Is biportal technique/endoscopic spinal surgery satisfactory for lumbar spinal stenosis patients?: A prospective randomized comparative study

Endoscopic Treatment of Lumbar Degenerative Disc Disease: A Narrative Review of Full-Endoscopic and Unilateral Biportal Endoscopic Spine Surgery

BACKGROUND

Degenerative lumbar spine disease is the leading cause of disability and work absenteeism worldwide. Lumbar microdiscectomy became the standard treatment for herniated discs and stenotic disease. With the evolution of different techniques, endoscopic spinal surgery emerged to minimize the surgical footprint while providing at least non-inferior results. Currently, two different types of endoscopic spine procedures are dominating the surgical scenario: "Full-Endoscopic" (FE) and Unilateral Biportal Endoscopic" (UBE) Spine Surgery. The aim of this study is to describe and analyze their indications, their technical characteristicswithitsadvantagesanddisadvantagesofbothtechniquesandtheirfuture trends.

METHODS

We performed a narrative review of the most relevant articles published up to August 2023 through a Pub Med search. The search terms " FE Spine Surgery" and " UBE Spine Surgery" were used. The articles selected, were independently reviewed by 3 authors and 55 full text articles were reviewed.

RESULTS

The FE and UBE Spine Surgery techniques were described. The FE technique is performed with a monoportal access under constant saline irrigation. The FE comprises the transforaminal and the interlaminar approaches, and the indication depends from the pathology to treat, and still remains controversial. UBE can approach also the spine from a posterior, postero lateral,and para spinal route. It uses two different ports addressed to a target with continuous irrigation. The process of establishing these two portals is called triangulation.

CONCLUSIONS

FE and UBE spine surgery have demonstrated outcomes comparable to open surgery, minimizing complications and surgical footprint.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Global utilization of biportal spinal endoscopy: Case series on management of lumbar pathology in Soddo, Ethiopia

INTRODUCTION

Biportal spinal endoscopy is a safe and cost-effective methodology for the management of lumbar pathology in rural underserved hospitals that have standard orthopaedic arthroscopic equipment, but lack access to microscopy.

METHODS

This is a case series noting 1-year outcomes from 5 patients managed with biportal spinal endoscopy during an 11-day mission trip to Soddo, Ethiopia in November 2022. Surgical complications, postoperative assessments, and patient-reported outcomes (PROs) were retrospectively collected and analyzed. Surgical techniques and equipment utilized were shared with residents and faculty at the hospital.

RESULTS

Five Ethiopian patients (4:1, female:male) with no prior spine surgery history elected to undergo biportal surgery for the diagnoses of lumbar stenosis and disc herniation, averaging 31 years of age with Body-Mass-Indices (BMI) <35. Two patients underwent endoscopic discectomy, and three patients underwent endoscopic unilateral laminotomy and bilateral decompression (ULBD). There were no complications. No postoperative functional deficits, infections, readmissions, revisions, or wound dehiscences were noted at 12 months follow-up. VAS-back and VAS-leg scores improved to <2/10 for 80 % of patients. All patients returned to work/activities of daily living. No patients required postoperative pain management beyond the 2-week post-operative follow-up.

CONCLUSION

With these five patients, we found that biportal spinal endoscopy can be safely applied in rural hospital settings with limited resources. This supports biportal spinal endoscopy as a viable minimally invasive modality for the management of lumbar pathology. For hospitals with limited resources, but access to arthroscopic equipment, biportal spinal endoscopy is a feasible option.

LEVEL OF EVIDENCE

IV.

Comparison of the Clinical and Radiological Outcomes of Full-Endoscopic Laminotomy and Conventional Subtotal Laminectomy for Lumbar Spinal Stenosis: A Randomized Controlled Trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

The primary objective of this study was to compare the short-term clinical and radiological outcomes of full-endoscopic lumbar laminotomy (FEL) with those of subtotal lumbar laminectomy (STL) for lumbar spinal stenosis (LSS).

METHODS

In this prospective randomized trial a total of 52 patients were enrolled from May 2016 to September 2021 after providing written informed consent. The authors investigated 45 patients who were followed up for more than 6 months.

RESULTS

There were significant improvements in visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores after the operation in both groups. The FEL group tended to have significantly shorter hospital stay. Interestingly, a statistically significant increase in postoperative lumbar lordosis and segmental angle was observed in the FEL group and both groups, respectively. Spondylolisthesis was exacerbated or newly developed in five of the 21 patients (24%) in the STL group. In contrast, improvement in spondylolisthesis was observed in two of the 24 patients (8%) in the FEL group. There were no complications that resulted in fatal sequelae and no significant difference in the complication rate.

CONCLUSIONS

The clinical results of FEL were similar to those of STL. In addition, the results of FEL were superior to those of STL in terms of a decrease in the postoperative length of stay and radiologic instability, such as iatrogenic spondylolisthesis. The results of this study indicate that FEL is a comparable surgical method to STL for LSS.

Full-endoscopic versus microscopic spinal decompression for lumbar spinal stenosis: a systematic review & meta-analysis

BACKGROUND CONTEXT

Symptomatic lumbar spinal stenosis is routinely treated with spinal decompression surgery, with an increasing trend towards minimally invasive techniques. Endoscopic decompression has emerged as a technique which minimizes approach-related morbidity while achieving similar clinical outcomes to conventional open or microscopic approaches.

PURPOSE

To assess the safety and efficacy of endoscopic versus microscopic decompression for treatment of lumbar spinal stenosis.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review on randomized and nonrandomized studies comparing endoscopic versus microscopic decompression was conducted, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Treatment effects were computed using pairwise random-effects meta-analysis. Risk of bias was assessed using the Cochrane Risk-of-bias and ROBINS-I tools for randomized and nonrandomized trials respectively. Quality of the overall body of evidence was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

A total of 19 primary references comprising 1,997 patients and 2,132 spinal levels were included. Endoscopic decompression was associated with significantly reduced intraoperative blood-loss (weighted mean differences [WMD]=-33.29 mL, 95% CI:-51.80 to -14.78, p=.0032), shorter duration of hospital stay (WMD=-1.79 days, 95% CI: -2.63 to 0.95, p=.001), rates of incidental durotomy (RR = 0.63, 95% CI: 0.43 to 0.91, p=.0184) and surgical site infections (RR=0.23, 95% CI: 0.10 to-0.51, p=.001), and a nonsignificant trend towards less back pain, leg pain, and better functional outcomes compared to its microscopic counterpart up to 2-year follow up.

