Contralateral Keyhole Biportal Endoscopic Surgery for Ruptured Lumbar Herniated Disc: A Technical Feasibility and Early Clinical Outcomes

Comparison of complications of biportal endoscopic discectomy: ipsilateral versus contralateral approach

BACKGROUND

Biportal endoscopic discectomy using the contralateral approach is effective for highly down- or upward-migrated disc removal and upper lumbar disc herniation. Despite its benefits, there are potential complications that have yet to be fully explored, including possible transient neurological deficits, excessive nerve pull, and incomplete discectomy. Thus, in this study, we aimed to understand these complications by comparing the contralateral and ipsilateral approaches for biportal endoscopic discectomy.

METHODS

This study included 326 patients who underwent biportal endoscopic discectomy, with 168 and 158 patients undergoing endoscopic discectomy via the contralateral and ipsilateral approaches, respectively, between March 2020 and July 2023. Patient demographic characteristics, operation level, length of hospital stay, blood loss, and operation time were reviewed. Complications included early recurrence, neurological deficits, postoperative pain, and long-term recurrence. Only single-level patients were included. Patients with infections, stenosis, instability, tumors, revision surgery, multilevel pathology, or ambiguous symptoms were excluded.

RESULTS

Operation time, length of hospital stay, and blood loss were similar between groups. L3-4 and L4-5 were the most common contralateral and ipsilateral approach discectomies, respectively. The frequency of dural tear occurrence showed no difference between groups. Early recurrence occurred more in the ipsilateral than in the contralateral approach group. Neurological deficits occurred more in the contralateral than in the ipsilateral approach group. Postoperative pain and long-term recurrence rates were not significantly different between groups. However, the rate of revision surgery due to long-term recurrence was higher in the contralateral than in the ipsilateral approach group.

CONCLUSIONS

No significant differences were observed in duration, postoperative pain, or long-term recurrence between the ipsilateral and contralateral approaches. However, early recurrence, neurological deficit, and revision surgery rates differed between the ipsilateral and contralateral approaches. The appropriate approach should be carefully determined according to the case before surgery. Contralateral discectomy may be an excellent surgical option.

Unilateral Biportal Endoscopic Discectomy via the Contralateral Approach in Upward Migrated Foraminal Disc Herniations

OBJECTIVE

Lumbar upward migrated foraminal disc herniations are extremely rare and technically challenging to operate. In this study, a contralateral approach using unilateral biportal endoscopy, which has the advantages of structural protection, efficacy, and safety is presented.

METHODS

Between 2019 and December 2022, five patients with lumbar upward migrated foraminal disc herniations underwent unilateral biportal endoscopic discectomy via the contralateral approach. The patients were 4 males and 1 female patient. All patients had severe radicular pain. Neurological examination revealed sensory impairment and motor weakness in 2 patients but no deficits in the others. Magnetic resonance images confirmed lumbar upward migrated foraminal disc herniations in all patients.

RESULTS

The study shows a significant reduction in Oswestry Disability Index. Symptoms improved immediately after surgery in all patients, and satisfactory results were achieved at the last follow-up. No surgical complications or recurrent herniations were observed. The mean preoperative Oswestry Disability Index decreased from 44.6 to 11.4. In addition, mean preoperative Visual Analog Scale declined from 8.4 to 1.6. The patients were assessed after a follow-up period of at least 22 months, and their level of pain level was documented.

CONCLUSIONS

Although unilateral biportal endoscopic discectomy via the contralateral approach is not a common surgical procedure, it can offer a viable alternative for patients with lumbar upward migrated foraminal disc herniations.

Safety and Utility of Bilateral-contralateral Decompression for Adjacent Segment Stenosis After Lumbar Interbody Fusion Using Unilateral Biportal Endoscopy

STUDY DESIGN

Retrospective case series study.

OBJECTIVE

To evaluate the safety and efficacy of bilateral-contralateral decompression using unilateral biportal endoscopy (UBE) for treating adjacent segment disease (ASD) after lumbar interbody fusion (LIF).

SUMMARY OF BACKGROUND DATA

ASD is a well-documented complication following LIF, often requiring additional surgical interventions. Traditional decompression techniques risk damaging the facet joints, potentially leading to further instability and degeneration. However, our bilateral-contralateral decompression using UBE focuses on minimizing facet joint resection and reducing the risk of postoperative instability.

METHODS

This study included 37 patients who underwent bilateral-contralateral UBE decompression for ASD following LIF at the L4-5 level between September 2020 and March 2022. Radiographic evaluations included measurements of vertebral range of motion (ROM), slip distance, disk height, lumbar lordosis, and facet joint preservation. Clinical assessments were performed using the visual analog scale (VAS) for back and leg pain and the Oswestry disability index (ODI).

