Clinical and radiological outcomes of unilateral biportal endoscopic lumbar interbody fusion (ULIF) compared with conventional posterior lumbar interbody fusion (PLIF): 1-year follow-up

Arthroscopic-assisted uni-portal ligament flavum sparing bone anchoring annular suture technique for lumbar disc herniation: A case report and literature review

RATIONALE

Lumbar disc herniation (LDH) manifests in diverse forms. If the nucleus pulposus or endplate tissues protrudes, the location of annular tears also varies, which poses various challenges for the annular suture technique. Tears at the annular attachment area at the edge of the vertebral body (cephalad or caudad) are considered a prohibitively challenging area for annular suturing.

PATIENT CONCERNS

A 37-year-old woman presented with a gradual onset of symptoms, experiencing leg pain and numbness over the left leg for 1 year before presentation. The pain radiated to the left S1 dermatome. Despite undergoing continuous medical therapy for more than 6 months, her symptoms showed no improvement. The strength of the left plantar flexion in the ankle and great toe was rated at 4 out of 5. The straight leg-raising and strengthening tests were positive for the left sides. Lumbar computed tomography and magnetic resonance imaging revealed left-sided disc herniation at the L5-S1 level, and nerve root compression, confirming the diagnosis of LDH.

DIAGNOSES

The preoperative impression was LDH, intraoperative confirmation of a tear in the annular attachment area at the vertebral body edge.

INTERVENTIONS

This patient was treated with an arthroscopic-assisted uniportal spinal surgery (AUSS) technique focusing on ligament flavum (LF) preservation, protruding nucleus pulposus removal, nerve root decompression, and vertebral edge tear was then sutured using a bone anchoring annular suture with the Smile suture device.

OUTCOMES

This technique was performed successfully in a patient with LDH. Significant improvements were observed in postoperative pain and numbness, Visual Analog Scale, and Japanese Orthopaedic Association scores. No postoperative instability or complications were observed, with computed tomography and magnetic resonance imaging confirming complete decompression. To the best of our knowledge, this is the first used AUSS with LF preservation and bone anchoring annular suture technique for LDH.

LESSONS

This case study demonstrates the AUSS combined with LF preservation and the bone anchoring annular suture technique provides favorable clinical and imaging outcomes and is a safe and effective technique for the treatment of LDH.

Unilateral biportal endoscopic versus microscopic transforaminal lumbar interbody fusion for degenerative lumbar spinal stenosis in China: study protocol for a prospective, randomised, controlled, non-inferiority trial

INTRODUCTION

Degenerative lumbar spinal stenosis is a common cause of low back or leg pain and disability in the elderly population. Patients with spinal stenosis who fail to respond to conservative treatment often require surgical interventions. Minimally invasive transforaminal lumbar interbody fusion (TLIF) with microscopic tubular technique (MT-TLIF) is a well-established procedure for lumbar spinal stenosis. Recently, a novel MIS technique, unilateral biportal endoscopic TLIF (UBE-TLIF), has been frequently performed to treat spinal stenosis. However, the efficacy and safety of using UBE-TLIF in this population have not been well examined.

METHODS AND ANALYSIS

A total of 96 patients with lumbar spinal stenosis will be randomly assigned to the UBE-TLIF group or the MT-TLIF group at a 1:1 ratio to receive UBE-TLIF or MT-TLIF treatment respectively. The primary outcome is the Oswestry Disability Index (ODI) score at 1 year after receiving the surgery. Secondary outcomes include the ODI scores at additional time points, Visual Analogue Scale score, 36-Item Short Form Survey questionnaire, EuroQol 5 Dimensions questionnaire, radiological measurements (disc height, lumbar lordosis angles and vertebral fusion rate) and general condition during hospitalisation.

ETHICS AND DISSEMINATION

This protocol is approved by the Medical Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University. All participants of the study will be well informed and written informed consent will be requested. Findings from this trial will be published in peer-reviewed publications, specifically in orthopedic and spinal journals. The completion of this study will not only examine the use of UBE-TLIF in lumbar spinal stenosis but also provide helpful clinical references.

TRIAL REGISTRATION NUMBER

ChiCTR2300069333.

Effect of Cage Material and Size on Fusion Rate and Subsidence Following Biportal Endoscopic Transforaminal Lumbar Interbody Fusion

OBJECTIVE

Biportal endoscopic transforaminal lumbar interbody fusion (BE-TLIF) is an emerging, minimally invasive technique performed under biportal endoscopic guidance. However, concerns regarding cage subsidence and sufficient fusion during BE-TLIF necessitate careful selection of an appropriate interbody cage to improve surgical outcomes. This study compared the fusion rate, subsidence, and other radiographic parameters according to the material and size of the cages used in BE-TLIF.

METHODS

In this retrospective cohort study, patients who underwent single-segment BE-TLIF between April 2019 and February 2023 were divided into 3 groups: group A, regular-sized three-dimensionally (3D)-printed titanium cages; group B, regular-sized polyetheretherketone cages; and group C, large-sized 3D-printed titanium cages. Radiographic parameters, including lumbar lordosis, segmental lordosis, anterior and posterior disc heights, disc angle, and foraminal height, were measured before and after surgery. The fusion rate and severity of cage subsidence were compared between the groups.

RESULTS

No significant differences were noted in the demographic data or radiographic parameters between the groups. The fusion rate on 1-year postoperative computed tomography was comparable between the groups. The cage subsidence rate was significantly lower in group C than in group A (41.9% vs. 16.7%, p=0.044). The severity of cage subsidence was significantly lower in group C (0.93±0.83) than in groups A (2.20±1.84, p=0.004) and B (1.79±1.47, p=0.048).

CONCLUSION

Cage materials did not affect the 1-year postoperative outcomes of BE-TLIF; however, subsidence was markedly reduced in large cages. Larger cages may provide more stable postoperative segments.

Comparison of Fusion Rate and Clinical Outcomes in Minimally Invasive and Conventional Posterior Fusion for Lumbar Degenerative Disease: A Network Meta-Analysis

BACKGROUND

The fusion rate, clinical efficacy, and complications of minimally invasive fusion surgery and open fusion surgery in the treatment of lumbar degenerative disease are still unclear.

METHODS

We conducted a literature search using PubMed, Embase, Cochrane Library, CNKI, and WANFANG databases.

RESULTS

This study included 38 retrospective studies involving 3097 patients. Five intervention modalities were considered: unilateral biportal endoscopic-lumbar interbody fusion (UBE-LIF), percutaneous endoscopic-lumbar interbody fusion (PE-LIF), minimally invasive-transforaminal lumbar interbody fusion (MIS-TLIF), transforaminal lumbar interbody fusion (TLIF), and posterior lumbar interbody fusion (PLIF). Quality assessment indicated that each study met acceptable quality standards. PE-LIF demonstrated reduced low back pain (Odds Ratio = 0.50, Confidence Interval: 0.38-0.65) and lower complication rate (Odds Ratio = 0.46, Confidence Interval: 0.25-0.87) compared to PLIF. However, in indirect comparisons, PE-LIF showed the lowest fusion rates, with the ranking as follows: UBE-LIF (83.2%) > MIS-TLIF (59.6%) > TLIF (44.3%) > PLIF (39.8%) > PE-LIF (23.1%). With respect to low back pain relief, PE-LIF yielded the best results, with the order of relief as follows: PE-LIF (96.4%) > MIS-TLIF (64.8%) > UBE-LIF (62.6%) > TLIF (23.0%) > PLIF (3.2%). Global and local consistency tests showed satisfactory results, and heterogeneity tests indicated good stability.

CONCLUSIONS

Compared to conventional open surgery, minimally invasive fusion surgery offered better scores for low back pain and Oswestry Disability Index, lower complication rates, reduced bleeding, and shorter hospital stays. However, minimally invasive fusion surgery did not show a significant advantage in terms of fusion rate and had a longer operative time.

Full-Endoscopic Posterior Lumbar Interbody Fusion: A Review and Technical Note

Remarkable innovations in spinal endoscopic surgery have broadened its applications over the past 20 years. Full-endoscopic fusions have been widely reported, and several full-endoscopic approaches for interbody fusion have been published. In general, full-endoscopic lumbar interbody fusion (LIF) is called Endo-LIF, and facet-preserving Endo-LIF through the transforaminal route is called trans-Kambin's triangle LIF, which has a relatively longer history than facet-sacrificing Endo-LIF via the posterolateral route. Both approaches can reduce intraoperative and postoperative bleeding. However, there is a higher risk of subsidence and exit nerve root injury. There is no direct decompression in either of the interbody fusions, and additional decompression is required if there is severe lumbar bony canal stenosis. However, the posterior interlaminar approach, which is a well-known standard in full-endoscopic spine surgery, has rarely been applied in the field of endoscopic lumbar fusion surgery. Full-endoscopic posterior LIF (FE-PLIF) via an interlaminar approach can accomplish direct decompression of bony canal stenosis and safe interbody fusion. FE-PLIF via an interlaminar approach demonstrated a longer operation time, less blood loss, and shorter hospitalization duration than minimally invasive transforaminal LIF. FE-PLIF, which can accomplish direct decompression for bony spinal canal stenosis, is superior to other Endo-LIFs. However, FE-PLIF requires technical dexterity to improve efficiency and reduce technical complexity.

Complications in Minimally Invasive Spine Surgery in the Last 10 Years: A Narrative Review

OBJECTIVE

Minimally invasive spine surgery (MISS) employs small incisions and advanced techniques to minimize tissue damage while achieving similar outcomes to open surgery. MISS offers benefits such as reduced blood loss, shorter hospital stays, and lower costs. This review analyzes complications associated with MISS over the last 10 years, highlighting common issues and the impact of technological advancements.

METHODS

A systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines was conducted using PubMed, MEDLINE, Embase via OVID, and Cochrane databases, covering publications from January 2013 to March 2024. Keywords related to MISS and complications were used. Studies on adult patients undergoing MISS with tubular, uniportal, or biportal endoscopy, reporting intraoperative or postoperative complications, were included. Non-English publications, abstracts, and small case series were excluded. Data on MISS approach, patient demographics, and complications were extracted and reviewed by 2 independent researchers.