CONCLUSIONS

Endoscopic and microscopic decompression are safe and effective techniques for treatment of symptomatic lumbar spinal stenosis. Prospective studies of larger power considering medium to long-term outcomes and rates of iatrogenic instability are warranted to compare potential alignment changes and destabilization from either techniques.

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.

Is Minimally Invasive Spinal Surgery Superior to Endoscopic Spine Surgery in Postoperative Radiologic Outcomes of Lumbar Spine Degenerative Disease? A Systematic Review

BACKGROUND

 Minimally invasive spinal surgery (ESS) are both well-established surgical techniques for lumbar spinal stenosis; however, there is limited literature comparing the efficacy of the two techniques with respect to radiologic decompression data.

METHODS

 In this review, PubMed, Google Scholar, and Scopus databases were systematically searched from inception until July 2022 for studies that reported the radiologic outcomes of endoscopic and minimally invasive approaches for decompressive spinal surgery, namely, the spinal canal area, neural foraminal area, and neural foraminal heights.

RESULTS

 Of the 378 articles initially retrieved using MeSH and keyword search, 9 studies reporting preoperative and postoperative spinal areas and foraminal areas and heights were finally included in our review. Of the total 581 patients, 391 (67.30%) underwent MISS and 190 (32.70%) underwent ESS. The weighted mean difference between the spinal canal diameter in pre- and postoperative conditions was 56.64 ± 7.11 and 79.52 ± 21.31 mm2 in the MISS and ESS groups, respectively. ESS was also associated with a higher mean difference in the foraminal area postoperatively (72 ± 1 vs. 35.81 ± 11.3 mm2 in the MISS and ESS groups, respectively), but it was comparable to MISS in terms of the foraminal height (0.32 ± 0.037 vs. 0.29 ± 0.03 cm in the MISS and endoscopic groups, respectively).

CONCLUSIONS

 Compared with MISS, ESS was associated with improved radiologic parameters, including spinal canal area and neural foraminal area in the lumbar spinal segments. Both techniques led to the same endpoint of neural decompression when starting with a more severe compression. However, the present data do not allow the correlation of the radiographic results with the related clinical outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Biportal Endoscopic Spine Surgery: Clinical Results for 163 Patients

BACKGROUND

Biportal endoscopy spine surgery is an endoscopic procedure that uses 2 portals, 1 for the endoscope and 1 for the instruments. It provides an excellent and very versatile field of view, with the advantage of another portal to approach the most common degenerative lumbar pathologies.

METHODS

We evaluated a retrospective series of patients who underwent biportal endoscopy with ≥1 year of follow-up. Relevant epidemiological and clinical data, such as the Oswestry disability index and visual analog scale for pain, were also considered. Complications and the effects of the learning curve are also discussed.

RESULTS

We included 163 patients treated within a 5-year period with ≥1 year of follow-up available. The main pathologies were disc herniation (53.4%), foraminal stenosis (19%), and central canal stenosis (16.6%). The outcomes regarding disability and pain scores after surgery were very good, with a redistribution of the patient sample to the mild categories of disability. Inferential analysis showed relative and absolute improvements for both disc herniation and canal stenosis in terms of the Oswestry disability index and visual analog scale for pain, especially for disc herniation. The incidence of complications was approximately 7%. The most common approach was interlaminar (89%), and the most common pathology was disc herniation (54.9%). The duration of surgery overall and for the different stages had improved at the end of the learning curve with a reduction of almost 58 minutes.

CONCLUSIONS

Biportal endoscopy is a minimally invasive procedure that is safe and effective, with a low rate of complications. It has a reproducible learning curve and provides very good outcomes regarding functionality and pain scores.

Comparative efficacy of unilateral biportal endoscopy and micro-endoscopic discectomy in the treatment of degenerative lumbar spinal stenosis: a systematic review and meta-analysis

BACKGROUND

Given the inconclusive literature on operative time, pain relief, functional outcomes, and complications, this meta-analysis aims to compare the efficacy of Unilateral Biportal Endoscopy (UBE) and Micro-Endoscopic Discectomy (MED) in treating Degenerative Lumbar Spinal Stenosis (DLSS).

METHODS

A thorough literature search was conducted in accordance with the PRISMA guidelines and based on the PICO framework. The study interrogated four primary databases-PubMed, Embase, Web of Science, and the Cochrane Library-on August 16, 2023, without time restrictions. The search employed a strategic selection of keywords and was devoid of language barriers. Studies were included based on strict criteria, such as the diagnosis, surgical intervention types, and specific outcome measures. Quality assessment was performed using the Newcastle-Ottawa Scale, and statistical analysis was executed through Stata version 17.

RESULTS

The meta-analysis incorporated 9 articles out of an initial yield of 1,136 potential studies. Considerable heterogeneity was observed in surgical duration, but no statistically significant difference was identified (MD = - 2.11, P = 0.56). For VAS scores assessing lumbar and leg pain, UBE was statistically superior to MED (MD = - 0.18, P = 0.013; MD = - 0.15, P = 0.006, respectively). ODI scores demonstrated no significant difference between the two surgical methods (MD = - 0.57, P = 0.26). UBE had a lower incidence of complications compared to those receiving MED (OR = 0.54, P = 0.036).

CONCLUSIONS

UBE and MED exhibited comparable surgical durations and disability outcomes as measured by ODI. However, UBE demonstrated superior efficacy in alleviating lumbar and leg pain based on VAS scores. The findings present an intricate evaluation of the two surgical interventions for DLSS, lending valuable insights for clinical decision-making.

Modified facet joint fusion for multilevel lumbar spinal stenosis: a retrospective study of 135 consecutive patients

OBJECTIVE

To evaluate the safety and efficacy of modified facet joint fusion (MFF) for the treatment of multilevel (three-level or more) lumbar spinal stenosis (LSS).

