Biportal endoscopic technique in the treatment of spinal stenosis: early clinical experiences and results

Efficacy of Biportal Endoscopic Decompression for Lumbar Spinal Stenosis: A Meta-Analysis With Single-Arm Analysis and Comparative Analysis With Microscopic Decompression and Uniportal Endoscopic Decompression

BACKGROUND AND OBJECTIVE

Biportal endoscopic decompression is a minimally invasive surgical technique for lumbar spinal stenosis (LSS). This meta-analysis aimed to evaluate the efficacy and safety of biportal endoscopic decompression through both a single-arm analysis and a comparative analysis.

METHODS

A comprehensive literature search was conducted to identify eligible studies reporting the outcomes of biportal endoscopic decompression for LSS. Single-arm analysis and comparisons with microscopic and uniportal endoscopic decompression were performed. Evaluated outcomes included visual analog scale (VAS) scores for back pain and leg pain, Oswestry Disability Index (ODI) scores, operation time, estimated blood loss, duration of hospital stay, and adverse events.

RESULTS

Single-arm analysis demonstrated significant improvements in VAS back pain, VAS leg pain, and ODI scores after biportal endoscopic decompression at postoperative 1-day to 36-month follow-up (all P < .001), compared with preoperative levels. The pooled mean single-level operation time was 71.44 min, and the pooled mean hospital stay was 3.63 days. The overall adverse event rate was 4.0%, with dural tear being the most common complication (3.0%). Compared with microscopic decompression, biportal endoscopic decompression showed significantly lower VAS back pain at 1-month ( P < .001) and 6-month ( P < .001) follow-up; lower VAS leg pain at 1-month ( P = .045) follow-up; lower ODI scores at 3-month ( P < .001), 12-month ( P = .017), and >12-month ( P = .007) follow-up; lower estimated blood loss ( P = .003); and shorter hospital stay ( P < .001). Adverse event rates did not differ between the techniques. No significant differences were observed between biportal endoscopic and uniportal endoscopic decompression groups for most efficacy and safety outcomes.

CONCLUSION

Biportal endoscopic decompression emerges as a safe and effective alternative for LSS, presenting potential advantages over the microscopic technique and comparable efficacy with the uniportal endoscopic technique.

Complications and Management of Endoscopic Spinal Surgery

In the past, the use of endoscopic spine surgery was limited to intervertebral discectomy; however, it has recently become possible to treat various spinal degenerative diseases, such as spinal stenosis and foraminal stenosis, and the treatment range has also expanded from the lumbar spine to the cervical and thoracic regions. However, as endoscopic spine surgery develops and its indications widen, more diverse and advanced surgical techniques are being introduced, and the complications of endoscopic spine surgery are also increasing accordingly. We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and key words were set as “endoscopic spinal surgery,” “endoscopic cervical foramoinotomy,” “PECD,” “percutaneous transforaminal discectomy,” “percutaneous endoscopic interlaminar discectomy,” “PELD,” “PETD,” “PEID,” “YESS” and “TESSYS.” We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic lumbar surgery was divided into full endoscopic interlaminar and transforaminal approaches and a unilateral biportal approach. We performed a comprehensive review of available literature on complications of endoscopic spinal surgery. This study particularly focused on the prevention of complications. Regardless of the surgical methods, the most common complications related to endoscopic spinal surgery include dural tears and perioperative hematoma. transient dysesthesia, nerve root injury and recurrence. However, Endoscopic spinal surgery, including full endoscopic transforaminal and interlaminar and unilateral biportal approaches, is a safe and effective a treatment for lumbar as well as cervical and thoracic spinal diseases such as disc herniation, lumbar spinal stenosis, foraminal stenosis and recurrent disc herniation.

Complications of Unilateral Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis: A Meta-Analysis and Systematic Review

BACKGROUND

In recent years, unilateral biportal endoscopic spinal surgery has been used for the treatment of lumbar spinal stenosis with good results. Some investigators counted the total incidence of complications in unilateral biportal endoscopic surgery for lumbar spinal stenosis, but none have analyzed the incidence of specific complications. The present study further counted the incidence of specific complications and gave the possible causes of the complications.

METHODS

English databases including PubMed were searched to collect relevant literature on unilateral biportal endoscopic spinal surgery for lumbar spinal stenosis. The inquiry period is from January 1, 2015, to July 1, 2022. The literature was screened, information extracted, and risk of bias evaluated by the researchers, followed by Meta analysis using R4.2.1 and RStudio statistical software.