RESULTS

The search identified 880 studies, with 137 included after screening and exclusions. Key complications in cervical MISS were hematomas, transient nerve root palsy, and dural tears. In thoracic MISS, complications included cerebrospinal fluid leaks and durotomy. In lumbar MISS, common complications were incidental dural injuries, postoperative neuropathic conditions, and disc herniation recurrences. Complications varied by surgical approach.

CONCLUSION

MISS offers reduced anatomical disruption compared to open surgery, potentially decreasing nerve injury risk. However, complications such as nerve injuries, durotomies, and hardware misplacement still occur. Intraoperative neuromonitoring and advanced technologies like navigation can help mitigate these risks. Despite variability in complication rates, MISS remains a safe, effective alternative with ongoing advancements enhancing its outcomes.

Treatment of lumbar disc herniation with robot combined with unilateral biportal endoscopic technology: A case report

BACKGROUND

This reported procedure combines the orthopedic surgical robot with the unilateral biportal endoscopy-lumbar interbody fusion (UBE-LIF), utilizing the UBE's wide viewing field and operating space to perform minimally invasive decompressive fusion of the lesioned segment, and the orthopedic surgical robot's intelligence and precision to perform percutaneous pedicle screw placement. The advancement of this procedure lies in the superposition of advantages and offsetting disadvantages of the two new technologies, and the maximum effect of treatment is achieved with maximum minimization of invasiveness and precision under the monitoring of imaging instruments to maximize the benefit of patients, and this review reports a case of multiple-segment lumbar decompression and fusion surgery for lumbar disc herniation via robot-assisted UBE for reference.

CASE SUMMARY

A 44-year-old patient presented to our hospital. Combining various clinical data, we diagnosed the patient with lumbar disc herniation with radiculopathy, lumbar spondylolisthesis, and lumbar spinal stenosis. We developed a surgical plan of "UBE decompression + UBE-LIF + orthopedic surgery robot-assisted percutaneous pedicle screw implantation for internal fixation". The results were satisfactory.

CONCLUSION

We present an extremely rare case of multiple-segment lumbar decompression and fusion surgery for lumbar disc herniation via robot-assisted UBE and achieved good results. Therefore, the technique is worthy of clinical promotion.

Innovative Developments in Lumbar Interbody Cage Materials and Design: A Comprehensive Narrative Review

This review comprehensively examines the evolution and current state of interbody cage technology for lumbar interbody fusion (LIF). This review highlights the biomechanical and clinical implications of the transition from traditional static cage designs to advanced expandable variants for spinal surgery. The review begins by exploring the early developments in cage materials, highlighting the roles of titanium and polyetheretherketone in the advancement of LIF techniques. This review also discusses the strengths and limitations of these materials, leading to innovations in surface modifications and the introduction of novel materials, such as tantalum, as alternative materials. Advancements in three-dimensional printing and surface modification technologies form a significant part of this review, emphasizing the role of these technologies in enhancing the biomechanical compatibility and osseointegration of interbody cages. In addition, this review explores the increase in biodegradable and composite materials such as polylactic acid and polycaprolactone, addressing their potential to mitigate long-term implant-related complications. A critical evaluation of static and expandable cages is presented, including their respective clinical and radiological outcomes. While static cages have been a mainstay of LIF, expandable cages are noted for their adaptability to the patient's anatomy, reducing complications such as cage subsidence. However, this review highlights the ongoing debate and the lack of conclusive evidence regarding the superiority of either cage type in terms of clinical outcomes. Finally, this review proposes future directions for cage technology, focusing on the integration of bioactive substances and multifunctional coatings and the development of patient-specific implants. These advancements aim to further enhance the efficacy, safety, and personalized approach of spinal fusion surgeries. Moreover, this review offers a nuanced understanding of the evolving landscape of cage technology in LIF and provides insights into current practices and future possibilities in spinal surgery.

A Comparison of 2 Cage Sizes in Biportal Endoscopic Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

This study compared the fusion and subsidence rate and clinical outcomes when using different-sized static PEEK cages in BE-TLIF.

SUMMARY OF BACKGROUND DATA

Biportal endoscopic techniques for transforaminal lumbar interbody fusion (BE-TLIF) have been shown to have similar clinical and fusion outcomes with faster clinical recovery in comparison to tubular surgery. Subsidence of the interbody, however, could be a complication.

METHODS

Patients who underwent 1 or 2 level BE-TLIF for degenerative and isthmic spondylolisthesis between January 2019 and January 2022 were included. A 32×10 mm cage (group A) and a 40×15 mm cage (group B) were compared. The visual analog scale (VAS) for back and leg symptoms, and Oswestry disability index (ODI) were collected. Plain radiographs and computed tomography assessed fusion and subsidence at a minimum of 12 months.

RESULTS

Of the 69 enrolled patients, 39 group A patients (51 levels) and 30 group B patients (32 levels) were compared. The operation time per level was 123 ± 15.8 and 138 ± 10.5 minutes per fusion level in groups A and B, respectively (P < 0.05). ODI improved from 64.8 ± 6.2 to 15.7 ± 7.1 in group A and from 65.3 ± 5.6 to 15.1 ± 6.3 in group B at the final follow-up (P < 0.05). VAS leg and back score improvement between the groups did not differ; however, the 3-month postoperative VAS back improvement was significantly higher in group B. The final fusion rate at the final follow-up did not significantly differ; however, the fusion ratio at 1 year was higher in group B (P < 0.05). Subsidence occurred in 5 cases (9.8%) in group A and none in group B (P < 0.05).

CONCLUSION

BE-TLIF using a larger cage can be performed safely with similar patient-reported outcome measures with a faster fusion rate with less subsidence risk.

LEVEL OF STUDY

III.

Evaluation of the learning curve and complications in unilateral biportal endoscopic transforaminal lumbar interbody fusion: cumulative sum analysis and risk-adjusted cumulative sum analysis

PURPOSE

To evaluate the learning curve and complications in unilateral biportal endoscopic transforaminal lumbar interbody fusion (ULIF) using the Cumulative Sum (CUSUM) analysis and Risk-adjusted Cumulative Sum (RA-CUSUM) analysis.

METHODS

This study retrospectively analyzed 184 consecutive patients who received ULIF in our hospital, including 104 males and 80 females. CUSUM analysis and RA-CUSUM analysis were used to evaluate the learning curve of ULIF based on the operation time and surgical failure rate, respectively. All postoperative complications were defined as surgical failure. Variables of different phases were compared based on the learning curve.

RESULTS

The CUSUM analysis showed the cutoff point for ULIF was 29 cases, and the RA-CUSUM analysis showed the cutoff point for ULIF was 41 cases. Operating time and hospital stay were significantly decreased as the learning curve progressed (P < 0.05). Visual analogue score (VAS) and Oswestry disability index (ODI) at the last follow-up were significantly lower than preoperatively. At the last follow-up, a total of 171 patients reached intervertebral fusion, with a fusion rate of 92.9% (171/184). A total of eleven complications were observed, and RA-CUSUM analysis showed that the incidence of complications in the early phase was 17.07% and in the late phase was 2.6%, with a significant difference (P < 0.05).

CONCLUSION

ULIF is an effective minimally invasive lumbar fusion surgical technique. But a learning curve of at least 29 cases will be required to master ULIF, while 41 cases will be required to achieve a stable surgical success rate.

The clinical effect of unilateral decompressive laminectomy plus fusion with unilateral biportal endoscopic technique for single level lumbar spinal stenosis

PURPOSE

This study aimed to compare and analyze the effectiveness of unilateral biportal endoscopic (UBE) decompressive laminectomy plus fusion and microscope-assisted open decompressive laminectomy plus fusion.

METHODS

A total of 143 patients with lumbar spinal stenosis were enrolled in this study between March 2020 and February 2021 with a minimum 2 years follow-up visit to our hospital. Sixty-five patients underwent the unilateral biportal endoscopic technique and were assigned to the UBE group, and the remaining 78 patients with microscope assistant were assigned to the Microscope group. The baseline characteristics, clinical outcomes, and radiological data were retrospectively collected and analyzed, as well as Clinical outcomes, radiological data and complications.

RESULTS

There were no significant differences between the two groups in terms of baseline characteristics (P > 0.05). The UBE group was demonstrated to be significantly superior in CRP, drainage, blood loss, treatment cost and Hospital stay than the Microscope group (P < 0.05), whereas a significant longer operation time was observed (P < 0.05). The VAS-B, ODI, and JOA-L scores of the UBE group at 1 year follow-up were significantly greater than those of the Microscope group (P < 0.05). Regarding radiological data, there were no significant differences in the section area of the spinal canal and fusion grade between the two groups (P > 0.05).

CONCLUSION

In view of the satisfactory clinical outcomes of patients and notable decompression at the stenosed segment, UBE is a feasible, minimally invasive technique for single level lumbar canal stenosis.

Endoscopic Lumbar Interbody Fusion, Minimally Invasive Transforaminal Lumbar Interbody Fusion, and Open Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Degenerative Diseases: A Systematic Review and Network Meta-Analysis

STUDY DESIGN

network meta-analysis.

OBJECTIVE

To compare the clinical efficacy and safety of endoscopic lumbar interbody fusion (Endo-LIF), minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and open transforaminal lumbar interbody fusion (OTLIF) in the treatment of lumbar degenerative diseases (LDDs).

METHOD

A literature search was conducted in the PubMed, Embase, and Cochrane Library databases. Studies comparing Endo-LIF, MIS-TLIF and OTLIF published from September 2017 to September 2022 for the treatment of LDD were retrieved. Data were extracted from preset clinical outcome measures, including operation time, estimated intraoperative estimated blood loss (EBL), length of hospital stay (LOS), complications, visual analog scale (VAS) score, Oswestry disability index (ODI) score, etc.

RESULT

Thirty-one studies with 3467 patients were included in this study. Network meta-analysis showed that in the comparison of the 3 procedures, Endo-LIF was superior to MIS-TLIF and OTLIF in terms of reducing EBL, LOS, time to ambulation, and VAS score of back pain. MIS-TLIF was superior to Endo-LIF in terms of ODI improvement, and OTLIF required the shortest intraoperative fluoroscopy time. There was no significant difference in operative time, complication rate, fusion rate, VAS score of leg pain, or JOA score among the 3 procedures.

CONCLUSION

Endo-LIF, MIS-TLIF and OTLIF each have their own advantages and disadvantages and show similar results in many respects, except for better early outcomes achieved with the more minimally invasive procedure.