PATIENTS AND METHODS

In this retrospective study, 135 consecutive patients who underwent initial MFF for multilevel LSS were included. Clinical outcomes included fusion rate, change of visual analogue scale pain scores for low back pain (VAS-LBP) and leg pain (VAS-LP), Japanese Orthopedic Association scores (JOA), Oswestry Disability Index (ODI) and MacNab classification before and after MFF. The complications were also analyzed.

RESULTS

The fusion rates were 46.7% (63/135) at 6-month and 89.6% (121/135) at 1-year. The mean VAS-LBP, VAS-LP, and ODI significantly decreased from 5.2 ± 0.6, 5.7 ± 0.8 and 65 ± 7.9 to 1.58 ± 0.4, 0.58 ± 0.3 and 20.8 ± 5.8, respectively (all p < 0.001). The mean JOA markedly improved from 10.0 ± 1.3 to 26.1 ± 1.5 (p < 0.001). Excellent/good results of MacNab classification were achieved in 88.9% (120/135) of the patients. The overall rate of complications after MFF was 5.9%, including poor wound healing (2.2%), calf muscular venous thrombosis (0.74%), deep venous thrombosis (0.74%), superficial wound infection (1.48%), transient foot drop (0.74%). All the complications were transient and improved without prolonged hospital stay and sequelae.

CONCLUSION

MFF may be safe and efficient for multilevel LSS with high fusion rate and significant symptom relief, which is worthy of further study.

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.

Clinical outcomes of uniportal compared with biportal endoscopic decompression for the treatment of lumbar spinal stenosis: a systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Lumbar spinal stenosis (LSS) treatment has evolved with the introduction of minimally invasive surgery (MIS) techniques. Endoscopic methods take the concepts applied to MIS a step further, with multiple studies showing that endoscopic techniques have outcomes that are similar to those of more traditional approaches. The aim of this study was to perform an updated meta-analysis and systematic review of studies comparing the outcomes between both available endoscopic techniques (uni and biportal) for the treatment of LSS.

METHODS

Following PRISMA guidelines, we conducted a systematic literature search and compared the randomized controlled trials and retrospective studies of uniportal and biportal endoscopy in the treatment of LSS from several databases. Bias was assessed using quality assessment criteria and funnel plots. Meta-analysis using a random-effects model was used to synthesize the metadata. The authors used Review Manager 5.4 to manage the date and perform the review.

RESULTS

After a preliminary selection of 388 studies from electronic databases, the full inclusion criteria were applied; three studies were found to be eligible for inclusion. There were 184 patients from three unique studies. Meta-analysis of visual analog scale score for low back pain and leg pain showed no significant difference at the final follow-up (P = 0.51 and P = 0.66). ODI score after biportal surgery was lower than uniportal surgery [SMD = 0.34, 95% CI (0.04, 0.63), P = 0.02]. The mean operation time was similar in the unilateral biportal endoscopy (UBE) and uniportal groups (P = 0.53). The UBE group was associated with a shorter length of hospital stay (P = 0.05). Complications were similar in both groups (P = 0.89).

CONCLUSIONS

Current evidence shows no significant differences in most clinical outcomes between uniportal and biportal surgery. UBE may have a better ODI score at the end of the follow-up compared to uniportal. Further studies are required before drawing a definite conclusion.

STUDY REGISTRATION

PROSPERO prospective register of systematic reviews: Registration Nº. CRD42022339078, Available from: https://www.crd.york.ac.uk/prospero/displayrecord.php?ID=CRD42022339078.

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.

Efficacy and safety of unilateral biportal endoscopy compared with microscopic decompression in the treatment of lumbar spinal stenosis: A systematic review and updated meta‑analysis

The incidence of lumbar spinal stenosis is increasing annually, and with an ever-aging population and longer life expectancies, this trend will further continue. It is hoped that a more effective treatment can be found so that the patients can be relieved of their pain. The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of unilateral biportal endoscopic surgery (UBE) and microscopic decompression surgery (MD) for the treatment of lumbar spinal stenosis. A literature search of related studies published until April 2022 was performed using PubMed, EMBASE, Cochrane Library, Web of Science, ClinicalTrials.gov, Google Scholar, China National Knowledge Infrastructure (CNKI), and other databases. After filtering of references, 12 eligible studies were identified that compared UBE with MD as a treatment for lumbar spinal stenosis. Data were extracted and analysed using R. A total of 12 articles (four randomized controlled and eight cohort studies) were included, with a total of 1,067 patients: 250 men and 249 women in the UBE group and 290 men and 278 women in the MD group. The meta-analysis showed that the mean intraoperative blood loss in the UBE group [standardized mean difference (SMD)=-2.10, 95% confidence interval (CI) (-3.97, -0.23), P=0.03] was lower than that in the MD group. The postoperative Visual analogue scale (VAS) score for back pain [SMD=-0.52, 95% CI (-0.76, -0.27), P<0.01], leg pain [SMD=-0.30, 95% CI (-0.51, -0.08), P<0.01], postoperative Oswestry disability index [(ODI); SMD=-0.25, 95% CI (-0.48, -0.03), P=0.03], and postoperative C-reactive protein [(CRP); odds ratio (OR)=-0.92, 95% CI (-1.80, 0.03), P=0.04] were lower than those in the MD group. Complications (OR=0.60, 95% CI (0.37, 0.98), P=0.04) and hospital stay (SMD=-1.84, 95% CI (-2.85, 0.83), P <0.01] were also lesser in the UBE group than in the MD group. UBE was preferable to that in the MD group according to the modified MacNab score [OR=2.28, 95% CI (1.28, 4.06), P<0.01]. No significant differences were observed in the operation times between the groups. UBE surgery was found to be a better option for the treatment of lumbar spinal stenosis than MD surgery.

Unilateral Biportal Endoscopy for Lumbar Spinal Stenosis and Lumbar Disc Herniation

Background

Unilateral biportal endoscopy (UBE) is a novel minimally invasive technique for the treatment of lumbar spinal stenosis and lumbar disc herniations. Uniportal endoscopy was utilized prior to the advent of UBE and has been considered the workhorse of endoscopic spine surgery (ESS) for lumbar discectomy and decompressive laminectomy. However, there are theoretical advantages to UBE compared with traditional uniportal endoscopy, including that the procedure utilizes typical spinal equipment that should be readily available, requires less capital cost and optical instrumentation, and provides greater operative flexibility as a result of utilizing both a working and a viewing portal7,8.

