Retinal hemorrhage and transient consciousness disturbance after biportal endoscopic lumbar discectomy: A case report and literature review

Managing water dynamics for optimal outcomes in unilateral biportal endoscopic surgery: preliminary results in a new operative channel

BACKGROUND

In recent years, unilateral biportal endoscopic (UBE) surgery has become one of the most popular minimally invasive spine surgeries. Unlike traditional open surgery, UBE surgery is performed in isotonic saline solution. Therefore, comprehending the water dynamics involved in UBE surgery is crucial.

METHODS

This prospective study involved 29 patients with single-level lumbar instability or degenerative disk disease who underwent UBE surgery between April 2021 and March 2022. Water flow pressure was measured using a disposable pressure transducer. Multifidus muscle MRI images were analyzed by ImageJ software at intervertebral disc levels. Perioperative blood loss was estimated by the Gross formula. The obtained data were then analyzed with independent t tests, chi-squared tests, and Pearson's correlation.

RESULTS

Height and weight were risk factors for increased water flow pressure during UBE surgery (r = 0.424, P = 0.022, r = 0.384, P = 0.040). The phenomenon of low water flow pressure led to escalations in perioperative total blood loss, hematocrit loss and hemoglobin loss (r = -0.369, P = 0.049, r = -0.424, P = 0.022, r = -0.405, P = 0.029). An excessive water flow pressure can worsen postoperative multifidus swelling and elevate the patient's leg pain visual analogue scale (VAS) score at 1 week (r = 0.442, P = 0.016, r = 0.394, P = 0.034).

REGISTRATION

Trial registration Chinese Clinical Trial Registry, registration number ChiCTR2300078497, date of registration: 11/12/2023.

CONCLUSION

Both low and high water flow pressures can have deleterious effects. The water flow pressure should be controlled within a reasonable range during UBE surgery.

Unilateral biportal endoscopic discectomy for lumbar disc herniation: Learning curve analysis with CUSUM analysis and clinical outcomes

BACKGROUND

The evolution of spinal surgery has significantly benefited from advances in medical technology. From the introduction of the microscope to spinal surgery by Gazi Yaşargil in 1967 to Kambin's fully endoscopic series in the late 20th century, minimally invasive techniques have continually evolved. One of the latest developments, Unilateral Biportal Endoscopy (UBE), has gained popularity due to its effectiveness and the use of standard arthroscopic instruments, facilitating anatomical orientation for surgeons familiar with microsurgery. Despite its advantages, UBE presents challenges during the learning phase, necessitating a thorough understanding of its learning curve. This study aims to evaluate the learning curve of unilateral biportal endoscopic (UBE) discectomy for the treatment of lumbar disc herniation using CUSUM and risk-adjusted CUSUM (RA-CUSUM) analyses and to share the challenges encountered in the learning process and clinical outcomes.

METHOD

This retrospective study is based on data from patients treated between March 2022 and March 2023. The study included patients with lumbar disc herniation treated via UBE, excluding those with other spinal conditions or previous endoscopic fusions. Data collected included demographics, surgical details, and clinical outcomes, such as VAS, ODI scores, complication rate, recurrence rate, and MacNab criteria.

RESULTS

117 patients (126 levels) were included, with a mean age of 46.02 years and a male predominance (62 %). The mean operation time was 77.93 minutes, with significant postoperative improvements in VAS and ODI scores. The overall complication rate was 10.3 %, with a recurrence rate of 5.1 %. CUSUM analysis indicated that the learning curve for UBE was completed after 43 cases, while RA-CUSUM suggested proficiency after 23 cases.

CONCLUSION

UBE discectomy is an effective minimally invasive technique with a learning curve. Using CUSUM and RA-CUSUM analyses, our study provides insights into the learning process and highlights the need for gradual case selection and surgical considerations to achieve proficiency. This technique is considered a promising alternative for surgeons looking to expand their spinal surgery spectrum.

Biportal endoscopic versus microscopic discectomy for lumbar herniated disc: a randomized controlled trial

BACKGROUND CONTEXT

Biportal endoscopic discectomy has been frequently performed in recent years and has shown acceptable clinical outcomes. However, evidence regarding its efficacy and safety remains limited.

PURPOSE

This study aimed to compare the clinical efficacy and safety of biportal endoscopic with that of open microscopic discectomy in patients with single-level herniated lumbar discs.

STUDY DESIGN

Prospective, randomized, multicenter, open-label, assessor-blind, non-inferiority controlled trial.

PATIENT SAMPLE

Sixty-four participants suffering from low back and leg pain with a single-level herniated lumbar disc and required discectomy.

OUTCOME MEASURES

Outcomes were assessed with the use of patient-reported outcome measures (PROMs), visual analog scale (VAS) pain score for surgical site, low back and lower extremity, Oswestry Disability Index (ODI) for lumbar disabilities, European Quality of Life-5 Dimensions value for quality of life, and painDETECT for neuropathic pain. Surgery-related outcomes such as hospital stay, operation time, and opioid usage were collected. Adverse events occurring during the follow-up period were also noted.

METHODS

All participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic (biportal group) or microscopic discectomy (microscopy group). The primary outcome was the difference in ODI scores at 12-months post surgically based on a modified intention-to-treat strategy, with a non-inferiority margin of 12.8 points. The secondary outcomes included PROMs, surgery-related outcomes, and adverse events.

RESULTS

The ODI score at the 12-month follow-up was 11.97 in the microscopy group and 13.89 in the biportal group (mean difference, 1.92; 95% confidence interval [CI], -3.50 to 7.34), showing the non-inferiority of biportal group. The results for the secondary outcomes were similar to those for the primary outcome. Creatinine phosphokinase ratios were low in the biportal group. Early surgical site pain was slightly lower in the biportal group (mean difference of VAS pain score at 48-hr, -0.98; 95% CI, -1.77 to -0.19). Adverse events including reoperation showed no significant difference between the groups.

CONCLUSION

Biportal endoscopic discectomy was non-inferior to microscopic discectomy over a 12 month period. Biportal endoscopic discectomy is suggested to be a relatively safe and effective surgical technique with the slight advantage of reduced muscle damage. However, the clinical implications of surgical site pain should be carefully considered.