The Endoscopic Lumbar Interbody Fusion: A Narrative Review, and Future Perspective

Lumbar interbody fusion stands as a preferred surgical solution for degenerative lumbar spine diseases. The procedure primarily aims to establish lumbar segment stability, directly addressing patient symptoms associated with spinal complications. Traditional open surgery, though effective, is linked with notable morbidities and extended recovery time. To mitigate these concerns, minimally invasive surgery (MIS) has garnered significant popularity, presenting an appealing alternative with numerous benefits such as reduced soft tissue trauma, decreased blood loss, and expedited recovery. Among MIS procedures, full endoscopic spinal surgery, characterized by its minimal invasiveness, holds the potential to further minimize morbidities while enhancing surgical outcomes. Endoscopic lumbar interbody fusion, a novel procedure within this paradigm, has gained attention for offering advantages comparable to those of minimally invasive transforaminal lumbar interbody fusion. However, the safety, efficacy, and associated surgical techniques and instrument design of this method continue to be subjects of ongoing debate. This paper critically reviews current evidence on the safety, efficacy, and advantages of endoscopic lumbar spinal interbody fusion, examining whether it could indeed supersede existing mainstream techniques.

Comparing the efficacy of unilateral biportal endoscopic transforaminal lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion in lumbar degenerative diseases: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of unilateral biportal endoscopic transforaminal lumbar interbody fusion (BE-TLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in lumbar degenerative diseases.

METHODS

This study was registered on International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42023432460). We searched PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wan Fang Database, and Wei Pu Database by computer to collect controlled clinical studies on the efficacy and safety of unilateral BE-TLIF and MIS-TLIF in lumbar degenerative diseases from database establishment to May 2023. Two researchers screened the literature, extracted data and evaluated the risk of bias of the included studies, recorded the authors, and sample size, and extracted the intraoperative blood loss, operation time, postoperative drainage, Oswestry disability index, Visual analogue scale, lumbar lordosis, disk height, hospital length stay, fusion rate, and complications in each study. Meta-analysis was performed using Revman 5.4 software provided by Cochrane Library.

RESULTS

A total of 14 cohort studies with a total of 1007 patients were included in this study, including 472 patients in the BE-TLIF group and 535 patients in the MIS-TLIF group. The BE-TLIF group had lower intraoperative blood loss than the MIS-TLIF group [mean difference (MD) = - 78.72, 95% CI (- 98.47, - 58.97), P < 0.00001] and significantly reduced postoperative drainage than the MIS-TLIF group [MD = - 43.20, 95% CI (- 56.57, - 29.83), P < 0.00001], and the operation time was longer than that of the MIS-TLIF group [MD = 22.68, 95% CI (12.03, 33.33), P < 0.0001]. Hospital length stay in BE-TLIF group was significantly less than that in MIS-TLIF group [MD = - 1.20, 95% CI (- 1.82, - 0.57), P = 0.0002].

CONCLUSION

Compared with MIS-TLIF, BE-TLIF for lumbar degenerative diseases has the advantages of less intraoperative blood loss, less early postoperative low back and leg pain, shorter postoperative hospital length stay, and faster early functional recovery.

Complications of Endoscopic Thoracic Spine Surgery: Overview and Complication Avoidance

In endoscopic thoracic spine surgery, adaptations of thoracic surgical techniques such as full endoscopic uniportal and biportal surgical techniques have been developed. Full endoscopic uniportal surgery for thoracic disc herniation or thoracic ossified ligamentum flavum (OLF) has been performed via transforaminal and interlaminar approaches. In the case of thoracic OLF or thoracic spinal stenosis, the uniportal interlaminar approach is appropriate. The uniportal interlaminar approach has been used to treat thoracic OLF and has shown good surgical results. Thoracic OLF removal via a biportal endoscopic technique has been developed recently and is described in a few studies. Although endoscopic thoracic spine surgery has significant advantages, complications often occur with this approach. We reviewed the literature to date on the complications associated with endoscopic spine surgery in thoracic pathology. This review emphasizes how to avoid and manage complications. Based on the results of several previous studies, endoscopic thoracic spine surgery could be associated with fewer potential complications than conventional surgery. Endoscopic spine surgery has remarkable advantages; however, endoscopic thoracic surgery is technically challenging and is potentially associated with serious complications. To minimize the risk of avoidable complications, surgeons should be familiar with prevention methods and pitfalls.

Unilateral biportal endoscopic transforaminal lumbar interbody fusion versus conventional interbody fusion for the treatment of degenerative lumbar spine disease: a systematic review and meta-analysis

BACKGROUND

This meta-analysis compares the efficacy of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) to conventional interbody fusion in lumbar degenerative diseases (LDD).

METHODS

An extensive literature search was conducted in PubMed, Web of Science, and the Cochrane Library. Research related to UBE-TLIF published up to November 2022 was reviewed. The relevant articles were selected based on inclusion and exclusion criteria, as well as an evaluation of the quality of the data extraction literature. Meta-analysis was performed using Review Manager 5.3 software.

RESULTS

This meta-analysis included six high-quality case-control trials (CCTs) involving 621 subjects. The clinical outcomes assessment showed no statistical differences in complication rates, fusion rates, leg pain VAS scores, or ODI scores. After UBE-TLIF, low back pain VAS scores were significantly improved with less intraoperative blood loss and a shorter hospital stay. A longer time was required for UBE-TLIF, however.

CONCLUSION

Despite the lack of sufficient high quality randomized controlled trials (RCTs) in this study, the results of this meta-analysis suggest that UBE-TLIF is more effective than open surgery in terms of length of stay, blood loss reduction during surgery, and improved low back pain after surgery. Nevertheless, the evidence will be supplemented in the future by more and better quality multicenter randomized controlled trials.

A Beginner's Perspective on Biportal Endoscopic Spine Surgery in Single-Level Lumbar Decompression: A Comparative Study with a Microscopic Surgery

Background

The application of biportal endoscopic spinal surgery (BESS) in spine surgery is increasing. However, the clinical results of related studies have been inconsistent. In this study, the perioperative and clinical outcomes of two techniques in single-level lumbar decompression surgery were compared using the perspective of a spine surgeon experienced in microscopic surgery but inexperienced in BESS.

Methods

This is a retrospective study performed with prospectively collected data. From April 2019, 50 consecutive patients who underwent a single-level lumbar decompression surgery with BESS were evaluated. Additionally, the data of 150 consecutive patients who underwent the same microscopic surgery before April 2019 were collected. We performed 1 : 1 ratio propensity score matching for these two groups to adjust for baseline variables. The postoperative patient-reported outcome measures included the Oswestry Disability Index (ODI) and numeric rating scale for the back and leg preoperatively and at 6 months after surgery. The laboratory data (C-reactive protein [CRP, mg/L] and hemoglobin [Hb, g/dL]) were measured preoperatively and 3 times (1, 2, and 3 or 4 days) postoperatively. In these periods, the peak and lowest CRP and Hb concentrations were evaluated. The perioperative outcomes, operation time (from skin incision to dressing), length of hospital stay, drainage (for 24 hours after surgery), and surgery-related complications were also evaluated.

Results

Forty-seven patients (27 men and 20 women) were included in each group. The postoperative 6-month ODI was significantly lower in the BESS group than in the microscope group (6.90 ± 5.98 vs. 11.54 ± 9.70). The peak CRP concentration (16.63 ± 19.41 vs. 42.40 ± 37.73, p < 0.001) and CRP increment (peak CRP minus preoperative CRP, 14.69 ± 19.47 vs. 40.71 ± 37.32, p < 0.001) were significantly higher in the microscope group. Operation time (83.72 ± 35.71 vs. 70.27 ± 23.24, p = 0.047) was significantly longer in the BESS group. Surgery-related complications were found in 6 and 3 cases in the BESS group (3 revisions, 2 dural tears, and 1 conversion to open surgery) and microscope group (2 revisions and 1 hematoma), respectively.

Conclusions

BESS as a new technique resulted in satisfying short-term outcomes. It was a well-tolerated option for surgical treatment of single-level lumbar degenerative disease. The relatively high incidence of recurrence at the index level and incidental dural tears should be considered for surgeons new to BESS; however, these were manageable complications.

Comparison of efficacy between unilateral biportal endoscopic lumbar fusion versus minimally invasive transforaminal lumbar fusion in the treatment of lumbar degenerative diseases: A systematic review and meta-analysis

BACKGROUND

To evaluate the clinical efficacy and prognosis of unilateral biportal endoscopic lumbar fusion (ULIF) and minimally invasive transforaminal lumbar fusion (MIS-TLIF) for lumbar degenerative diseases.

METHODS

Chinese and English databases were retrieved for the period from database creation to December 31, 2022. Case-control studies on unilateral biportal endoscopic lumbar fusion were collected. The observation indexes consisted of operation times, intraoperative blood loss, postoperative drainage volume, length of hospital stay, postoperative pain score, postoperative oswestry disability index score, postoperative MacNab excellent and good rate, imaging fusion rate at the last follow-up, and complications. The NO rating table was employed to assess the quality of the included literature, and a meta-analysis was conducted using Revman5.4.1 and Stata17.

RESULTS

Ten studies with 738 surgical patients were considered, including 347 patients in the ULIF group and 391 in the MIS-TLIF group. This Meta-analysis demonstrated statistically significant differences in mean operation duration, intraoperative blood loss, postoperative drainage volume, length of hospital stay, and early postoperative (1-2W) visual analogue scale/score (VAS) scores for back pain. No significant differences were observed in the final follow-up postoperative VAS scores for back pain, postoperative leg VAS score, postoperative oswestry disability index score, excellent and good rate of postoperative modified MacNab, imaging fusion rate, and complications.

CONCLUSION

Compared with the MIS-TLIF group, the ULIF group had longer operation time, lower intraoperative blood loss and postoperative drainage volume, lower lumbar VAS score in the early postoperative period, and shorter hospital stay. ULIF is less invasive than traditional MIS-TLIF, making it a trustworthy surgical option for lumbar degenerative diseases with comparable fusion efficiency, superior MacNab rate, and complication rate.