RESULTS

The average final follow-up period was 14.5±1.9 mo. The average preoperative ROM was 3.0 degrees, which significantly increased to 4.8° at the final follow-up (P<0.05). Static structure and dynamic stability parameters, including the vertebral slip distance, lumbar lordosis, and disk height, showed no significant differences between the preoperative examination and 1-year postoperative follow-up. The facet joint preservation rate was 97.4±2.1% on average. Significant improvements in VAS scores for leg and back pain and ODI were observed. Despite improvement with conservative treatment in 7 patients with delayed instability, 2 patients required fusion surgery.

CONCLUSIONS

Bilateral-contralateral decompression through UBE has proven to be an effective and safe method for treating ASD following LIF. This technique is particularly suitable for patients requiring spinal stability maintenance. The high rates of facet joint preservation and low incidence of reoperation highlight this technique as a compelling alternative treatment for spinal stenosis.

LEVEL OF EVIDENCE

Level III.

[Short-term effectiveness of unilateral biportal endoscopy technique in treatment of lumbar lateral saphenous fossa combined with intervertebral foramina stenosis via contralateral sublaminar approach]

Objective

To investigate the short-term effectiveness of unilateral biportal endoscopy (UBE) in treatment of lumbar lateral saphenous fossa combined with intervertebral foramina stenosis via contralateral sublaminar approach.

Methods

A clinical data of 15 patients with lumbar lateral saphenous fossa combined with intervertebral foramina stenosis, who were admitted between September 2021 and December 2023 and met selective criteria, was retrospectively analyzed. There were 5 males and 10 females with an average age of 70.3 years (range, 46-83 years). Surgical segment was L 4, 5 in 12 cases and L 5, S 1 in 3 cases. The disease duration was 12-30 months (mean, 18.7 months). All patients were treated by UBE via contralateral sublaminar approach. The operation time, intraoperative blood loss, postoperative hospital stay, and the occurrence of complications were recorded. The visual analogue scale (VAS) score was used to evaluate the degree of lower back and leg pain before and after operation; the Japanese Orthopaedic Association (JOA) score and the Oswestry disability index (ODI) were used to evaluate the lumbar function; and the clinical outcome was evaluated using the MacNab criteria at 6 months after operation. Postoperative MRI and CT were taken to observe whether the lateral saphenous fossa and intervertebral foramen stenosis were removed or not, and the cross-sectional area of the spinal canal (CSA-SC), cross-sectional area of the intervertebral foramen (CSA-IVF), and cross-sectional area of the facet joint (CSA-FJ) were measured.

Results

The operation time was 55-200 minutes (mean, 127.5 minutes); the intraoperative blood loss was 10-50 mL (mean, 27.3 mL); the length of postoperative hospital stay was 3-12 days (mean, 6.8 days). All patients were followed up 6-12 months (mean, 8.9 months). At 1 day, 1 month, 3 months, and 6 months after operation, the VAS scores of low back and leg pain and ODI scores after operation were significantly lower than preoperative scores and showed a gradual decrease with time; the JOA scores showed a gradual increase with time; the differences in the above indexes between different time points were significant ( P<0.05). The clinical outcome was rated as excellent in 10 cases, good in 4 cases, and poor in 1 case according to the MacNab criteria at 6 months after operation, with an excellent and good rate of 93.33%. Imaging review showed that the compression on the lateral saphenous fossa and intervertebral foramina had been significantly relieved, and the affected articular process joint was preserved to the maximum extent; the CSA-SC and CSA-IVF at 3 days after operation significantly increased compared to the preoperative values ( P<0.05), and the CSA-FJ significantly reduced ( P<0.05).

Conclusion

The UBE via contralateral sublaminar approach can effectively reduce pressure in the lateral saphenous fossa and the intervertebral foramina of the same segment while preserving the bilateral articular process joints. The short-term effectiveness is good and it is expected to avoid fusion surgery caused by iatrogenic instability of the lumbar spine. However, further follow-up is needed to clarify the mid- and long-term effectiveness.

Contralateral translaminar endoscopic approach for highly down-migrated lumbar disc herniation using percutaneous biportal endoscopic surgery : Original research

OBJECTIVE

Unilateral biportal endoscopy (UBE)is a minimally invasive spine surgery with reduced traumatization of the posterior lumbar ligament and muscular structures. This study reports contralateral translaminar approach with UBE for highly down-migrated lumbar disc herniation (LDH).

