The role of minimally invasive surgery (MIS) in spine surgery is evolving rapidly, driven by potential benefits in postoperative recovery and patient outcomes. Endoscopic spine surgery is increasingly available in Canada, with centers in Calgary, Vancouver, Ottawa, Montreal, Sherbrooke, and Chicoutimi offering this MIS technique. In a publicly funded and often resource-constrained healthcare system, determining whether innovative surgical technologies provide sufficient value to justify their implementation is increasingly important. Yet health economic evidence remains limited. In a recent scoping review of endoscopic spine surgery, health economics studies represented only 0.7% of the published literature. ^{Reference Mulhall, Kow and Veilleux1}

Against this background, Saini et al. ^{Reference Saini, Tieu and Lozano2} examined the lifetime cost-utility of endoscopic microdiscectomy (EM) compared with open microdiscectomy for lumbar disc herniation. In the base-case analysis, EM yielded an incremental gain of 0.042 quality-adjusted life-years (QALYs) at an additional lifetime cost of CAD ＄18 per patient, corresponding to an incremental cost-effectiveness ratio (ICER) of ＄434/QALY. However, EM was cost-effective in only 55.2% of probabilistic simulations at a willingness-to-pay threshold of ＄50,000/QALY, suggesting substantial uncertainty rather than a firm economic advantage. ^{Reference Saini, Tieu and Lozano2}

The lifetime horizon is valuable but requires extrapolation beyond relatively short-term data. Transition probabilities derived from earlier postoperative data may not fully represent recurrent symptoms, delayed recovery, or revision surgery years later. Although these events are incorporated indirectly into the model, ^{Reference Saini, Tieu and Lozano2} long-term observational data show that reoperations continue to accumulate beyond one year. ^{Reference Kim, Chung and Choi3} Prospective Canadian data would help validate these assumptions and their economic consequences.

Implementation costs also warrant consideration. ^{Reference Findlay, Hamrick, Kim, Twitchell and Mahan4} The authors’ volume-based capital-cost scenarios demonstrate progressively higher ICERs at lower procedural volumes, while training and learning-curve costs remain unquantified. ^{Reference Saini, Tieu and Lozano2} Structured training, supervised adoption, and maintenance of proficiency are important considerations. ^{Reference Gadjradj, Schutte, Vreeling, Depauw and Harhangi5} Future evaluations should examine how surgeon experience and procedural volume influence both costs and outcomes.

Potential societal benefits may also be incompletely captured. Excluding productivity losses is consistent with the payer perspective, ^{Reference Saini, Tieu and Lozano2} but complementary societal analyses could examine earlier return to work and caregiver costs. Early improvements in pain and function also contribute to QALYs. As such, annual cycles and constant health-state utilities may incompletely capture differences occurring over the first postoperative weeks. ^{Reference Saini, Tieu and Lozano2} Repeated early utility measurements could better characterize these recovery benefits.

Overall, this study provides a useful framework for evaluating endoscopic spine surgery within a publicly funded Canadian system. Further real-world evidence incorporating implementation costs, longitudinal outcomes, and early patient-reported recovery may better define where endoscopic spine surgery provides the greatest value.