Description

A 0-degree arthroscope is typically utilized for discectomy and lumbar laminectomies. The use of a radiofrequency ablator is critical to help coagulate osseous and muscle bleeders. For irrigation, gravity or a low-pressure pump, typically <40 mm Hg, can be utilized9,10. Further details regarding irrigation pressure are provided in "Important Tips." The use of a standard powered burr is typical to help osseous decompression, and Kerrison ronguers, pituitaries, osteotomes, and probes utilized in open or tubular cases suffice. Two incisions are made approximately 1 cm lateral to the midline. If working from the left side for a right-handed surgeon, the working portal is typically made at the lower laminar margin of the target level. The camera portal is then made typically 2 to 3 cm cephalad. A lateral radiograph is then utilized to confirm the portal placements. From the right side, the working portal is cephalad and the camera portal is caudal. Because of the switch, the portals may be shifted more distally.The first step is creating a working space because there is no true joint space in the spine. With use of radiofrequency ablation, a working space is created in the interlaminar space. Next, with use of a powered burr or a chiseled osteotomy, the base of the cephalad spinous process is thinned until the insertion of the ligamentum flavum is found. Next, the ipsilateral and contralateral laminae are thinned in a similar fashion. Once the osseous elements are removed, the ligamentum flavum is removed en bloc. The traversing nerve roots are checked under direct high-magnification visualization to ensure that they are decompressed. If a discectomy is necessary, standard nerve-root retractors can be utilized to retract the neural elements. With use of a blunt-tip elevator, the anular defect can be incised and the herniated disc can be removed under direct high-power visualization. In addition, a small curet can be utilized to create a defect in the weakened anulus or membrane covering the extruded disc material in order to help deliver the herniated disc material. Epidural veins are coagulated typically with use of a fine-point bipolar radiofrequency device.

Alternatives

Nonoperative treatments include oral anti-inflammatory drugs, physical therapy, and epidural injections; if these fail, alternative surgical treatments include open lumbar laminectomy and/or discectomy, tubular lumbar laminectomy and/or discectomy, and other minimally invasive techniques, such as microendoscopy, uniportal endoscopy, and microscopy-assisted decompression.

Rationale

UBE is a minimally invasive surgical procedure that better preserves osseous and muscular structure compared with open and tubular techniques. Conventional lumbar laminectomy involves dissection and retraction of the multifidus muscle from the spinous process to the facet joint. This exposure can damage the delicate posterior dorsal rami. Long retraction time can also lead to pressure-induced muscle atrophy and potentially increased chronic low back pain. Alternatively, smaller incisions and shorter hospital stays are possible with UBE.Similar to UBE, tubular surgery can minimize soft-tissue damage compared with open techniques; however, in a randomized trial assessing techniques for spinal stenosis surgery, Kang et al. found that UBE and tubular surgery had similarly favorable clinical outcomes at 6 months postoperatively but UBE resulted in decreased operative time, drain output, opiate use, and length of hospital stay5.Furthermore, the use of an endoscope in the biportal technique allows ultra-high magnification of the spinal pathology, decreased capital costs, and the ability to use 2 hands with freedom of movement. UBE provides clear visualization of the neural elements while keeping maximal ergonomic efficiency with the surgeon's head looking straight forward, the shoulders relaxed, and the elbows bent to 90°. Continuous irrigation through the endoscope also helps with bleeding and decreasing the risk of infection.

Expected Outcomes

Long-term outcomes do not differ substantially between discectomies performed with use of the presently described technique and procedures done with more traditional minimally invasive (i.e., tubular) techniques; however, visual analogue scale scores for back pain may be better in the short term, and there is evidence of a shorter hospital stay with UBE2. Complication rates did not differ from other minimally invasive techniques. When comparing UBE and stenosis, Aygun and Abdulshafi found that UBE was associated with decreased hospital stays, operative time, and blood loss and better clinical outcomes up to 2 years postoperatively compared with tubular laminectomy12.

Important Tips

The optimal hydrostatic pressure is 30 to 50 mm Hg. Pressure is determined by the distance between the fluid source and the working space. Because the working space does not change, the height of the bag decides pressure. A simple formula for pressure is calculated by dividing the distance from the working field to the irrigation source by 1.36. A rule of thumb is that if the bag is 50 to 70 cm above the patient's back, the pressure should be adequate. The advantages of using gravity rather than a pressure pump are that excessive fluid solution pressure in the epidural space can cause neurological issues such as nuchal pain, headache, and seizure11. Additionally, if the intertransverse membrane or the lateral margins of the disc are violated, hydroperitoneum can occur unknowingly due to the high-pressure system.Gravity or pump pressure of >40 mm Hg may elevate epidural pressure and mask operative bleeding. When the pump is turned off at the end of the surgical procedure, a postoperative epidural hematoma may occur because the bleeding source may not have been recognized while the pump pressure was on.Excessive pump pressure may lead to an increase in intracranial pressure, causing headache or delayed recovery from general anesthesia with stiff posture and hyperventilation.Make sure fluid is emerging from the working portal and the muscle area is not swelling to prevent soft-tissue fluid extravasation.Epidural veins are coagulated typically with a fine-point bipolar radiofrequency device.Osseous bleeding can be controlled with bone wax or a high-speed burr.

Acronyms and Abbreviations

MRI = magnetic resonance imagingRF = radiofrequencyAP = anteroposterior.

Indications for and Outcomes of Three Unilateral Biportal Endoscopic Approaches for the Decompression of Degenerative Lumbar Spinal Stenosis: A Systematic Review

Objective: In this systematic review, we summarized the indications for and outcomes of three main unilateral biportal endoscopic (UBE) approaches for the decompression of degenerative lumbar spinal stenosis (DLSS). Methods: A comprehensive search of the literature was performed using Ovid Embase, PubMed, Web of Science, and Ovid’s Cochrane Library. The following information was collected: surgical data; patients’ scores on the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Macnab criteria; and surgical complications. Results: In total, 23 articles comprising 7 retrospective comparative studies, 2 prospective comparative studies, 12 retrospectives case series, and 2 randomized controlled trials were selected for quantitative analysis. The interlaminar approach for central and bilateral lateral recess stenoses, contralateral approach for isolated lateral recess stenosis, and paraspinal approach for foraminal stenosis were used in 16, 2, and 4 studies, respectively. In one study, both interlaminar and contralateral approaches were used. L4-5 was the most common level decompressed using the interlaminar and contralateral approaches, whereas L5-S1 was the most common level decompressed using the paraspinal approach. All three approaches provided favorable clinical outcomes at the final follow-up, with considerable improvements in patients’ VAS scores for leg pain (63.6–73.5%) and ODI scores (67.2–71%). The overall complication rate was <6%. Conclusions: The three approaches of UBE surgery are effective and safe for the decompression of various types of DLSS. In the future, long-term prospective studies and randomized control trials are warranted to explore this new technique further and to compare it with conventional surgical techniques.

Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions

BACKGROUND

Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions.

OBJECTIVE

The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS.

METHODS

Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted.

RESULTS

Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I² = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms.

CONCLUSIONS

Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

The effectiveness of postoperative exercise based on gait analysis compared with conventional exercise in patients with lumbar spinal stenosis: A randomized clinical trial

BACKGROUND

Despite being used as a program of postoperative rehabilitation, few randomized controlled trials have compared the effectiveness of postoperative exercise based on gait analysis in patients with lumbar spinal stenosis (LSS).

OBJECTIVE

To investigate the effectiveness of postoperative exercise based on gait analysis in patients with LSS and to compare it with the effectiveness of conventional exercise.

METHODS

This was a double-blind, randomized clinical trial. Sixty-eight participants with LSS were randomly assigned to one of two groups. After receiving a standardized surgical procedure, the observation group received exercises based on 3-D gait analysis, and the control group received empirical physiotherapy containing 4 basic interventions. Both groups took a one-hour session twice daily for 2 weeks. The Oswestry Disability Index (ODI) scale and the Visual Analog Scale (VAS) were measured before and 2 weeks and 6 months after intervention. The gait indicators were measured before and 6 months after intervention.

RESULTS

At baseline, there were no significant differences in the ODI, VAS or absolute symmetry index (ASI) of the gait variables between the observation group and the control group. However, at 6 months, pain intensity, walking, standing, social life and summary scores of ODI and VAS of the leg demonstrated significant differences (p< 0.05, respectively) between groups, and the observation group had greater reductions in ASI of stride length, hip flexion, knee flexion and ankle dorsiflexion compared with the control group (p< 0.05, respectively).

CONCLUSIONS

The postoperative rehabilitation scheme based on gait analysis resulted in significant short- to medium-term improvements in pain intensity, walking, standing, social life and the summary score of ODI, VAS of leg and symmetry of stride length, hip flexion, knee flexion and ankle dorsiflexion compared with empirical exercise in patients with LSS.

Clinical and radiologic outcomes of biportal endoscopic lumbar discectomy in obese patients: a retrospective case-control study

BACKGROUND

Obese patients have a higher risk of complications during spinal surgery than non-obese patients. To the best of our knowledge, no studies have examined the differences in clinical and radiological outcomes after biportal endoscopic lumbar discectomy (BELD) between obese and non-obese patients. The study evaluated the association between obesity and outcomes after BELD in patients with lumbar disc herniation.

METHODS

This was a retrospective case-control study conducted from March 2017 to March 2021 at two hospitals with 360 patients who underwent BELD after showing no improvement with conservative treatment. Clinical and radiologic outcomes were retrospectively analyzed after BELD in the non-obese (body mass index [BMI] < 30 kg/m²) and obese (BMI ≥ 30 kg/m²) groups. Demographic data and surgery-related factors were compared between the two groups. Clinical outcomes were followed up for 12 months after surgery and analyzed for differences.

RESULTS

A total of 211 patients were enrolled in this study, and through case-control matching, the data of 115 patients (29, obese group; 86, non-obese group) were analyzed. The two groups showed no significant differences in Oswestry Disability Index, European Quality of Life-5 Dimensions (EQ-5D), and visual analog scale scores measured immediately after BELD and 12 months after surgery. After surgery, back pain, radiating leg pain, and EQ-5D scores improved. However, there was no significant difference in improvement, residual herniated disc, hematoma, or recurrence between the groups.

CONCLUSIONS

Obese patients who underwent BELD for lumbar disc herniation showed no significant difference in clinical and radiologic outcomes compared with non-obese patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is Biportal Endoscopic Spine Surgery More Advantageous Than Uniportal for the Treatment of Lumbar Degenerative Disease? A Meta-Analysis

Background and Objectives: To estimate the clinical outcomes of uniportal and biportal full-endoscopic spine surgery for the treatment of lumbar degenerative disease (LDD), and to provide the latest evidence for clinical selection. Materials and Methods: Relevant literatures published in PubMed, Web of Science, Embase, CNKI, and WanFang Database before 21 November 2021 were searched systematically. Two researchers independently screened the studies, extracted data, and evaluated the risk of bias of the included studies. The systematic review and meta-analysis were performed using the Review Manager software (version 5.4; The Cochrane Collaboration). Results: A total of seven studies were included in this meta-analysis, including 198 patients in a uniportal endoscopy group and 185 patients in a biportal endoscopy group. The results of this meta-analysis demonstrated that the biportal endoscopy group experienced less intraoperative estimated blood loss (WMD = -2.54, 95%CI [-4.48, -0.60], p = 0.01), while the uniportal endoscopy group displayed significantly better recovery results in Visual Analog Scale (VAS) assessments of the back within 3 days of surgery (WMD = 0.69, 95%CI [0.02, 1.37], p = 0.04). However, no significant differences in operation time, length of hospital stay, complication rates, Oswestry Disability Index (ODI) (within 3 months), ODI (last follow-up), VAS for back (within 3 months), VAS for back (last follow-up), and VAS for leg (within 3 days, within 3 months, last follow-up) were identified between the two groups. Conclusions: According to our meta-analysis, patients who underwent the uniportal endoscopic procedure had more significant early postoperative back pain relief than those who underwent the biportal endoscopic procedure. Nevertheless, both surgical techniques are safe and effective.

Endoscopic Spinal Surgery (BESS and UESS) Versus Microscopic Surgery in Lumbar Spinal Stenosis: Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-Analysis.