Minimally invasive transforaminal lumbar interbody fusion by a novel two-medium compatible bichannel endoscopy system, technique note and preliminary clinical results

PURPOSE

Our team designed a novel two-medium compatible bichannel endoscopy system for spinal surgery, V-shape bichannel endoscopy (VBE) system. Hereby, this study will introduce minimally invasive transforaminal lumbar interbody fusion (TLIF) with VBE system and report its preliminary clinical results.

METHODS

Fifty-two participants, who accepted VBE-assisted TLIF surgery (VBE-TLIF) in our hospital were included in this study. The duration of operation, off-bed time, and days of hospitalization were recorded. Besides, the patient's preoperative and postoperative pain were evaluated via visual analog scale (VAS), the functional status was evaluated via Oswestry dysfunction index (ODI) and modified MacNab criteria. Patients were asked to follow-up in the outpatient department at the 3rd, 6th, 12th, and 24th month after surgery. X-ray or CT was examined to evaluate the internal fixation position and interbody fusion result.

RESULTS

All patients received unilateral decompression with an average operation duration of 178.49 ± 27.49 min. After the surgery, their VAS score of leg pain and back pain reduced significantly. At the last follow-up, the VAS score of leg pain and back pain was 0.80 ± 0.69 and 0.86 ± 0.75 separately. The difference shows statistically significant with p < 0.05. At the last follow-up, the ODI was 15.20 ± 5.75. According to modified MacNab criteria, 39 patients rated their function as excellent, and 10 patients were good. The overall satisfaction rate reached 94%.

CONCLUSION

The VBE system reported in the current study can complete TLIF surgery safely and effectively.

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.

Transforaminal Interbody Fusion Using the Unilateral Biportal Endoscopic Technique Compared With Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Spine Diseases: Analysis of Clinical and Radiological Outcomes

BACKGROUND

There has been a widespread application of minimally invasive spinal surgery techniques in the past few years. Unilateral biportal endoscopic has been successfully used in a variety of lumbar spine diseases, but there are few studies on lumbar fusion assisted by unilateral biportal endoscopy.

OBJECTIVE

To compare the clinical and radiological outcomes of transforaminal interbody fusion using the unilateral biportal endoscopic technique (UBEIF) and transforaminal lumbar interbody fusion (TLIF) in patients with lumbar disease.

METHODS

We studied 128 patients, 58 in the UBEIF group and 70 in the TLIF group. The Oswestry disability index, creatine kinase, visual analog score (VAS) for leg and back pain were used to assess clinical outcomes. Radiographic outcomes were assessed using the fusion rate, internal fixation loosening, and adjacent segment degeneration.

RESULTS

Back and leg pain VAS scores in both groups were significantly lower 3, 6, and 12 months after surgery ( P < .05). A significant reduction in Oswestry disability index in both groups was observed 6 and 12 months after surgery ( P < .05). Compared with the TLIF group at 1 week after surgery, UBEIF patients' VAS score for back pain significantly improved ( P < .05). There was no difference in fusion rate between the 2 groups (98.27% vs 98.57%).

CONCLUSION

UBEIF and TLIF have similar clinical and radiographic outcomes in the treatment of single-segment lumbar disease with lumbar instability, including improved back and leg pain, improved disability, and high fusion rates. Furthermore, with UBEIF, less blood is lost, there is better relief of early back pain, and hospital stays are shorter.

Biportal endoscopic extraforaminal lumbar interbody fusion using a 3D-printed porous titanium cage with large footprints: technical note and preliminary results

PURPOSE

The aim of this study was to introduce biportal endoscopic extraforaminal lumbar interbody fusion (BE-EFLIF), which involves insertion of a cage through a more lateral side as compared to the conventional corridor of transforaminal lumbar interbody fusion. We described the advantages and surgical steps of 3D-printed porous titanium cage with large footprints insertion through multi-portal approach, and preliminary results of this technique.

METHODS

This retrospective study included 12 consecutive patients who underwent BE-EFLIF for symptomatic single-level lumbar degenerative disease. Clinical outcomes, including a visual analog scale (VAS) for back and leg pain and the Oswestry disability index (ODI), were collected at preoperative months 1 and 3, and 6 months postoperatively. In addition, perioperative data and radiographic parameters were analyzed.

RESULTS

The mean patient age, follow-up period, operation time, and volume of surgical drainage were 68.3 ± 8.4 years, 7.6 ± 2.8 months, 188.3 ± 42.4 min, 92.5 ± 49.6 mL, respectively. There were no transfusion cases. All patients showed significant improvement in VAS and ODI postoperatively, and these were maintained for 6 months after surgery (P < 0.001). The anterior and posterior disc heights significantly increased after surgery (P < 0.001), and the cage was ideally positioned in all patients. There were no incidences of early cage subsidence or other complications.

CONCLUSIONS

BE-EFLIF using a 3D-printed porous titanium cage with large footprints is a feasible option for minimally invasive lumbar interbody fusion. This technique is expected to reduce the risk of cage subsidence and improve the fusion rate.

Comparison of surgical invasiveness, hidden blood loss, and clinical outcome between unilateral biportal endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative disease: a retrospective cohort study

BACKGROUND

Currently, hidden blood loss (HBL) has been paid more and more attention by spine surgeons. Simultaneously, it has been the effort of spine surgeons to explore more advantages of minimally invasive surgery. More and more articles have compared unilateral biportal endoscopic lumbar interbody fusion (BE-LIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). But so far, there is no HBL comparison between BE-LIF and MIS-TLIF. This study aims to compare the surgical invasiveness, hidden blood loss, and clinical outcome of BE-LIF and MIS-TLIF and to provide insight regarding minimally invasive surgery for lumbar degenerative disease (LDD).

METHODS

We enrolled 103 eligible patients with LDD who underwent BE-LIF (n = 46) and MIS-TLIF (n = 57) during August 2020-March 2021. We collected data, including demographics, perioperative haematocrit, operative and postoperative hospital times, serum creatine kinase (CK) and C-reactive protein (CRP) levels, and hospitalization costs. Total and hidden blood loss was calculated. Clinical outcomes were assessed using a visual analogue scale (VAS) score for back and leg pain, Oswestry Disability Index (ODI), modified MacNab criteria, fusion rate, and complications.

RESULTS

Basic demographics and surgical data were comparable. The CRP and CK levels were generally lower in the BE-LIF than in the MIS-TLIF group, especially CRP levels on postoperative day (POD) three and CK levels on POD one. True total blood loss, postoperative blood loss, and hidden blood loss were significantly reduced in the BE-LIF group compared with the MIS-TLIF group. Postoperative hospital times was statistically significantly shorter in the BE-LIF group. The VAS pain and ODI scores improved in both groups. At three days and one month, the VAS lower back pain scores were significantly better after BE-LIF. Clinical outcomes did not otherwise differ between groups.

CONCLUSIONS

Compared with MIS-TLIF, BE-LIF has similar medium and short-term clinical outcomes. However, it is better regarding surgical trauma, early lower back pain, total and hidden blood loss, and recovery time. BE-LIF is an adequate option for selected LDD.

Postoperative bone graft migration into the thecal sac and shifting down to the lower level after an endoscopic lumbar interbody fusion: a case report

BACKGROUND

Postoperative bone graft migration (PBGM) is a fairly rare spinal postoperative complication. Its occurrence after endoscopic surgery has rarely been reported in the literature so far. This is a case report of a 52-year-old male occurring PBGM into the thecal sac in the 8th days after an endoscopic lumbar interbody fusion (ELIF), which can make surgeons more minded with such serious rare complication after BGM.

CASE PRESENTATION

A 52-year-old male patient, underwent a L4-5 ELIF, presented with an acute radiculopathy on right leg and urinary incontinence in the 8^th postoperative day. An emergency lumbar Computed Tomography(CT scan) and Magnetic Resonance Imaging (MRI) demonstrated bone graft migration into the thecal sac at the L4-5 level, and shifting down to the lower level. The revision surgery was performed at once successfully. Finally, the patient got well managed before discharge.

CONCLUSION

Supported by this case report, we believe that PBGM into the thecal sac is a rare but horrible complication of ELIF. However, too much volume of bone graft and its posterior placement are more prone to developing this complication. Finally, we are not sure that the outcome presented in this study will be repeated in future cases.

Clinical outcomes of unilateral biportal endoscopic lumbar interbody fusion (ULIF) compared with conventional posterior lumbar interbody fusion (PLIF)

BACKGROUND CONTEXT

In recent years, unilateral biportal endoscopic lumbar interbody fusion (ULIF) has been more and more favored by spinal surgeons because of its advantages of low trauma, rapid recovery, high fusion rate and fewer complications.

PURPOSE

To compare the clinical effects of ULIF with those of conventional open posterior lumbar interbody fusion (PLIF).

STUDY DESIGN

Prospective case control study.

PATIENT SAMPLE

Twenty-seven patients treated by ULIF and thirty-three patients treated by PLIF.

OUTCOME MEASURES

The preoperative baseline and surgical technique-related outcomes (mean operation time, blood loss during operation, postoperative drainage, and postoperative hospital stay) were compared between the two groups. The clinical status of the two groups before and after surgery were also compared: visual analogue scale (VAS) score of the legs and back, Japanese Orthopedic Association (JOA) score and Oswestry Disability Index (ODI). The clinical laboratory indexes of the two groups before and after the operation were compared: C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), creatine phosphokinase (CPK), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), as well as the incidence of complications, such as dural tear, nerve root injury and infection.

METHODS

Adult patients who underwent L3-S1 single level lumbar interbody fusion were included in the study. They were divided into a PLIF group and a ULIF group according to the type of surgery. This study comprised 60 cases: 27 cases in the ULIF group and thirty-three cases in the PLIF group.

RESULTS

There was no significant difference in preoperative baseline between the two groups. The ULIF group experienced less blood loss, postoperative drainage and a shorter postoperative hospital stay than the PLIF group; however the ULIF group required a longer operation time than the PLIF group (p<.05). CRP, ESR, CPK, IL-6, and TNF-α levels of the PLIF group were all significantly higher than those of the ULIF group 5 days after surgery (p<.05). The improvements in the VAS scores for back pain, VAS scores for leg pain and JOA score in the ULIF group were all significantly better than those in the PLIF group at 5 days after surgery (p<.05). There was no significant difference in fusion rate at 6 months between the 2 groups (p>.05).

