successful and safe execution of this technique fundamentally relies on both surgeons possessing a high level of individual proficiency and extensive experience in endoscopic spinal surgery.

Full-endoscopic spinal interventions have consistently demonstrated both safety and efficacy in the management of lumbar stenosis, enabling bilateral decompression through a single ipsilateral working portal [7-16].

It is generally acknowledged that both uniportal and biportal endoscopic techniques represent effective modalities for lumbar decompression [7-22]. While the learning curve inherent to any endoscopic technique demands dedicated training and practice, discussions regarding the relative steepness of learning curves for uniportal versus biportal approaches often present varied perspectives depending on individual surgical experience and specific training methodologies. Some studies, for instance, suggest that the bimanual freedom and triangulated working space afforded by biportal endoscopy might facilitate an initially more straightforward learning experience for certain trainees. Conversely, uniportal endoscopy, with its direct visualization through the working channel and controlled fluid dynamics, offers distinct advantages in terms of precision and potentially reduced tissue manipulation. However, recent meta-analyses, such as that by Álvarez de Mon-Montoliú et al. [20], indicate that the learning curve for biportal endoscopy is currently more pronounced. This observation, however, may evolve in the coming years as we delve deeper into studying the learning curves of master biportal surgeons, comparing them against the extensively documented and long-established uniportal technique.

Regarding the incidence of dural tears, current literature exhibits mixed findings. Nevertheless, a recent meta-analysis by González-Murillo et al. [7] suggests a higher incidence of dural tears in biportal surgery. This finding, too, could potentially be explained by the younger history and less mature evolutionary trajectory of the biportal procedure. It is plausible that as surgical proficiency improves and the technique becomes more widespread among new generations of surgeons, this particular aspect may also change. Both modalities, when performed by experienced surgeons, have consistently demonstrated low and manageable dural tear rates. Any observed differences may stem from variations in surgical technique, patient selection criteria, or the inherent complexity of the cases being managed. Consequently, robust comparative studies employing rigorous methodologies are still needed to definitively establish such potential distinctions.

This case report offers initial insights from our experience with this novel technique. While the potential benefits are promising, it is crucial to acknowledge the inherent limitations and practical considerations associated with its broader implementation. An obvious constraint is the significantly increased demand for resources. This approach necessitates access to 2 complete endoscopic tower setups, each comprising cameras, light sources, monitors, and duplicated instrument sets. This inherently translates into a higher initial capital expenditure for equipment and potentially greater consumable costs if single-use instruments are utilized for each side. Although time efficiency might partially offset some expenses by reducing overall operating room time, the direct intraoperative cost undeniably surpasses that of a single-surgeon procedure. Moreover, this technique demands an exceptional degree of synergy, mutual trust, and highly effective communication between the 2 surgeons. Poor interpersonal dynamics or a lack of established teamwork could severely compromise both surgical safety and efficiency; consequently, this approach is optimally suited for established surgical teams with a refined collaborative workflow. Coordinating 2 surgeons simultaneously also introduces an additional layer of complexity to the learning curve, requiring advanced spatial awareness, stringent communication protocols, and a shared mental model of the surgical progression, thus rendering it less suitable for less experienced teams or surgeons unfamiliar with complex multilevel endoscopic approaches. Furthermore, seamless communication and coordination with the anesthesia team and the surgical nursing staff are equally essential for the successful and safe execution of the procedure. Even with distinct entry points, the physical space within the operating room around the patient can become considerably crowded with 2 endoscopic towers, C-arms, and 2 surgical teams, underscoring the need for meticulous planning and adjustments in surgical logistics to ensure ergonomic access for both surgeons and nursing staff. Lastly, it is important to note that this approach is particularly well-suited for multilevel central or lateral recess stenosis where separate entry points facilitate simultaneous, independent decompression. However, its applicability may not extend to all multilevel pathologies, such as those necessitating extensive interbody fusion or highly asymmetrical unilateral symptoms that could be adequately addressed by a single surgeon with less resource intensity.