METHODS

Data of 32 patients with highly down-migrated LDH treated using UBE at our center from January 2020 to July 2022 were retrospectively analyzed. The operation time and perioperative complications were recorded, and the visual analog scale (VAS) of pain was recorded to evaluate the degree of lower back and extremity pain. The Oswestry disability index (ODI) was used to evaluate lumbar spine function. The modified MacNab score was used to evaluate clinical efficacy.

RESULTS

All patients successfully underwent the operation, with a time range from 47 to 65 min and an average operation time of 56.09 ± 5.11 min. Overall, 17 and 15 were males and females, respectively, with ages ranging from 34 to 72 years and an average age of 56 ± 7.89 years. The postoperative follow-up period was 12-18 months, with an average of 14.9 ± 2.3 months. The postoperative lower back VAS pain score and ODI were statistically significant compared with preoperatively (P < 0.05). At the final follow-up, according to the modified Macnab criteria, 90.6% of cases were classified as good or excellent.

CONCLUSION

UBE treatment of highly down-migrated LDH through the contralateral translaminar approach is safe and efficient. Therefore, this approach can be an efficient alternative for patients with highly downward-migrating LDH.

Early efficacy observation of the unilateral biportal endoscopic technique in the treatment of multi-level lumbar spinal stenosis

BACKGROUND

To explore the early curative effect of unilateral biportal endoscopy (UBE) in the treatment of multi-level lumbar spinal stenosis with the help of multiple small incisions.

METHODS

A retrospective analysis was performed on 26 patients with multi-level lumbar spinal stenosis treated by UBE in our hospital from August 1, 2021, to March 1, 2022. We collect patients' basic medical records and independently design surgical incisions. The visual analog score (VAS) and Oswestry Disability Index (ODI) were compared before surgery, 7 days after surgery and 6 months after surgery. Spinal canal diameters on CT were compared before surgery and 7 days after surgery. The modified MacNab standard was used to evaluate the efficacy satisfaction at 6 months after operation.

RESULTS

In this study, 26 patients were operated according to the predetermined surgical plan. The operative time was 145 ± 40.11 min, the intraoperative blood loss was 156.25 ± 44.32 ml, and the postoperative hospital stay was 4.79 ± 1.31 days. The VAS scores of postoperative lumbago and leg pain were lower than those before surgery (P < 0.05). The postoperative ODI score was significantly different from that before surgery (P < 0.05). The postoperative CT sagittal diameter was significantly different from that before surgery (P < 0.05). The curative effect of modified MacNab was 76.92% when followed up 7 days after surgery. The curative effect of modified MacNab was 92.31% when followed up 6 months after surgery, which was significantly improved compared with 7 days after surgery.

CONCLUSION

Under multiple small incision channels, UBE can effectively treat multi-level lumbar spinal stenosis, significantly relieve the clinical symptoms of patients, and significantly improve the quality of life of patients. It is a safe and feasible minimally invasive surgical treatment method for multi-level lumbar spinal stenosis.

Finite element mechanical analysis of ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery

BACKGROUND

Unilateral bilateral endoscopic spine surgery (UBE) is often performed to treat lumbar spinal stenosis and disc herniation. It has become a prominent method in endoscopic spine surgery because of its very low learning curve and broader operative field of vision. Currently, the ipsilateral approach and contralateral approach have been established for disc herniation in the foraminal area, intervertebral foramen region, or pedicle region. The contralateral method offers many benefits over the ipsilateral approach, including less bone labour during microsurgical decompression and the preservation of facet joints. However, because it uses the interlaminar window approach, it inevitably involves osteotomy of the patient's superior and inferior articular processes, which may result in corresponding deterioration in the spine's biomechanical stability and subsequent adjacent facet joint diseases caused by facet joint degeneration postoperatively.

OBJECTIVE

As a result, the purpose of this work is to use a finite element model to evaluate how the ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery affect spinal stability while treating identical intervertebral disc herniation.

STUDY DESIGN

In this study, a three-dimensional lumbar-sacral spine model was built and verified. Osteotomies were conducted for armpit-type lumbar disc herniation (LDH), periradicular-type LDH, and shoulder-type LDH. Postoperative lumbar spine models of the ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery were developed. The von Mises stress on the endplate, shear force on the annulus fibrosus, pressure inside the intervertebral disc, and range of motion (ROM) of the L3 segment were all determined. The results of our well-validated model showed that osteotomy done in the ipsilateral approach deteriorated most biomechanical metrics.

RESULTS

In the majority of loading conditions, the contralateral approach caused the intervertebral disc's biomechanical properties to increase, and the ipsilateral approach caused the intervertebral disc's biomechanical properties to increase sharply more than the contralateral approach.