CONCLUSIONS

This study showed that ULIF and PLIF were both effective surgical techniques for lumbar interbody fusion. However, ULIF caused less bleeding, reduced inflammatory reaction, less tissue damage and faster postoperative recovery compared with PLIF. Both long-term follow-up and larger clinical studies are needed to validate the clinical and radiological results of this surgery.

A single-arm retrospective study of the clinical efficacy of unilateral biportal endoscopic transforaminal lumbar interbody fusion for lumbar spinal stenosis

Objective

The purpose of this study was to investigate the clinical efficacy of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) for lumbar spinal stenosis (LSS).

Methods

Patients who underwent UBE-TLIF due to single-segment LSS between August 2019 and July 2021 were retrospectively included in the study. Clinical outcomes evaluated include operative time, estimated blood loss (including postoperative drainage), time to ambulation, postoperative hospital stay, complications, visual analog scale (VAS) scores of low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, Oswestry disability index (ODI), and modified Macnab criteria. Interbody bony fusion at the index level was assessed using Bridwell grading criteria.

Results

A total of 73 patients (29 males and 44 females) were enrolled in this study. All surgeries were successfully performed without intraoperative conversion to open surgery. Magnetic resonance imaging (MRI) revealed optimal direct neural decompression after UBE-TLIF. The mean operative time was 150.89 ± 15.58 min. The mean estimated blood loss was 126.03 ± 17.85 ml (postoperative drainage was 34.84 ± 8.31 ml). Time to ambulation was 2.0 ± 0.75 days after the procedure. Postoperatively, the mean hospital stay was 5.96 ± 1.38 days. VAS scores of low back pain and leg pain, JOA, and ODI were significantly improved postoperatively compared with those before the operation, and differences were statistically significant (P < 0.05). Excellent and good outcomes were reported by 87.67% of patients according to the modified Macnab criteria at the final follow-up. A total of nine perioperative complications occurred, with an incidence of 12.33%. X-ray or computerized tomography (CT) 6 months after the procedure showed that 37 cases (50.68%) presented with segmental fusion, 30 cases (41.10%) showed incomplete fusion, and 6 cases (8.22%) showed no signs of fusion. However, bony fusion was achieved in all cases at the final follow-up.

Conclusions

UBE-TLIF for LSS has the advantages of less surgical invasiveness and fast postoperative recovery.

Unilateral biportal endoscopic lumbar interbody fusion enhanced the recovery of patients with the lumbar degenerative disease compared with the conventional posterior procedures: A systematic review and meta-analysis

Background

Minimally invasive endoscopic technique is an important component of Enhanced Recovery After Surgery (ERAS) protocol for neurosurgery. In recent years, unilateral biportal endoscopic lumbar interbody fusion (ULIF) has been used in the treatment of lumbar degenerative diseases (LDD). This study aims to investigate whether ULIF could enhance the recovery of patients with LDD compared with the conventional minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) or posterior lumbar interbody fusion (PLIF).

Methods

A comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, Cochrane Library database, China National Knowledge Internet, and Wanfang database. Surgical data, clinical outcomes, radiographic outcomes, and surgical complications were compared between patients with LDD who underwent ULIF and those who underwent conventional MI-TLIF or PLIF.

Results

Notably, 12 studies, comprising 981 patients with LDD, were included. Of these patients, 449 underwent ULIF and 532 patients (355 MI-TLIF and 177 PLIF) were treated with conventional procedures. There was no significant difference in the fusion rate, cage subsidence rate, and surgical complications between the ULIF group and the MI-TLIF or PLIF group. Compared with MI-TLIF, the ULIF group presented a significantly reduced estimated blood loss (EBL) (WMD, -106.00; 95% CI -140.99 to -71.10, P < 0.001) and shorter length of hospital stay (LOS) (WMD, -1.27; 95% CI -1.88 to -0.66, P < 0.001); better short-term improvement in ODI (WMD, -2.12; 95% CI -3.53 to -0.72, P = 0.003) and VAS score for back pain (VAS-BP) (WMD, -0.86; 95% CI -1.15 to -0.58, P < 0.001) at 1 month post-operatively. Compared with PLIF, the ULIF group presented a significantly reduced EBL (WMD, -149.22; 95% CI -284.98 to -13.47, P = 0.031) and shorter LOS (WMD, -4.40; 95% CI -8.04 to -0.75, P = 0.018); better short-term improvement in VAS-BP (WMD, -1.07; 95% CI -1.77 to -0.38, P = 0.002) and VAS score for leg pain (VAS-LP) (WMD, -0.40; 95% CI -0.72 to -0.08, P = 0.014) at 1-2 week post-operatively; enhanced short- and long-term improvement in ODI at 1 month post-operatively (WMD, -3.12; 95% CI -5.72 to -0.53, P = 0.018) and the final follow-up (WMD, -1.97; 95% CI -3.32 to -0.62, P = 0.004), respectively.

Conclusion

Compared with conventional MI-TLIF and PLIF, ULIF was associated with reduced EBL, shorter LOS, and comparable fusion rate as well as complication management. Compared with MI-TLIF, a better short-term improvement in VAS-BP and ODI was achieved by ULIF; compared with open PLIF, additional enhanced short-term improvement in VAS-LP and long-term improvement in ODI were observed in ULIF. ULIF could enhance the recovery of patients with LDD compared with conventional posterior procedures.

Systematic trial registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=230695, CRD42021230695.

"Cave-in" decompression under unilateral biportal endoscopy in a patient with upper thoracic ossification of posterior longitudinal ligament: Case report

Background

Thoracic ossification of the posterior longitudinal ligament (TOPLL) requires surgery for spinal cord decompression. Traditional open surgery is extremely invasive and has various complications. Unilateral biportal endoscopy (UBE) is a newly developed technique for spine surgery, especially in the lumbar region, but rare in the thoracic spine. In this study, we first used a different percutaneous UBE "cave-in" decompression technique for the treatment of beak-type TOPLL.

Methods

A 31-year-old female with distinct zonesthesia and numbness below the T3 dermatome caused by beak-type TOPLL (T2-T3) underwent a two-step UBE decompression procedure. In the first step, the ipsilateral lamina, left facet joint, partial transverse process, and pedicles of T2 and T3 were removed. In the second step, a cave was created by removing the posterior third of the vertebral body (T2-T3). The eggshell-like TOPLL was excised by forceps, and the dural sac was decompressed. All procedures are performed under endoscopic guidance. A drainage tube was inserted, and the incisions were closed after compliance with the decompression scope via a C-arm. The patient's preoperative and postoperative radiological and clinical results were evaluated.

Results

Postoperative CT and MR films conformed complete decompression of the spinal cord. The patient's lower extremity muscle strength was greatly improved, and no complications occurred. The mJOA score improved from 5 to 7, with a recovery rate of 33.3%.

Conclusion

UBE spinal decompression for TOPLL showed favorable clinical and radiological results and offers the advantages of minimal soft tissue dissection, shorter hospital stays, and a faster return to daily life activities.

Complete removal of intraspinal extradural mass with unilateral biportal endoscopy

Introduction

Unilateral biportal endoscopic (UBE) technique can easily decompress the bony spinal canal and accommodate all open surgical instruments under endoscopic guidance. However, indications and reports of this technique have been limited to degenerative and infectious diseases.

Methods

We used the UBE technique for the decompression and removal of extradural mass lesions in five patients. Under endoscopic guidance, a unilateral approach was used, and decompression and flavectomy were performed. After decompression, removal of the tumor was performed using various forceps. We evaluated the technical process of the procedure, the patient's pre- and postoperative symptoms, and operative radiology and pathologic results.

Results

Postoperative pain and disability improved clinically for all patients. Four patients were confirmed as having an epidural cyst and one patient was diagnosed with hemangioma. During follow-up, no recurrence was observed.

Conclusions

We successfully removed five extradural mass lesions using a biportal endoscopic posterior approach without complications. The biportal endoscopic approach may have advantages, such as minimizing trauma to the normal structures, magnified endoscopic view, and early recovery after the surgery. Biportal endoscopy may be used as an alternative surgical treatment for symptomatic intraspinal extradural benign lesions.

Unilateral biportal endoscopic lumbar interbody fusion assisted by intraoperative O-arm total navigation for lumbar degenerative disease: A retrospective study

Background

Recently, unilateral biportal endoscopic lumbar interbody fusion (BE-LIF) has been successfully applied for degenerative diseases of the lumbar spine, with good clinical results reported. However, the drawbacks include radiation exposure, limited field of view, and steep learning curves.

Objective

This retrospective study aimed to compare the results between navigation and non-navigation groups and explore the benefits of BE-LIF assisted by intraoperative O-arm total navigation.

Methods

A total of 44 patients were retrospectively analyzed from August 2020 to June 2021. Perioperative data were collected, including operative time, estimated intraoperative blood loss, postoperative drainage, postoperative hospital stay, radiation dose, and duration of radiation exposure. In addition, clinical outcomes were evaluated using postoperative data, such as the Oswestry Disability Index (ODI), visual analog scale (VAS), modified MacNab criteria, Postoperative complications and fusion rate.

Results

The non-navigation and navigation groups included 23 and 21 patients, respectively. All the patients were followed up for at least 12 months. No significant differences were noted in the estimated intraoperative blood loss, postoperative drainage, postoperative hospital stay, fusion rate, or perioperative complications between the two groups. The radiation dose was significantly lower in the navigation group than in the non-navigation group. The average total operation time in the navigation group was lower than that in the non-navigation group (P < 0.01). All clinical outcomes showed improvement at different time points postoperatively, with no significant difference noted between the two groups (P > 0.05).

Conclusions

Compared with the non-navigation approach, O-arm total navigation assistive BE-LIF technology not only has similar clinical results, but also can provide accurate intraoperative guidance and help spinal surgeons achieve accurate decompression. Furthermore, it can reduce radiation exposure to surgeons and operation time, which improve the efficiency and safety of surgery.

Lumbar interbody fusion with bilateral cages using a biportal endoscopic technique with a third portal

BACKGROUND

Unilateral biportal endoscopic lumbar interbody fusion (ULIF) with one cage results in fewer definitive fusions (Park et al. in Neurosurg Rev 42(3):753-761, 2019). We succeeded in inserting bilateral cages during ULIF.

METHOD

We attempted posterior ULIF for degenerative lumbar spondylolisthesis with bilateral recess stenosis. With the help of a third portal, ULIF with bilateral cage insertion was performed under general anaesthesia.