OBJECTIVES

Various minimally invasive surgical techniques have been developed as alternatives to conventional surgery. According to recent studies, endoscopic spinal surgery (ESS) (biportal ESS [BESS] or uniportal ESS [UESS]) is more favorable compared with microscopic spinal surgery (MSS). This systematic review and meta-analysis aimed to assess the latest evidence on the use of ESS compared with MSS in lumbar spinal stenosis.

METHODS

A systematic electronic search using PubMed, Embase, Cochrane Central Database, and Korea Med was performed until December 2019 to identify studies that compared ESS and MSS in patients with lumbar spinal stenosis.

RESULTS

Overall, 1167 patients were included from three randomized controlled trials, six retrospective cohorts, and two prospective case-control studies. This review only presented 3 direct comparative studies. The study had inherent limitations specifically in terms of the study design. Meta-analysis of hospital stay (days) showed significant difference between BESS and MSS, UESS and MSS, BESS +UESS, and MSS at the final follow-up (95% confidence interval [CI]: -3.66 to -.77; P = .003; I² = 97%, 95% CI: -2.95 to -1.22; P <.00001; I² = 90%, and 95% CI: -2.89 to -1.48; P <.00001; I² = 96%, respectively). However, meta-analysis showed no significant difference in other results.

CONCLUSIONS

Although a shorter duration of hospital stay was observed in ESS, there were no significant differences in efficacy and safety between ESS and MSS. Further studies are required to validate these results.

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

Osbjective

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

Methods

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

Results

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

Conclusion

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

Unilateral Biportal Endoscopic Discectomy versus Microendoscopic Discectomy for the Treatment of Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

Objective

In minimally invasive spinal surgery, the treatment of lumbar spinal stenosis with microendoscopic discectomy (MED) or unilateral biportal endoscopic discectomy (UBED) shows effective results, but which is more effective is controversial. Our study aimed to evaluate the efficacy and safety of UBED versus MED in the treatment of lumbar spinal stenosis by a systematic review and meta-analysis, so as to provide reference for the promotion of UBED in clinical practice.

Methods

The multiple databases like PubMed, EMBASE, Web of Science, Cochrane Library, Chinese National Knowledge Databases, Chinese BioMedical Database, and Wanfang Database were used to search for the relevant studies. Review Manager 5.4 was adopted to estimate the effects of the results among selected articles. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were used to estimate the overall pooled effect. Subgroup analysis, forest plots, funnel plots and Egger's test for the articles included were also conducted.

Results

Three randomized clinical trials and seven cohort studies were finally retrieved, these studies included 685 and 829 patients in the UBED and MED groups, respectively. There were no differences in terms of operation time (MD = -0.92, P =0.72), estimated blood loss (MD = -26.31, P =0.08), complications (MD =0.81, P =0.38) and Oswestry Disability Index (ODI) score (P >0.05 in four subgroup) between the two groups. The visual analog scale (VAS) score of back pain in the UBED group was better than MED group only at 6 months (MD = -0.23, P =0.006) after operation, the VAS score of leg pain in the UBED group was better than that of MED group at 3 mouths (MD = -0.22, P =0.002) and 6 months (MD = -0.24, P =0.006) after operation, the UBED group had a less postoperative length of stay than the MED group (MD = -1.85, P <0.001). The bias analysis showed that there was no potential publication bias in the included literature.

Conclusion

This study showed that compared with MED, UBED has the advantages of short hospital stay and good short-term curative effect, but there is no significant difference in long-term efficacy and safety, they can be replaced by each other in clinical application.

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.

Case Report: Five-Level Unilateral Laminectomy Bilateral Decompression (ULBD) by Two-Stage Unilateral Biportal Endoscopy (UBE)

Introduction

Unilateral biportal endoscopy (UBE) is a relatively new yet common minimally invasive procedure in spine surgery, capable of achieving adequate decompression for lumbar spinal stenosis through unilateral laminectomy bilateral decompression (ULBD). Neither additional fusion nor rigid fixation is required, as UBE-ULBD rarely causes iatrogenic lumbar instability. However, to our knowledge, five-level ULBD via two-stage UBE without lumbar fusion has been yet to be reported in the treatment of multilevel lumbar spinal stenosis.

Case description

We present a case of an 80-year-old female patient who developed progressive paralysis of the lower extremities. Radiographic examinations showed multilevel degenerative lumbar spinal stenosis and extensive compression of the dural sac and nerve roots from L1-2 to L5-S1. The patient underwent five-level ULBD through two-stage UBE without lumbar fusion or fixation. One week after the final procedure, the patient could ambulate with walking aids and braces. Moreover, no back pain or limited lumbar motion was observed at the 6-month follow-up.

Conclusion

Multilevel ULBD through UBE may provide elderly patients with an alternative, minimally invasive procedure for treating spinal stenosis. This procedure could be achieved by staging surgeries. In this case, we reported complaints of little back pain, despite not needing to perform lumbar fusion or fixation.

Clinical Evaluation of Surgery for Single-Segment Lumbar Spinal Stenosis: A Systematic Review and Bayesian Network Meta-Analysis

To compare the efficacy and safety of different surgical procedures for patients with single‐segment lumbar spinal stenosis (LSS), Bayesian network meta‐analysis (NMA) was conducted in this study. Randomized controlled trials (RCTs) which reported 2 years' results after surgery were searched from PubMed, Embase, and Cochrane Register of Controlled Trials up to February 2021. Eligible RCTs that contained at least two of the following surgical procedures, bilateral decompression via the unilateral approach (BDUL), decompression with conventional laminectomy (CL), decompression with fusion (DF), endoscopic decompression (ED), interspinous process devices only (IPDs), decompression with interlaminar stabilization (DILS), decompression with lumbar spinal process‐splitting laminectomy (LSPSL), and minimally invasive tubular decompression (MTD), would be included after screening based on the inclusion and exclusion criteria. The primary outcome was Oswestry Disability Index (ODI). Twenty eligible RCTs were included, with a total of 2201 patients enrolled. The NMA showed that the following surgical procedures ranked first (surface under the cumulative ranking) when compared with CL and DF: DILS for ODI (SUCRA 87.8%); LSPSL for back pain (95%); and MTD for leg pain (95.6%). MTD ranked among the top three surgical procedures for most outcomes. The quality of the synthesized evidence was low according to the Grading of Recommendations Assessment, Development, and Evaluation criteria. DILS, LSPSL, MTD, IPDs, and ED are the most effective procedures for patients with single‐segment LSS. Because of combining efficacy and safety, MTD may be the most promising routine surgical option for treating single‐segment LSS.