RESULTS

In total, we included 14 studies involving 707 patients. The included studies were retrospective case series, The results of the single-arm rate meta-analysis showed that the total complication rate of unilateral biportal endoscopic surgery treatment of lumbar spinal stenosis was 8.1% (95% confidence interval [CI] [0.060; 0.103]); of which, the highest incidence of dural tear was 4.5% (95% CI [0.030; 0.064]), the incidence of symptomatic postoperative spinal epidural hematoma was approximately 1.1% (95% CI [0.001; 0.027]), the incidence of incomplete decompression was 2.0% (95% CI [0.007; 0.038]), the incidence of transient palsy was 2.6% (95% CI [0.005; 0.057]).

CONCLUSIONS

The incidence of total complications of unilateral biportal endoscopic surgery for lumbar spinal stenosis was 8.1%, dural tear remained a major complication with an incidence of 4.5%, incomplete decompression was 2.0%, transient palsy was 2.6%, and, unexpectedly, symptomatic postoperative spinal epidural hematoma was only 1.1%.

Complications of Unilateral Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis: A Systematic Review of the Literature and Meta-analysis of Single-arm Studies

PURPOSE

This article aims to summarize the incidence of these complications through a meta-analysis, analyze the causes of complications and provide clinical promotion and recommendations.

METHODS

Databases and retrieval platform including PubMed, Web of science, Springer link, Cochrane clinical trials, ProQuest, ScienceDirect, Europe PMC, Wiley online, OVID, Clinical trials, CNKI and WanFang, and supplement the literature through Google Scholar, collect all the unilateral biportal endoscopy (UBE) controlled trials and non-controlled trials of UBE in the treatment of lumbar spinal stenosis (LSS). The search time limit is from January 1, 2000 to December 25, 2021. After two reviewers independently screened the literature, extracted data and evaluated the risk of bias in the included studies, meta-analysis was performed using Stata 15.1 software.

RESULTS

Finally, 24 studies were included, including 999 patients. The results of a single-arm rate meta-analysis showed that the overall complication rate of UBE treatment of LSS was 6.27% [95% CI (0.0412, 0.0876)], and the incidence of dural tear was 2.49% [95% CI (0.0133, 0.0390)], the incidence of transient paresthesia was 0.14% [95% CI (0.0000, 0.0072)], the incidence of postoperative spinal epidural hematoma was 0.27% [95% CI (0.0000, 0.0096)], the incidence of postop headache, inadequate decompression, root injury and infection was 0.00%.

CONCLUSION

Current evidence shows that the complication rate of UBE in the treatment of LSS is low, mainly due to dural tears. Limited by the number and quality of included studies, the above conclusions still need to be confirmed by more studies.

Efficacy and Complications of Unilateral Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis: A Meta-Analysis and Systematic Review

OBJECTIVE

As an emerging minimally invasive endoscopic technique, unilateral biportal endoscopic spinal surgery (UBESS) has the advantages of flexibility, a wide and clear field of view, and less soft tissue damage. However, the clinical evidence is insufficient and controversy exists regarding UBESS for the treatment of lumbar spinal stenosis (LSS). In the present meta-analysis, we investigated the clinical efficacy and complications of UBESS for the treatment of LSS.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched through to June 1, 2021 to identify all reported studies on UBESS for LSS. Only English-language studies with original reported data from ≥30 cases were considered for inclusion. The patient demographics, operative time, hospital stay, complications, visual analog scale (VAS) score, Oswestry disability index, and Macnab criteria were extracted. Quality assessment was performed using the Cochrane collaboration tool for randomized controlled trials and the Newcastle-Ottawa scale for retrospective studies. A meta-analysis was performed using a random or fixed effect model according to the heterogeneity.

RESULTS

Thirteen studies with 586 patients and 607 operation levels were included. The mean single-level operative time, hospital stay, and follow-up duration were 61.10 minutes, 2.32 days, and 14.7 months, respectively. At the final follow-up visit, the mean VAS score for leg pain had decreased from 7.23 preoperatively to 1.83 postoperatively, the mean VAS score for back pain had decreased from 6.30 to 1.95, and the mean Oswestry disability index had significantly improved from 56.99 to 17.83. The average satisfied outcome (excellent or good using the Macnab criteria) was 86%. The overall complication rate was 5%, and the most common complication was a dural tear, with an incidence of 2%, followed by epidural hematoma with an incidence of 1%. The remaining complications were nerve root injury, inadequate decompression, and postoperative headache.

CONCLUSIONS

From the available clinical results and experience from reported studies, UBESS for LSS is a feasible and effective approach and a worthwhile choice for clinicians. However, the complications associated with the procedure should also be seriously considered.