CONCLUSION

The contralateral approach, which is now extensively employed in unilateral bilateral endoscopic spine surgery, may be regarded as an ideal surgical alternative for treating lumbar disc herniation without producing iatrogenic instability. This approach has a low facet joint reduction rate, minimum soft tissue injury, and precisely identifies the midline of the central spinal canal during the retraction of the thecal sac and nerve roots.

A Modified Laminotomy for Interlaminar Endoscopic Lumbar Discectomy: Technical Report and Preliminary Results

OBJECTIVE

To introduce a technique of laminotomy using a common trephine to enlarge the interlaminar space at L4/5 segment for interlaminar endoscopic lumbar discectomy (IELD) and report the anatomical basis of this procedure, technical details, as well as primary clinical outcomes of a consecutive patient cohort with L4/5 lumbar disc herniation (LDH).

METHODS

On anteroposterior fluoroscopy, the intersection of the medial edge of the inferior articular process and the inferior endplate of L4 vertebra was taken as the target. Using a common trephine, laminotomy was performed to remove a big portion of the posterior wall of the canal under the guidance of endoscopy. From June 2018 to December 2021, the consecutive patients who underwent L4/5 IELD were prospectively studied. Clinical outcomes were assessed at the day before surgery, 1 day, 1 month, 3 months, 12 months after surgery, and the last follow-up. Numerical Rating Scale, Roland-Morris Disability Questionnaire (RMDQ), and MacNab criteria were used to evaluate back and leg pain, the quality of life, and clinical efficacy, respectively.

RESULTS

There were 64 men and 44 women, with an age of 50.3 ± 14.9 years. The operating time was 74.54 ± 17.42 minutes. The mean follow-up time was 32.7 ± 18.6 months (range, 12-64 months). The complications of IELD included numbness, neck pain, and recurrence. Both leg pain (6.2 ± 1.9 vs. 1.8 ± 0.8, p < 0.001) and back pain (3.1 ± 2.3 vs. 1.7 ± 0.9, p < 0.001) quickly improved after this procedure and maintained (1.1 ± 1.5, 1.1 ± 1.3) at final follow-up. Physical disability due to back pain, as assessed using RMDQ, was improved remarkably after surgery (15.0 ± 5.8 vs. 2.9 ± 4.1, p < 0.001). In addition, MacNab outcome grade was evaluated as good-to-excellent in 96 cases (88.9%).

CONCLUSION

A convenient technique of laminotomy using a common trephine was proposed for the L4/5 IELD. It can efficiently enlarge the interlaminar entry to perform endoscopic discectomy. This procedure is particularly suitable for treating LDH with concomitant lumbar spinal stenosis and migrated herniated disc.

A case report: Unilateral biportal endoscopic revision for adjacent segmental disease: Case presentations and literature review

RATIONALE

Biportal endoscopic revision surgery for adjacent segmental disease (ASD) after lumbar arthrodesis is seldomly reported. Herein, we present 3 cases of ASD with radiculopathy wherein satisfactory results were obtained using unilateral biportal endoscopic (UBE) decompression.

PATIENT CONCERNS

Case 1 was of a 56-year-old male who presented with a chief complaint of Intermittent claudication since 2-year. Case 2 involved a 78-year-old female who was admitted to the hospital with a chief complaint of radiating pain and weakness in the left leg for at least 1 year. Case 3 was a 67-year-old woman who visited our hospital because of radiating leg pain for 5 months. All the cases had a history of L4 to L5 lumbar interbody fusion surgery.

DIAGNOSES

Computed tomography and magnetic resonance imaging showed the spinal epidural lipomatosis at the L3 to L4 level in case 1, the up-migrated lumbar disc herniation at L3 to L4 level in case 2 and unilateral foraminal stenosis at the L5 to S1 level in case 3.

INTERVENTIONS

Under UBE guidance, the ipsilateral approach was used to treat adjacent lumbar stenosis caused by spinal epidural lipomatosis. The contralateral approach was used to remove the up-migrated herniated disc. The paraspinal approach was applied to decompress the foraminal stenosis.

OUTCOMES

Postoperative parameters were improved clinically, and nerve roots were decompressed radiologically. No complications were developed.

LESSONS

UBE revision surgery showed a favorable clinical and radiological result without complications and may be a safe and effective alternative technique for ASD.

Saving Stabilizing Structure Treatment With Bilateral-Contralateral Decompression for Spinal Stenosis in Degenerative Spondylolisthesis Using Unilateral Biportal Endoscopy

OBJECTIVE

This study aimed to evaluate the treatment of spinal stenosis with spondylolisthesis using bilateral-contralateral unilateral biportal endoscopic (UBE) decompression to minimize facet joint damage.