CONCLUSIONS

We successfully performed ULIF with bilateral cages with the help of a third portal. This procedure may be an alternative for treating lumbar stenosis with instability.

Technical Note on Unilateral Biportal Lumbar Endoscopic Interbody Fusion

Unilateral biportal lumbar endoscopic interbody fusion is a relatively new technique in the field of minimally invasive spine surgery. It combines the benefits of preservation of the normal anatomy of the spine with direct visualization of the decompression of neural elements and endplate preparation for fusion. This results in high union rates and excellent outcomes for patients with back pain and lumbar spinal stenosis from spondylolisthesis while reducing the risk of injuries to the neural elements, endplate fractures and the theoretical rate of adjacent segment disease from disruption of the musculature. In this paper, we describe the steps and technical pearls pertaining to this technique and methods to avoid common pitfalls and complications. In conclusion, this technique would be a good tool in the armamentarium of a spinal surgeon specializing in minimally invasive spinal surgery.

Efficacy and safety of unilateral biportal endoscopy versus other spine surgery: A systematic review and meta-analysis

Background

This study aimed to evaluate the efficacy and safety of unilateral biportal endoscopy (UBE) versus other forms of spine surgery.

Methods

Electronic databases were systematically searched up to February 2022. The authors used Review Manager 5.3 to manage the data and perform the review.

Results

After the preliminary selection of 239 studies from electronic databases, the full inclusion criteria were applied; 16 studies were found to be eligible for inclusion. These 16 studies enrolled 1,488 patients: 653 patients in the UBE group, 570 in the microendoscopic discectomy group, 153 in the percutaneous endoscopic lumbar discectomy group, and 70 in the posterior lumbar interbody fusion group. UBE was superior to microendoscopic discectomy regarding 1-day Visual Analog Scale(VAS) back pain scores (P < 0.00001). No difference was found between UBE and microendoscopic discectomy regarding 1-day Visual Analog Scale leg pain scores (P = 0.25), long-term VAS back pain scores (P = 0.06), long-term VAS leg pain scores (P = 0.05), Oswestry Disability Index scores (P = 0.09) or complications (P = 0.19). Pooled analysis indicated that UBE was similar to percutaneous endoscopic lumbar discectomy regarding 1-day VAS back pain scores (P = 0.71), 1-day VAS leg pain scores (P = 0.37), long-term VAS back pain scores (P = 0.75), long-term VAS leg pain scores (P = 0.41), Oswestry Disability Index scores (P = 0.07) and complications (P = 0.88). One study reported no difference between UBE and posterior lumbar interbody fusion regarding long-term VAS back pain, long-term VAS leg pain, or Oswestry Disability Index scores.

Conclusions

UBE is superior to microendoscopic discectomy to relieve back pain 1 day postoperatively. However, these two procedures are similar regarding 1-day leg pain relief, long-term effects, and safety. UBE and percutaneous endoscopic lumbar discectomy are similar regarding 1-day pain relief, long-term effects and safety. More evidence is needed to evaluate the efficacy and safety of UBE versus posterior lumbar interbody fusion.

Full-Endoscopic versus Minimally Invasive Lumbar Interbody Fusion for Lumbar Degenerative Diseases : A Systematic Review and Meta-Analysis

OBJECTIVE

Although full-endoscopic lumbar interbody fusion (Endo-LIF) has been tried as the latest alternative technique to minimally invasive transforaminal lumbar interobody fusion (MIS-TLIF) since mid-2010, the evidence is still lacking. We compared the clinical outcome and safety of Endo-LIF to MIS-TLIF for lumbar degenerative disease.

METHODS

We systematically searched electronic databases, including PubMed, EMBASE, and Cochrane Library to find literature comparing Endo-LIF to MIS-TLIF. The results retrieved were last updated on December 11, 2020. The perioperative outcome included the operation time, blood loss, complication, and hospital stay. The clinical outcomes included Visual analog scale (VAS) of low back pain and leg pain and Oswestry disability index (ODI), and the radiological outcome included pseudoarthosis rate with 12-month minimum follow-up.

RESULTS

Four retrospective observational studies and one prospective observational study comprising 423 patients (183 Endo-LIF and 241 MIS-TLIF) were included, and the pooled data analysis revealed low heterogeneity between studies in our review. Baseline characteristics including age and sex were not different between the two groups. Operation time was significantly longer in Endo- LIF (mean difference [MD], 23.220 minutes; 95% confidence interval [CI], 10.669-35.771; p=0.001). However, Endo-LIF resulted in less perioperative blood loss (MD, -144.710 mL; 95% CI, 247.941-41.478; p=0.023). Although VAS back pain at final (MD, -0.120; p=0.586), leg pain within 2 weeks (MD, 0.005; p=0.293), VAS leg pain at final (MD, 0.099; p=0.099), ODI at final (MD, 0.141; p=0.093) were not different, VAS back pain within 2 weeks was more favorable in the Endo-LIF (MD, -1.538; 95% CI, -2.044 to -1.032; p<0.001). On the other hand, no statistically significant group difference in complication rate (relative risk [RR], 0.709; p=0.774), hospital stay (MD, -2.399; p=0.151), and pseudoarthrosis rate (RR, 1.284; p=0.736) were found.

CONCLUSION

Relative to MIS-TLIF, immediate outcomes were favorable in Endo-LIF in terms of blood loss and immediate VAS back pain, although complication rate, mid-term clinical outcomes, and fusion rate were not different. However, the challenges for Endo-LIF include longer operation time which means a difficult learning curve and limited surgical indication which means patient selection bias. Larger-scale, well-designed study with long-term follow-up and randomized controlled trials are needed to confirm and update the results of this systematic review.

Case Report: Bilateral Biportal Endoscopic Open-Door Laminoplasty With the Use of Suture Anchors: A Technical Report and Literature Review

Background

Unilateral biportal endoscopy (UBE) is a newly developed technique for spine surgery. Owing to the convenience of nerve decompression and compatibility with open surgical instruments under endoscopic guidance, this technique has seen widespread global use. In this study, we first used modified UBE with suture anchor fixation for cervical laminoplasty in a 65-year-old female patient with good clinical outcomes.

Methods

We used bilateral biportal endoscopy (BBE) for cervical laminoplasty with suture anchor fixation in a patient with cervical stenosis. Under endoscopic guidance, a bilateral approach was used to make the gutter and lift the lamina door. After the lamina doors were opened, sutures were tied tightly using facia cannula and knot pusher. After confirming the solidarity of the open-door status, the drainage tube was inserted and the incisions were closed. The patient’s pre- and postoperative radiological and clinical results were evaluated.

Results

Postoperative Japanese Orthopaedic Association (JOA) and Neck Disability Index (NDI) scores were improved clinically, and cervical canal was decompressed radiologically.

Conclusions

BBE laminoplasty combined with suture anchor fixation showed a favorable clinical and radiological result and appears to be a safe and effective technique for cervical stenosis.

[Comparison of effectiveness between percutaneous coaxial large-channel endoscopic lumbar interbody fusion and minimal invasive transforaminal lumbar interbody fusion in treatment of degenerative lumbar spinal stenosis]

OBJECTIVE

To compare the effectiveness of percutaneous coaxial large-channel endoscopic lumbar interbody fusion (PE-LIF) and minimal invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of degenerative lumbar spinal stenosis.

METHODS

The clinical data of 134 patients with single-segment degenerative lumbar spinal stenosis who met the selection criteria between January 2019 and January 2021 were retrospectively analyzed, including 52 cases in PE-LIF group and 82 cases in MIS-TLIF group. There was no significant difference in general data such as gender, age, disease duration, surgical segment, and preoperative visual analogue scale (VAS) scores of low back pain and lower extremity pain, and Oswestry disability index (ODI) between the two groups ( P>0.05). The operation time, intraoperative blood loss, postoperative drainage, hospitalization stay, and complications were recorded and compared between the two groups. The level of serum creatine kinase (CK) was recorded at 1 day before operation and at 1 and 3 days after operation to evaluate intraoperative muscle damage. The Brantigan criteria was used to evaluate the interbody fusion in the two groups. The VAS scores of low back pain and lower extremity pain at 1 day before operation and at 3 days, 3 months, and 1 year after operation, and the ODI scores at 1 day before operation and at 3 months and 1 year after operation were recorded and compared between the two groups.

RESULTS

There was no significant difference in operation time and hospitalization stay between the two groups ( P>0.05). The intraoperative blood loss and postoperative drainage in the PE-LIF group were significantly lower than those in the MIS-TLIF group ( P<0.05). There was no significant difference in serum CK between the two groups before operation ( P>0.05), and the serum CK in the PE-LIF group at 1 and 3 days after operation were significantly lower than those in the MIS-TLIF group ( P<0.05). All patients were followed up regularly for 1 year. The postoperative VAS scores of low back pain and lower extremity pain and ODI score in both groups were significantly lower than those before operation ( P<0.05); there was no significant difference between the two groups ( P>0.05). At 1 year after operation, 48 patients in PE-LIF group had successful interbody fusion, and 77 patients in MIS-TLIF group had successful interbody fusion. There was no significant difference in the interbody fusion distribution between the two groups at 3 months and 1 year after operation ( P>0.05). There were 2 and 3 cases of lower limb numbness, 1 and 3 cases of neuroedema pain, 1 and 1 case of Cage displacement, 1 and 1 case of pedicle screw loosening in the PE-LIF group and MIS-TLIF group, respectively. No infection or dural sac tearing occurred in the two groups. There was no significant difference in the incidence of complications between the two groups (9.6% vs. 9.8%) ( χ ²=0.001, P=0.979).

CONCLUSION

In the treatment of single-segment degenerative lumbar spinal stenosis, PE-LIF can achieve similar effectiveness as MIS-TLIF, and PE-LIF has less intraoperative blood loss and less muscle damage.

