A Systematic Review of Complication Management During Uniportal and Biportal Endoscopic Spine Surgery: Dural Tear and Bleeding

Study Design: Systematic Review and Narrative Review. Objective: To evaluate the incidence, risk factors, and management strategies for iatrogenic dural tears and to provide a narrative review of intraoperative bleeding management during uniportal and biportal endoscopic spine surgery (ESS). Methods: A systematic literature search was conducted according to PRISMA guidelines using PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science for studies published between January 1990 and August 2025. Eligible studies included English-language clinical investigations involving degenerative spinal pathology treated with full-endoscopic or unilateral biportal endoscopic (UBE) techniques. Risk of bias was assessed using the ROBINS-E tool. Data on dural tear incidence and management were systematically synthesized, while bleeding control strategies were addressed through a structured narrative review of the technical literature. Results: Nineteen studies including 10 578 patients were analyzed. The incidence of incidental durotomy ranged from 0.54% to 13.2%. Revision surgery was the strongest predictor of dural tears, followed by lumbar spinal stenosis and surgeon learning curve. Management strategies were stratified by defect size and containment: small tears were treated conservatively or with sealants; intermediate defects with patch techniques; and large or uncontained defects with endoscopic suturing or non-penetrating clips. The biportal approach facilitated complex dural repair. Bleeding management emphasized a prevention-first strategy focused on hemodynamic control, hydrostatic tamponade, and targeted use of radiofrequency and topical hemostatic agents. Conclusion: Effective complication management in ESS requires adaptation to the hydrostatic environment. A stratified algorithm allows safe dural repair, while structured bleeding control is essential for maintaining visualization and surgical safety.