METHODS

We retrospectively evaluated 42 patients with grade 1 spondylolisthesis who underwent bilateral-contralateral UBE decompression between July 2018 and September 2019. To identify segmental instability, static and dynamic images from preoperative and postoperative procedures and final follow-up radiographs were reviewed. Lateral radiograph slippage ratio, sagittal motion, and facet joint preservation were evaluated. Clinical assessments were conducted using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria.

RESULTS

The average final follow-up period was 26.5 ± 1.3 months. The average preoperative slip percentage was 15.70% ± 5.25%, which worsened to 18.80% ± 5.41% at the final follow-up (p < 0.005). The facet joint preservation rate was 95.6% ± 4.1% on the contralateral side. Improvements in the VAS scores (leg pain: from 7.9 ± 2.2 to 3.1 ± 0.7; p < 0.005; back pain: from 7.2 ± 3.0 to 2.8 ± 1.0; p < 0.005) were observed at the final follow-up. The mean preoperative ODI was 26.19 ± 3.42, which improved to 9.6 ± 1.0 (p < 0.005). Thirteen patients exhibited delayed focal segmental instability following decompression. Despite the absence of symptoms or improvement with conservative treatment in the majority of patients with delayed instability, two patients required fusion surgery to address the instability. Additionally, 2 patients developed facet synovial cysts, while 2 experienced spinous process fractures.

CONCLUSION

Bilateral decompression with a contralateral UBE approach could be an effective and alternative treatment method to reduce instability in spinal stenosis with grade 1 spondylolisthesis.

Clinical outcomes and complications after biportal endoscopic spine surgery: a comprehensive systematic review and meta-analysis of 3673 cases

PURPOSE

Current literature suggests that biportal spinal endoscopy is safe and effective in treating lumbar spine pathology such as lumbar disc herniation, lumbar stenosis, and degenerative spondylolisthesis. No prior study has investigated the postoperative outcomes or complication profile of the technique as a whole. This study serves as the first comprehensive systematic review and meta-analysis of biportal spinal endoscopy in the lumbar spine.

METHODS

A PubMed literature search provided over 100 studies. 42 papers were reviewed and 3673 cases were identified with average follow-up time of 12.5 months. Preoperative diagnoses consisted of acute disc herniation (1098), lumbar stenosis (2432), and degenerative spondylolisthesis (229). Demographics, operative details, complications, and perioperative outcome and satisfaction scores were analyzed.

RESULTS

Average age was 61.32 years, 48% male. 2402 decompressions, 1056 discectomies, and 261 transforaminal lumbar Interbody fusions (TLIFs) were performed. Surgery was performed on 4376 lumbar levels, with L4-5 being most common(61.3%). 290 total complications occurred, 2.23% durotomies, 1.29% inadequate decompressions, 3.79% epidural hematomas, and < 1% transient nerve root injuries, infections, and iatrogenic instability. Significant improvement in VAS-Back, VAS-Leg, ODI, and Macnab Scores were seen across the cohort.

CONCLUSION

Biportal spinal endoscopy is a novel method to address pathology in the lumbar spine with direct visualization through an endoscopic approach. Complications are comparable to previously published rates. Clinical outcomes demonstrate effectiveness. Prospective studies are required to assess the efficacy of the technique as compared to traditional techniques. This study demonstrates that the technique can be successful in the lumbar spine.

Biportal Endoscopic Posterior Thoracic Laminectomy for Thoracic Spondylotic Myelopathy Caused by Ossification of the Ligamentum Flavum: Technical Developments and Outcomes

Objective: Advanced biportal endoscopic surgery techniques can be used to treat thoracic myelopathy secondary to ossification of the ligamentum flavum (OLF). This case series elaborates on a feasible biportal endoscopic technique for thoracic OLF removal and evaluates clinical and radiological outcomes.Methods: A biportal endoscopic posterior thoracic laminectomy was performed to remove the thoracic OLF. Surgical techniques have evolved from inside-out piecemeal removal methods to outside-in <i>en bloc</i> removal methods. Preoperative computed tomography was performed to analyze dural ossification and OLF types. Intraoperative videos were reviewed to observe dural ossification and to determine the surgical method. Neurological outcomes were assessed using the Japanese Orthopaedic Association (JOA) score.Results: Clinical symptoms and neurological function improved markedly after surgery (JOA score, preoperative: 12.6 ± 1.0, final follow-up: 15.6 ± 1.2). The mean operation time per segment was not short (106.6 ± 38 minutes). At early experience stages, inside-out piecemeal decompression was used and it caused intraoperative spinal cord injury. However, outside-in <i>en bloc</i> decompression technique did not induce neural complications. Postoperative segmental instability and correlated mechanical back pain were not observed.Conclusion: The biportal endoscopic posterior thoracic approach is an attractive surgical option to treat thoracic spondylotic myelopathy secondary to OLF. Piecemeal inside-out decompression can induce irreversible spinal cord injury, especially in the early experience stages. Outside-in decompression is more efficient and safer than inside-out pattern procedures by minimizing dural manipulation. Nonetheless, this technique is technically demanding and should only be performed in selected patients after acquiring abundant experience with endoscopic spine surgeries.