The Learning Curve of Unilateral Biportal Endoscopic (UBE) Spinal Surgery by CUSUM Analysis

Objective

To assess the learning curve of the unilateral biportal endoscopic (UBE) technique for the treatment of single-level lumbar disc herniation by cumulative summation (CUSUM) method analysis.

Methods

A retrospective analysis was conducted to assess 97 patients' general condition, operation time, complications, and curative effect of single segmental UBE surgery performed by a spinal surgeon in his early stage of this technique. The learning curve of operation time was studied using a CUSUM method, and the cut-off point of the learning curve was obtained.

Results

The operation time was 30 – 241(97.9 ± 34.7) min. The visual analog scale score of lower limb pain decreased from 5.75 ± 0.81 before the operation to 0.39 ± 0.28 at the last follow-up (P &lt; 0.05). The Oswestry disability index score decreased from 66.48 ± 4.43 before the operation to 14.57 ± 3.99 at the last follow-up (P &lt; 0.05). The CUSUM assessment of operation time revealed the learning curve was the highest in 24 cases. In the learning stage (1–24 cases), the operation time was 120.3 ± 43.8 min. In the skilled stage (25–97 cases), the operation time was 90.5 ± 27.8 min.

Conclusions

About 24 cases of single segmental UBE operation are needed to master the UBE technique.

Comparison of Microscopic Decompression and Biportal Endoscopic Spinal Surgery in the Treatment of Lumbar Canal Stenosis and Herniated Disc: A One-year Follow-up

Backgrounds. Microscopic decompression (MD) has been widely used as an alternative to open decompression. Lately, biportal endoscopic spinal surgery (BESS) - a new approach in minimal-invasive spinal surgery – has also been used with good results.  Although both groups can achieve adequate lumbar decompression, there is still a lack of evidence regarding their comparison. We aim to compare the outcomes of both techniques in a one-year follow-up. Methods. This is a retrospective study in 100 consecutive patients with symptomatic lumbar spine compression due to herniated nucleus pulposus (HNP) and lumbar canal stenosis (LCS) that was treated by either BESS or MD. Clinical evaluations using Visual Analog Score (VAS), Oswestry Disability Index (ODI), and SF-36 questionnaire were obtained. Objective data such as surgery duration, amount of postoperative drain production, and hospital length of stay were collected. Complications were noted throughout the follow-up time. Results. The BESS group had a significantly lesser surgical duration, drain production, and length of stay. At one year follow-up, both groups achieved significant improvement in VAS, ODI, and SF-36 compared to the preoperative condition. Complications were not observed in the BESS group. Conclusions. Both procedures were comparably effective to treat lumbar stenosis. Although this study shows superiority with BESS technique in immediate and long-term follow-up, the final choice may depend on the surgeon's preference

Endoscopic decompression for the treatment of lumbar spinal stenosis: an updated systematic review and meta-analysis

OBJECTIVE

Lumbar stenosis treatment has evolved with the introduction of minimally invasive surgery (MIS) techniques. Endoscopic methods take the concepts applied to MIS a step further, with multiple studies showing that endoscopic techniques have outcomes that are similar to those of more traditional approaches. The aim of this study was to perform an updated meta-analysis and systematic review of studies comparing the outcomes between endoscopic (uni- and biportal) and microscopic techniques for the treatment of lumbar stenosis.

METHODS

Following PRISMA guidelines, a systematic search was performed using the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Ovid Embase, and PubMed databases from their dates of inception to December 14, 2020. All identified articles were then systematically screened against the following inclusion criteria: 1) studies comparing endoscopic (either uniportal or biportal) with minimally invasive approaches, 2) patient age ≥ 18 years, and 3) diagnosis of lumbar spinal stenosis. Bias was assessed using quality assessment criteria and funnel plots. Meta-analysis using a random-effects model was used to synthesize the metadata.

RESULTS

From a total of 470 studies, 14 underwent full-text assessment. Of these 14 studies, 13 comparative studies were included for quantitative analysis, totaling 1406 procedures satisfying all criteria for selection. Regarding postoperative back pain, 9 studies showed that endoscopic methods resulted in significantly lower pain scores compared with MIS (mean difference [MD] -1.0, 95% CI -1.6 to -0.4, p < 0.01). The length of stay data were reported by 7 studies, with endoscopic methods associated with a significantly shorter length of stay versus the MIS technique (MD -2.1 days, 95% CI -2.7 to -1.4, p < 0.01). There was no significant difference with respect to leg visual analog scale scores, Oswestry Disability Index scores, blood loss, surgical time, and complications, and there were not any significant quality or bias concerns.

CONCLUSIONS

Both endoscopic and MIS techniques are safe and effective methods for treating patients with symptomatic lumbar stenosis. Patients who undergo endoscopic surgery seem to report less postoperative low-back pain and significantly reduced hospital stay with a trend toward less perioperative blood loss. Future large prospective randomized trials are needed to confirm the findings in this study.

Global and Current Research Trends of Unilateral Biportal Endoscopy/Biportal Endoscopic Spinal Surgery in the Treatment of Lumbar Degenerative Diseases: A Bibliometric and Visualization Study