Endoscopic Extreme Transforaminal Lumbar Interbody Fusion With Large Spacers: A Technical Note and Preliminary Report

This report describes a novel endoscopic fusion technique performed with unilateral biportal endoscopy (UBE) that is known as extreme transforaminal lumbar interbody fusion (eXTLIF) and is performed with a large spacer. We also present the short-term results of this procedure. Previous studies reported that minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) could achieve acceptable rates of fusion; therefore, it is often used for treating various degenerative lumbar diseases. Moreover, MIS-TLIF can be performed with a unilateral approach; hence, it is commonly performed with the UBE technique. The biportal endoscopic TLIF procedure is usually performed with a single spacer in the interbody space. It is important to insert the maximum amount of graft material into the preparation site via an autologous bone marrow transplant or any other suitable substance with spacer insertion. Because MIS-TLIF with UBE is performed in water, it might provide an inadequate environment for excellent fusion. Therefore, a modified method was used to increase the surface contact area and insert the maximum amount of bone material with a larger spacer. However, the use of a large spacer necessitates a larger spacer orifice. For this purpose, eXTLIF was performed, which inserts the spacer more laterally compared with the current TLIF position. We report the surgical method and short-term results, which have been satisfactory thus far. [Orthopedics. 2022;45(3):163-168.].

[Comparison of unilateral biportal endoscopic transforaminal lumbar interbody fusion versus minimally invasive tubular transforaminal lumbar interbody fusion for lumbar degenerative disease]

OBJECTIVE

To compare the clinical and radiological outcomes of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) and minimally invasive tubular TLIF (MT-TLIF) in treatment of lumbar degenerative diseases.

METHODS

A clinical data of 75 patients with lumbar degenerative diseases, who met the selection criteria between August 2019 and August 2020, was retrospectively analyzed, including 35 patients in the UBE- TLIF group and 40 patients in the MT-TLIF group. There was no significant difference in general data such as gender, age, body mass index, disease type and duration, and surgical segment between the two groups ( P>0.05), which was comparable. The operation time, intraoperative blood loss, hemoglobin (Hb) before operation and at 1 day after operation, the length of hospital stay, incidence of complications, and visual analogue scale (VAS) score of low back and leg pain, Oswestry Disability Index (ODI), Short-Form 36 Health Survey Scale (SF-36 scale), intervertebral disc height (IDH), sagittal Cobb angle, lumbar lordosis (LL), and the intervertebral fusion were compared between the two groups.

RESULTS

Compared with MT-TLIF group, UBE-TLIF group had significantly longer operation time but less intraoperative blood loss and shorter length of hospital stay ( P<0.05). The Hb levels in both groups decreased at 1 day after operation, but there was no significant difference in the difference before and after operation between the two groups ( P>0.05). All patients were followed up, and the follow-up time was (14.7±2.5) months in the UBE-TLIF group and (15.0±3.4) months in the MT-TLIF group, with no significant difference ( t=0.406, P=0.686). In both groups, the VAS score of low back pain, VAS score of leg pain, SF-36 scale, and ODI after operation significantly improved when compared with those before operation ( P<0.05). There was no significant difference between 1 month after operation and last follow-up ( P>0.05). There was no significant difference in the VAS score of low back pain, VAS score of leg pain, and SF-36 scale between the two groups before and after operation ( P>0.05). At 1 month after operation, the ODI in the UBE-TLIF group was significantly better than that in the MT-TLIF group ( P<0.05). At 1 month after operation, IDH, Cobb angle, and LL in both groups recovered when compared with those before operation ( P<0.05), and were maintained until last follow-up ( P>0.05). There was no significant difference in the IDH, Cobb angle, and LL between the two groups at each time point ( P>0.05). Thirty-three cases (89.2%) in the UBE-TLIF group and 35 cases (87.5%) in the MT-TLIF group achieved fusion, and the difference was not significant ( χ ²=0.015, P=0.901). In the UBE-TLIF group, 1 case of intraoperative dural tear and 1 case of postoperative epidural hematoma occurred, with an incidence of 5.7%. In the MT-TLIF group, 1 case of intraoperative dural tear, 1 case of postoperative epidural hematoma, and 1 case of superficial infection of the surgical incision occurred, with an incidence of 7.5%. There was no significant difference in the incidence of complications between the two groups ( χ ²=1.234, P=1.000).

CONCLUSION

Compared with MT-TLIF, UBE-TILF can achieve similar interbody fusion in the treatment of lumbar degenerative diseases, and has the advantages of smaller incision, less bleeding, and shorter length of hospital stay.

Learning Curve and Initial Outcomes of Full-Endoscopic Posterior Lumbar Interbody Fusion

Study Design

This was a retrospective cohort study.

Objective

We evaluated the feasibility, safety, and accuracy of full-endoscopic posterior lumbar interbody fusion (FE-PLIF) by assessing the learning curve and initial clinical outcomes.

Summary of Background Data

Low back pain is one of the crucial medical conditions worldwide. FE-PLIF has been reported to be a minimally invasive method to treat mechanical low back pain, but there lacks a thorough evaluation on this new technique.

Methods

The patients were divided into three groups in the order of operating date, implying that Group A consisted of the initial 12 cases, Group B the subsequent 12 cases, and Group C the last 12 cases. The data of patients were reviewed for gender, age, preoperative symptoms, satisfaction, as well as clinical outcomes demonstrated by visual analog scale (VAS). The operative time and intraoperative fluoroscopy were recorded to demonstrate the learning curve and the extent of radiographic exposure. Statistical significance was set at a p &lt; 0.05 (two-sided).

Results

The patients enrolled in this study were followed up at an average of 1.41 ± 0.24 years. Overall, patients were satisfied with the surgery. The average number of intraoperative fluoroscopy was 6.97 ± 0.74. A significant improvement was observed in the VAS of both lumbar pain and leg pain. The overall fusion rate was 77.7%. Complications were reported in two patients in Group A, one in Group B, and none in Group C. The average operative time showed a trend of gradual decline. The learning curve was characterized using a cubic regression analysis as y = –27.07x + 1.42x2–0.24x3 + 521.84 (R2 = 0.617, p = 0.000).

Conclusions

FE-PLIF is an effective and safe method for treating low back pain caused by short-segmental degenerative diseases. The learning curve of this technique is steep at the initial stage but acceptable and shows great potential for improvement.

Short-Term Postoperative Pain and Function of Unilateral Biportal Endoscopic Discectomy versus Percutaneous Endoscopic Lumbar Discectomy for Single-Segment Lumbar Disc Herniation: A Systematic Review and Meta-analysis

Objective

Spinal surgery is gradually moving toward minimally invasive surgery, but there is still some lack of knowledge about the Unilateral Biportal Endoscopic (UBE) technique that has been hotly debated in recent years. We performed this systematic review and meta-analysis to clarify whether UBE is superior to percutaneous endoscopic lumbar discectomy (PELD) for relieving short-term postoperative pain and promoting functional recovery.

Methods

Computer searches of PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wanfang databases were performed to search for studies on UBE versus PELD for single-segment lumbar disc herniation (ssLDH) from the time of database construction to Mar. 2022, and two investigators independently performed literature screening and data extraction, and evaluation of the quality of the included studies was observed as operation time, complications, and visual analogue scale (VAS) at each preoperative and postoperative stage as well as Oswestry Disability Index (ODI), and meta-analysis was performed by applying the Review Manager 5.4 software.

Results

Meta-analysis showed that PELD had shorter operation time (MD = 35.36, 95% CI (4.67, 66.04), P = 0.02) and had lower VAS of back pain at 3 days postoperatively (MD = 0.62, 95% CI (0.04, 1.19), P = 0.04) compared to the UBE. However, there was no statistical significance between the two groups in terms of complications (MD = 2.53, 95% CI (0.40, 16.11), P = 0.33), VAS of back pain at 30 days postoperatively (MD = 0.05, 95% CI (-0.19, 0.28), P = 0.70), VAS of leg pain at 3 days postoperatively (MD = 0.21, 95% CI (-0.20, 0.61), P = 0.33), VAS of leg pain at 30 days postoperatively (MD = 0.09, 95% CI (-0.29, 0.46), P = 0.65), and ODI at 30 days postoperatively (MD = -0.81, 95% CI (-3.03, 1.41), P = 0.47).

Conclusions

Current evidence suggests that both UBE and PELD are effective in relieving short-term postoperative pain and promoting functional recovery, and there is no difference in complications between them; UBE requires longer operation time, and PELD may be superior in relieving immediate postoperative pain. This trial is registered with PROSPERO ID: CRD42021287810.

Comparison of percutaneous endoscopic and open posterior lumbar interbody fusion for the treatment of single-segmental lumbar degenerative diseases

Background

Endoscopic lumbar interbody fusion has become an emerging technique. Some researchers have reported the technique of percutaneous endoscopic transforaminal lumbar interbody fusion. We propose percutaneous endoscopic posterior lumbar interbody fusion (PE-PLIF) as an alternative approach. The purpose of this study was to assess the clinical efficacy of PE-PLIF by comparing percutaneous endoscopic and open posterior lumbar interbody fusion (PLIF).

Methods

Thirty patients were enrolled in each group. Demographic data, perioperative data, and radiological parameters were collected prospectively. The clinical outcomes were evaluated by visual analog scale (VAS) and Oswestry Disability Index (ODI) scores.

Results

The background data were comparable between the two groups. The mean operation time was longer in the PE-PLIF group. The PE-PLIF group showed benefits in less blood loss and shorter hospital stay. VAS and ODI scores significantly improved in both groups. However, the VAS score of low-back pain was lower in the PE-PLIF group. The satisfaction rate was 96.7% in both groups. The radiological outcomes were similar in both groups. In the PE-PLIF group, the fusion rate was 93.3%, and the cage subsidence rate was 6.7%; in the open PLIF group, the fusion and cage subsidence rates were 96.7% and 16.7%. There were minor complications in one patient in the PE-PLIF group and two in the open PLIF group.

Conclusions

The current study revealed that PE-PLIF is safe and effective compared with open PLIF. In addition, this minimally invasive technique may enhance postoperative recovery by reducing tissue damage and blood loss.

Enhanced Recovery after an Innovative Percutaneous Endoscopic Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Spinal Stenosis: A Prospective Observational Study

Background

The objective of this study was to investigate the enhanced recovery clinical effects of an innovative percutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF) for the treatment of patients with LSS and degenerative instability.

Methods

From January 2019 to March 2020, 51 patients with single-segment LSS and degenerative instability were prospectively included in our study (ChiCTR1900020679). The Oswestry Disability Index (ODI), the visual analogue scale (VAS) on lumbar and leg pain (VAS-LBP and VAS-LP), serum creatine kinase (CK), the peak intensity of sulphur hexafluoride microbubble contrast agent (PI), and the maximal cross-sectional area of multifidus muscle (Max-CSA) around the surgical incision were assessed preoperatively, postoperatively, and at regular follow-up.