Modified Unilateral Biportal Endoscopic Lumbar Discectomy Results in Improved Clinical Outcomes

OBJECTIVE

To evaluate and describe the clinical efficacy and safety of a modified unilateral biportal endoscopic lumbar discectomy.

METHODS

From February 2019 to February 2020, patients who met the inclusion criteria were treated using a modified unilateral biportal endoscopic lumbar discectomy. During the operation, the herniated disc was removed and the ligamentum flavum was preserved. Clinical efficacy was assessed via postoperative imaging and follow-up.

RESULTS

A total of 70 patients were followed up for more than 2 years, including 51 males and 19 females, aged 49.4 ± 16.0 years. All operations were completed and no complications were noted. Postoperative lumbar magnetic resonance imaging showed that the decompression of the nerve root was sufficient and the ligamentum flavum was preserved in all patients. Postoperative lumbar CT showed that the caudal lamina and inferior articular process of the cephalad vertebral were partially removed. Lower back and leg pain were significantly relieved after surgery, and the Oswestry Disability Index was significantly improved compared to presurgery measurements (P ＜ 0.01). After 2 years of follow-up, the sensory and muscle strength of nerve roots were significantly recovered (P ＜ 0.01). According to the MacNab score of the patients, 40 cases were defined as "excellent," 26 cases were "good," 2 cases were "fair," and 2 cases were "poor."

CONCLUSIONS

Modified unilateral biportal endoscopic lumbar discectomy can completely remove a lumbar herniated disc; relieve lower back and leg pain; improve lumbar function; reduce the risk of dural tearing, cerebrospinal fluid leakage, and epidural hematoma; and reduce the epidural adhesion and arachnoiditis caused by ligamentum flavum resection.

A meta-analysis of clinical effects of microscopic unilateral laminectomy bilateral decompression (ULBD) versus biportal endoscopic ULBD for lumbar canal stenosis

Osbjective

Several studies have shown that both microscopic unilateral laminotomy bilateral decompression (ULBD) and unilateral biportal endoscopic (UBE) ULBD are effective for treating lumbar canal stenosis (LCS). However, there are different viewpoints as to which surgical technique is superior. Therefore, this meta-analysis investigated the clinical efficacy and side effects of microscopic ULBD and UBE ULBD for treating LCS.

Methods

To identify relevant studies describing the clinical outcomes and complication rates of microscopic ULBD and UBE ULBD for LCS, several databases were systematically searched in the Internet. The visual analog scale score for back and leg pain and the Oswestry Disability Index were used to assess clinical outcomes. Furthermore, data about perioperative outcomes and complications were documented.

Results

In total, six studies with 450 participants were included in this meta-analysis. The UBE ULBD was found to be superior to microscopic ULBD in terms of efficacy against early postoperative back and leg pain. However, there was no significant difference between the two procedures in terms of final clinical outcomes and complications. In addition, compared with microscopic ULBD, UBE ULBD was associated with a significant reduction in the length of hospital stay and C-reactive protein levels 2 days after surgery.

Conclusion

UBE ULBD and microscopic ULBD for the treatment of LCS were similar in terms of final clinical outcomes and complications. However, UBE ULBD has several advantages over microscopic ULBE, including a shorter hospital stay and faster alleviation of postoperative back and leg pain.

Learning Curve and Complications of Unilateral Biportal Endoscopy: Cumulative Sum and Risk-Adjusted Cumulative Sum Analysis

OBJECTIVE

The purpose of this study was to investigate the learning curve and complications of unilateral biportal endoscopy (UBE) in the treatment of lumbar disc herniation (LDH) and lumbar spinal stenosis (LSS).

METHODS

This was a retrospective cohort analysis of 197 consecutive patients who received UBE unilateral laminotomy bilateral decompression (UBE-ULBD) or lumbar discectomy (UBE-LD) surgery, including 107 males and 90 females with an average age of 64.83 ± 14.29 years. Cumulative sum (CUSUM) and risk-adjusted cumulative sum analysis (RA-CUSUM) were used to evaluate the learning curve, with the occurrence of complications defined as surgical failure, and variables of different phase of the learning curve were compared.

