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Beyond visible blood loss: Rethinking perioperative bleeding in endoscopic spine surgery
Stylianos Kapetanakis, Department of 2nd Orthopaedic, Aristotle University of Thessaloniki, Thessaloniki 54635, Kentrikí Makedonía, Greece
Byron Chalidis, Department of First Academic Orthopaedic, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
Author contributions: Kapetanakis S drafted the original manuscript; Chalidis B contributed to study design and review and editing; all authors critically revised the manuscript for important intellectual content and approved the final version.
AI contribution statement: The authors declare that no AI tools were used in the development or writing of this manuscript and take full responsibility for its integrity, accuracy, and originality.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Byron Chalidis, MD, PhD, Assistant Professor, Department of First Academic Orthopaedic, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Exohi, Thessaloniki 57010, Greece. byronchalidis@gmail.com
Received: May 18, 2026
Revised: July 11, 2026
Accepted: July 28, 2026
Published online: August 18, 2026
Processing time: 94 Days and 13.5 Hours
Revised: July 11, 2026
Accepted: July 28, 2026
Published online: August 18, 2026
Processing time: 94 Days and 13.5 Hours
Core Tip
Core Tip: Hidden blood loss (HBL) represents a substantial and often underestimated component of perioperative bleeding in endoscopic spine surgery. As highlighted by recent evidence, irrigation-based techniques may obscure ongoing hemorrhage, which creates a disconnect between visible and physiological blood loss. While HBL is consistently observed across endoscopic procedures, its predictors remain context-dependent and its clinical relevance is not yet fully defined. Rather than relying on visible intraoperative blood loss alone, clinicians should interpret perioperative bleeding within a broader framework that accounts for procedural complexity and patient factors.