Results

All patients were followed up. The mean postoperative bedridden time was 20.45 ± 2.66 hours. The ODI, VAS-LBP, and VAS-LP were improved significantly after operation compared to these data before operation in all the patients (P < 0.05). The CK at 1 day after operation was higher compared to the data before the operation (P < 0.05), and there was no significant difference on CK at 1 week after operation (P > 0.05). The PI at 1 week after operation was higher compared to this item before operation (P < 0.05), and there was no significant difference on PI at 1 month or 3 months after operation (P > 0.05). The Max-CSA at 1 week after operation was higher compared to this item before the operation (P < 0.05), and there was no significant difference in Max-CSA at 1 month or 3 months after operation compared with before the operation (P > 0.05).

Conclusions

Our results and systematic review presented the innovative PE-TLIF technique could obtain satisfactory and effective outcomes for the treatment of patients with LSS and degenerative instability. Our PE-TLIF technique also had the ability to decrease the MF injury and obtain an enhanced recovery.

Finite analysis of stability between modified articular fusion technique, posterior lumbar interbody fusion and posteriorlateral lumbar fusion

Background

It is not clear whether modified facet fusion (MFF) is biomechanically different from traditional fusion techniques such as posterior lateral lumbar fusion (PLF) and posterior lumbar interbody fusion (PLIF).

Methods

In this study, a healthy adult Chinese male volunteer was selected to perform 3D reconstruction of CT image data and simulate the successful fusion of L4–5 MFF, PLF and PLIF, respectively. The motion range of L4–5 segments of the model was simulated under 6 working conditions, including forward flexion, extension, lateral flexion and rotation under normal physiological conditions, and the stability of the three fusion procedures in the pathological segments of the lumbar spine was compared.

Results

There was no difference in range of motion between MFF model and PLF or PLIF model (P < 0.05). Also, the stiffness of the PLFand the MFF model were comparable (P > 0.05), but were smaller than the PLIF model (P < 0.05).

Conclusions

MFF provides reliable stability at the lumbar fixation fusion level and does not differ significantly from PLF and PLIF in terms of range of motion.

Clinical comparison of unilateral biportal endoscopic discectomy with percutaneous endoscopic lumbar discectomy for single l4/5-level lumbar disk herniation

OBJECTIVE

The purpose of this research was to investigate the outcomes between unilateral biportal endoscopic discectomy (UBE) and percutaneous endoscopic lumbar discectomy (PELD) for the single L4/5-level lumbar disk herniation (sLDH).

METHODS

From January 2018 to January 2021, a total of 40 patients with sLDH were retrospectively analyzed in this study. All the patients had received spinal surgeries in Affiliated Hospital of Nantong University and Affiliated Nantong Hospital 3 of Nantong University. Among them, 20 patients were treated with PELD (PELD group), and 20 patients were treated with UBE discectomy (UBE group). Postoperative length of hospital stay, estimated blood loss, operation time, and clinical complications of the patients were compared between the two groups. The visual analog scale (VAS) and Oswestry Disability Index (ODI) were measured before surgeries and 3 days, 1, and 6 months after surgeries.

RESULTS

Compared with the UBE group, the PELD group had obviously less intraoperative blood loss, shorter operative time, and shorter hospital stay. The differences in the rate of complications were not statistically significant between the two groups. The VAS score and the ODI score of the two groups had a great reduction after operation. In addition, both the groups had satisfactory clinical outcome; the VAS score and ODI of the PELD group decreased more obviously.

CONCLUSION

The UBE for sLDH yielded similar clinical outcomes to PELD as minimally invasive surgeries; however, PELD is superior to UBE in terms of intraoperative blood loss, operative time, postoperative hospitalization, and short-term postoperative pain relief. The advantages and disadvantages of the two surgeries should be circumspectly balanced when evaluating a patient for a minimally invasive surgery for sLDH, selecting the most appropriate surgical method for patients.

"Pin Method" for Endoscopic Lumbar Interbody Fusion

BACKGROUND

 Endoscopic lumbar interbody fusion using a cage can have a similar fusion rate as minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) or open lumbar interbody fusion. Direct visual control during cage insertion is the key to prevent neural structure incarceration in endoscopic lumbar interbody fusion. Creating a track with any kind of retractor or cannula for cage insertion under fluoroscopic guidance is not safe enough, because the retractor and cannula can create many blind spots and can displace during cage insertion.

METHOD

 The pin method utilizes two flexible metallic guide pins inserted from the skin incision through the annulotomy site into the disk space until the anterior longitudinal ligament is reached under direct endoscopic monitoring. The two guide pins could be oriented parallel or perpendicular or even reduce to one or increase to many as needed to serve as a sliding track and a see-through barrier to prevent neural incarceration.

RESULTS AND CONCLUSION

 Two cases of L4/L5 grade 2 spondylolisthesis with neurogenic claudication were treated with endoscopic lumbar interbody fusion with 1-year follow-up, and the visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, EuroQol five-dimensional questionnaire (EQ-5D, %) score, and modified Macnab score all improved greatly in both. The author developed an original, cheap, accessible, and safe method called the "pin method," which can be used in both full-endoscopic and biportal surgery and can apply to various approaches and has no limitation on the size and shape of the cage.

Full-Endoscopic Oblique Lateral Lumbar Interbody Fusion: A Technical Note With 1-Year Follow-Up

BACKGROUND

Oblique lateral lumbar interbody fusion (OLLIF) is a minimally invasive lumbar interbody fusion procedure using a bullet-shaped polyetheretherketone (PEEK) nonexpandable fusion cage modified to diminish risk to the exiting nerve root during posterolateral implantation through the Kambin safe zone under fluoroscopic guidance. The objective of this study was to present feasibility of this procedure and 1-year clinical outcome data.

METHODS

The authors present a prospective cohort study of 20 patients who underwent fluoroscopy-guided and full-endoscopic OLLIF in 22 segments allowing protection of the exiting nerve root from January 2018 to March 2019. The foraminoplasty, discectomy, endplate preparation, placement of bone graft and insertion of the fusion cage was done under continuous full-endoscopic visualization. The OLLIF fusion was backed up with bilateral percutaneous posterior supplemental pedicle screw fixation. Primary clinical outcome measures were the visual analog scale (VAS) of low back and leg pain, and Oswestry disability index (ODI) at 1 week, 3 months, 6 months, and 1 year after the operation. At final follow-up, the Macnab score was also evaluated. Secondary outcome measures were computed tomography (CT) assessment fusion using the Mannion classification of spinal fusion and adverse events related to the device as well as magnetic resonance imaging (MRI) assessment of nerve root decompression.

RESULTS

All patients had significant relief of low back pain and leg pain, by VAS and ODI scores that improved significantly (P < .01). There were no complications. Postoperative lumbar MRI of all patients showed sufficient direct nerve decompression. At 1-year follow-up, excellent Macnab outcomes were obtained 13 patients, good in six, and fair in one. Impaired sensation and muscle strength of the involved nerve root significantly recovered in all but 2 patients (P < .05). According to the Mannion CT-based classification of spinal fusion, CT showed complete interbody fusion achieved in all 22 segments.

CONCLUSIONS

Full-endoscopic OLLIF is a safe, effective, minimally invasive, economical, practical, and widely applicable minimally invasive interbody fusion technique in the lumbar spine.

LEVEL OF EVIDENCE

3.

Surgical treatment of senile spinal diseases

Advanced age is a well-known risk factor for spinal surgery-related complications. Decisions on spine surgery in the elderly are difficult due to higher morbidity and mortality than in younger age groups. In addition, spine surgery is a kind of ‘functional surgery’ which does not directly affect the survival of patients. In recent years, individualized risk stratification has gained ground over simple chronological age-based assessment. In the elderly, frailty is one of the strongest factors which affect surgical outcomes for both cervical and thoracolumbar spine surgery, regardless of the surgical technique used. Spine surgery in the elderly have worse surgical outcomes in terms of duration of hospital stay, degree of functional recovery, and complication, readmission, and mortality rates. However, the benefit of spine surgery even in the very-elderly is substantial. In conclusion, surgical decisions should be made based on both personalized risk assessment and benefits of surgery. Recent advanced surgical techniques such as minimally invasive surgical techniques and robotics assistance are likely to be helpful in minimizing surgical complications. Therefore, advanced age in itself should not be considered as a contraindication for spine surgery.

Learning Curve and Clinical Outcome of Biportal Endoscopic-Assisted Lumbar Interbody Fusion

Interbody fusion is a common surgical technique for diseases of the lumbar spine. Biportal endoscopic-assisted lumbar interbody fusion (BE-LIF) is a novel minimally invasive technique that has a long learning curve, which can be a barrier for surgeons. Therefore, we analyzed the learning curve in terms of operative time and evaluated the outcomes of BE-LIF. A retrospective study of fifty-seven consecutive patients who underwent BE-LIF for degenerative lumbar disease by a single surgeon from January 2017 to December 2018 was performed. Fifty patients underwent a single-level procedure, and 7 underwent surgery at two levels. The mean follow-up period was 24 months (range, 14-38). Total operative time, postoperative drainage volume, time to ambulation, and complications were analyzed. Clinical outcome was measured using the Oswestry Disability Index (ODI), Visual Analog Scale (VAS) score for back and leg pain, and modified Macnab criteria. The learning curve was evaluated by a nonparametric regression locally weighted scatterplot smoothing curve. Cases before the stable point on the curve were designated as group A, and those after the stable point were designated group B. Operative time decreased as the number of cases increased. A stable point was noticed on the 400th day and the 34th case after the first BE-LIF was performed. All cases showed improved ODI and VAS scores at the final follow-up. Overall mean operative time was 171.74 ± 35.1 min. Mean operative time was significantly lower in group B (139.7 ± 11.6 min) compared to group A (193.4 ± 28.3 min). Time to ambulation was significantly lower in group B compared to group A. VAS and ODI scores did not differ between the two groups. BE-LIF is an effective minimally invasive technique for lumbar degenerative disease. In our case series, this technique required approximately 34 cases to reach an adequate performance level.