RESULTS

The cutoff point of learning curve of UBE surgery was 54 cases according to CUSUM analysis. The learning curve of UBE-ULBD and UBE-LD were divided into 3 phases. The first cutoff points were 31 and 12 cases, and the second cutoff point were 67 and 32 cases respectively. With the progress of the learning curve, the operation time and postoperative hospital stays decreased. The visual analogue scale and Oswestry Disability Index at the last follow-up were significantly lower than that before surgery. The incidence of surgical failure was 6.11% and began to decrease after the 89th case based on RA-CUSUM analysis. The surgical failure rate decreased from 10.11% to 2.78 after the 89th case with significant different.

CONCLUSION

UBE surgery is effective in the treatment of LDH and LSS with low incidence of complications. But a learning curve of at least 54 cases still required for mastering UBE surgery.

Comparison of the efficacy of fully endoscopic spine surgery using transforaminal and interlaminar approaches in the treatment of prolapsed lumbar 4/5 disc herniation

Background

There is still much controversy about whether transforaminal or interlaminar fully endoscopic spine surgery can better treat lumbar 4/5 disc herniation. Therefore, this study intends to compare the clinical efficacy of fully endoscopic spine surgery through transforaminal and interlaminar approaches in the treatment of lumbar 4/5 disc herniation.

Methods

Seventy-six patients with lumbar 4/5 disc herniation admitted from March 2019 to June 2020 were divided into the transforaminal approach group (endoscopic transforaminal lumbar discectomy, ETLD; 54 cases) and the interlaminar approach group (endoscopic interlaminar lumbar discectomy, EILD; 22 cases) according to different surgical methods. The general clinical data and clinical evaluation scale of the patients were compared.

Results

The post-operative ODI and VAS scores were significantly better in the EILD group (P < 0.05). The VAS and ODI scores of patients with upper-shoulder and sub-axillary types in the EILD group were superior to those in the ETLD group (P < 0.05), while the VAS and ODI scores of patients with the pre-radicular type were better when they underwent ETLD rather than EILD (P < 0.05). Patients with Lee zone III type in the EILD group had better post-operative ODI scores than those in the ETLD group (P < 0.05), but there was no significant difference in VAS scores (P > 0.05). Patients with Lee zone IV type who underwent EILD had better VAS and ODI scores than those who underwent ETLD (P < 0.05).

Conclusions

For patients with a prolapsed intervertebral disc that belongs to the upper-shoulder type, sub-axillary type, or Lee III or IV type, EILD can achieve better outcomes.

Comparing the efficacy and safety of minimally invasive biportal endoscopic spine surgery versus conventional microscopic discectomy in single-level lumbar herniated intervertebral disc (ENDO-BH Trial): a multicenter, prospective, randomized controlled equivalence trial study protocol

Background

Biportal endoscopic surgery has recently been performed in lumbar discectomy, with advantages over conventional surgery, such as less skin scarring and muscle damage. However, the clinical results have not been established. Although previous studies reported no difference between the biportal endoscopic and microscopic discectomy clinical results, the evidence was weak. Therefore, this study aims to evaluate the efficacy and safety of the biportal endoscopic discectomy versus the microscopic discectomy.

Methods

This prospective multicenter randomized controlled equivalence trial is designed to compare the efficacy and safety outcomes of patients who underwent lumbar discectomy using biportal endoscopy or microscopy. We will include 100 participants (50 per group) with a lumbar herniated disc. The primary outcome will be the Oswestry Disability Index (ODI) score 12 months after surgery based on a modified intention-to-treat strategy. The secondary outcomes will include the visual analog scale score for low back and lower extremity radiating pain, the ODI score, the Euro-Qol-5-Dimensions score, surgery satisfaction, walking time, postoperative return to daily life period, postoperative surgical scar, and surgery-related variables, such as postoperative drainage, operation time, admission duration, postoperative creatine kinase, and implementation status of conversion to open surgery. Radiographic outcomes will also be analyzed using magnetic resonance imaging (MRI) or computed tomography (CT) and simple radiographs. Safety will be assessed by evaluating all adverse and severe adverse events and surgery-related effects. The participants will be assessed by a blinded assessor before surgery (baseline) and 2 weeks and 3, 6, and 12 months after surgery.

Discussion

This trial will be the first prospective, multicenter, randomized controlled trial to analyze the efficacy and safety of biportal endoscopic discectomy in lumbar herniated disc.

This trial is designed for evaluating the equivalence of the results between biportal endoscopic and microscopic discectomy including adequate sample size, blinded analyses, and prospective registration to reduce bias. This trial will provide enough data on the effectiveness and safety of biportal endoscopic surgery and will be an important study that allows clear conclusions.

Trial registration

Clinical Research Information Service (cris.nih.go.kr.) (KCT0006191). Registered on 27 March 2021

Clinical Experiences of 3-Dimensional Biportal Endoscopic Spine Surgery for Lumbar Degenerative Disease

BACKGROUND

The lack of stereoscopic vision in endoscopic spine surgery may lead to a risk of neural or vascular injury during endoscopic surgery. Three-dimensional (3D) endoscopy has not yet been attempted in the field of spinal endoscopic surgery.

OBJECTIVE

To present the technique, clinical efficacy, and safety of the 3D biportal endoscopic approach for the treatment of lumbar degenerative disease.

METHODS

We attempted 3D biportal endoscopic surgery for lumbar degenerative disease in a series of patients. Clinical outcomes and complications were evaluated postoperatively using a short questionnaire about 3D biportal endoscopic spine surgery that solicited respondents' opinions on the advantages and disadvantages of 3D biportal endoscopic surgery compared to the conventional 2D biportal endoscopic approach.

RESULTS

We performed 3D biportal endoscopic spine surgery in 38 patients with lumbar degenerative disease. Optimal neural decompression was revealed by postoperative magnetic resonance imaging in all enrolled patients. The 3D endoscopic vision clearly demonstrated the surgical anatomy starting with the exposure of ligamentum flavum, dura, and nerve root, and 3D endoscopy precisely depicted pathologic lesions such as bony osteophytes and ruptured disc herniation. There were no major complications including neural injury or durotomy.

CONCLUSION

The 3D endoscope may be able to distinguish between normal structures and lesions. The stereognosis and depth sensation of 3D biportal endoscopic spinal surgery might have a favorable impact on the safety of patients during endoscopic spine surgery.

Unilateral Biportal Endoscopy for Decompression of Extraforaminal Stenosis at the Lumbosacral Junction: Surgical Techniques and Clinical Outcomes

Objective

The aims of this study were to describe the unilateral biportal endoscopic (UBE) technique for decompression of extraforaminal stenosis at L5–S1 and evaluate 1-year clinical outcomes. Especially, we evaluated compression factors of extraforaminal stenosis at L5–S1 and described the surgical technique for decompression in detail.

Methods

Thirty-five patients who underwent UBE decompression for extraforaminal stenosis at L5–S1 between March 2018 and February 2019 were enrolled. Clinical results were analyzed using the MacNab criteria, the visual analogue scale (VAS) for back and leg pain, and the Oswestry Disability Index (ODI). Compression factors evaluated pseudoarthrosis within the transverse process of L5 and ala of sacrum, disc bulging with or without osteophytes, and the thickened lumbosacral and extraforaminal ligament.

Results

The mean back VAS was 3.7±1.8 before surgery, which dropped to 2.3±0.8 at 1-year postoperative follow-up (p<0.001). There was a significant drop in postoperative mean VAS for leg pain from 7.2±1.1 to 2.3±1.2 at 1 year (p<0.001). The ODI was 61.5 before surgery and 28.6 (p<0.001). Pseudoarthrosis between the transverse process and the ala was noted in all cases (35 of 35, 100%). Pure disc bulging was seen in 12 patients (34.3%), and disc bulging with osteophytes was demonstrated in 23 patients. The thickened lumbosacral and extraforaminal ligament were identified in 19 cases (51.4%). No complications occurred in any of the patients.

Conclusion

In the current study, good surgical outcomes without complications were achieved after UBE decompression for extraforaminal stenosis at L5–S1.

Contralateral sublaminar approach for decompression of the combined lateral recess, foraminal, and extraforaminal lesions using biportal endoscopy: a technical report

BACKGROUND

The development of specialized instruments and surgical techniques has enabled the biportal endoscopic system to access the foraminal and extraforaminal area using the contralateral sublaminar approach at the lumbar level.

METHODS

Biportal endoscopic contralateral sublaminar approach was used to resolve the contralateral foraminal, and extraforaminal stenosis at the lumbar level. Prominent syndesmophytes and herniated disc compression of the exiting nerve root were successfully removed, and the distorted nerve root was restored to a smooth downward angulation in the far-out area.

CONCLUSION

We successfully utilized biportal endoscopy to decompress the combined lumbar lateral recess, foraminal, and extraforaminal lesions using a contralateral sublaminar approach.