The study aimed to make a bibliometric analysis of the current research situation in unilateral biportal endoscopy/biportal endoscopic spinal surgery (UBE/BESS). Research data sets were acquired from the Web of Science database. The study chosed “biportal endoscopic spinal surgery” OR “two portal endoscopic spinal surgery” OR “percutaneous biportal endoscopic decompression” OR “unilateral biportal endoscopy” OR “irrigation endoscopic discectomy” as the search terms. The literature search was limited to articles published before March 5, 2021. We only included original articles and reviews. VOS viewer and Citespace software were used to analyze the data and generate visualization knowledge maps. Annual trend of publications, distribution, H‐index status, co‐authorship status, and research hotspots were analyzed. A total of 74 publications met the requirement. The sum number of citations was 31,204, in which 19,336 were no self‐citations. The average citation of all the papers was 21.84 times. The H‐index of all the publications was 85. South Korea's total number of articles was far higher than that of other countries and regions (61, 82.4%), followed by United Arab Emirates, Egypt, and Peoples Republic of China (three, ranking second, accounting for 12.2% of the total). For the most productive authors, Choi ranked first with 21 articles, Kim ranked second with 16 articles, and Heo ranked third with 12 articles. The journal with the greatest number of publications was World Neurosurgery, with a total of 18 (39.1%) papers. Clinics in Orthopedic Surgery ranked second with six (13.0%) papers. In third place, there were fix articles published by Asian Spine Journal and Neurospine, accounting for 21.8% of the total articles. These top three journals accounted for 73.9% of all the papers. Spondylolisthesis and endoscopic decompression were the research hotspots in recent years. The number of publications has showed an upward trend with a stable rise in recent years. South Korea is the country with the highest productivity, not only in quality, but also in quantity. Barun Hosp and Leon Wiltse Mem Hosphave published most articles. Choi is the most productive author. World Neurosurgery is the most productive journal. Spondylolisthesis and endoscopic decompression are the research hotspots in recent years. Indeed, this study provides new insight into the growth and development of UBE/BESS.

Artificial Intelligence Algorithm-Based Lumbar and Spinal MRI for Evaluation of Efficacy of Chinkuei Shin Chewan Decoction on Lumbar Spinal Stenosis

The study aimed to explore the application value of lumbar Magnetic Resonance Imaging (MRI) images processed by artificial intelligence algorithms in evaluating the efficacy of chinkuei shin chewan decoction (a traditional Chinese medicine to nourish the kidney) in the treatment of lumbar spinal stenosis (LSS). Specifically, 110 LSS patients admitted to the hospital were selected as the research subjects. They were randomly divided into the control group (n = 55) and experimental group (n = 55) according to different treatment methods. The control group was treated with traditional medicine, and the experimental group additionally took chinkuei shin chewan decoction on its basis. Based on the traditional U-net algorithm, a U-net registration algorithm based on artificial intelligence was designed by introducing the information entropy theory, and the algorithm was applied to the lumbar MRI image evaluation of LSS patients. Compared with the traditional U-net algorithm, the artificial intelligence-based U-net registration algorithm had a decreased noise level (P < 0.05), the Jaccard (J) value (0.84) and the Dice value (0.93) increased significantly versus the traditional algorithm (J = 0.63, Dice = 0.81), and the characteristics of the image were more accurate. Before treatment, the Oswestry Disability Index (ODI) scores of the experimental group and the control group were 44.32 ± 6.45 and 43.32 ± 5.45, respectively. After treatment, the ODI scores of the two groups were 10.21 ± 5.05 and 17.09 ± 5.23, respectively. Both showed significant improvement, while the improvement of the experimental group was more obvious than that of the control group (P < 0.05). The overall effective rates of the two groups of patients were 96.44% and 82.47%, respectively, and the experimental group was significantly higher than the control group (P < 0.05). Under the U-net registration algorithm based on artificial intelligence, the diagnostic accuracy of lumbar MRI in the experimental group was 94.45%, significantly higher than 67.5% before the introduction of the algorithm (P < 0.05). In conclusion, chinkuei shin chewan decoction are effective for the treatment of LSS, and lumbar MRI based on the artificial intelligence U-net registration algorithm can evaluate the efficacy of LSS well and is worthy of promotion.

Evaluation of the efficacy and safety of conventional and biportal endoscopic decompressive laminectomy in patients with lumbar spinal stenosis (ENDO-B trial): a protocol for a prospective, randomized, assessor-blind, multicenter trial

BACKGROUND

Recent studies on biportal endoscopic spine surgery in patients with lumbar spinal stenosis have reported good clinical results. However, these studies have been limited by the small sample sizes and use of a retrospective study design. Therefore, we aim to compare the efficacy and safety of biportal endoscopic decompressive laminectomy with those of conventional decompressive laminectomy in a multicenter, prospective, randomized controlled trial.

METHODS

This study will include 120 patients (60 per group, aged 20-80 years) with 1- or 2-level lumbar spinal stenosis, who will be recruited from six hospitals. The study will be conducted from July 2021 to December 2024. The primary outcome (Oswestry Disability Index at 12 months after surgery) will be evaluated through a modified intention-to-treat method. The secondary outcomes will include the following: visual analog scale score for low back and lower extremity radiating pain, EuroQol 5-dimensions score, surgery satisfaction, walking time, postoperative return to daily life period, postoperative surgical scars, and some surgery-related variables. Radiographic outcomes will be analyzed using magnetic resonance imaging or computed tomography. All outcomes will be evaluated before the surgery and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines for reporting of clinical trial protocols.

DISCUSSION

It is hypothesized that the efficacy and safety of biportal endoscopic and conventional decompressive laminectomy will be comparable in patients with lumbar spinal stenosis. The results of this trial will provide a high level of evidence for the efficacy and safety of the biportal endoscopic technique in patients with lumbar spinal stenosis and facilitate the development of clinical practice guidelines. Furthermore, the results of this study may indicate the feasibility of the biportal endoscopic technique for other types of spinal surgery.

TRIAL REGISTRATION

The ENDO-B trial is registered at Clinical Research Information Service (CRIS, cris.nih.go.kr ) (KCT0006057; April 52,021).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Incorporating New Technologies to Overcome the Limitations of Endoscopic Spine Surgery: Navigation, Robotics, and Visualization

Recently, spine surgery has gradually evolved from conventional open surgery to minimally invasive surgery, and endoscopic spine surgery (ESS) has become an important procedure in minimally invasive spine surgery. With improvements in the optics, spine endoscope, endoscopic burr, and irrigation pump, the indications of ESS are gradually widening from lumbar to cervical and thoracic spine. ESS was not only used previously for disc herniations that were contained without migration but is also used currently for highly migrated disc herniations and spinal stenosis; thus, the indications of ESS will be further expanded. Although ESS has certain advantages such as less soft tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent less epidural fibrosis and scarring, reduced hospital stay, early functional recovery, and improvement of quality of life as well as better cosmesis, several obstacles remain for ESS to be widespread because it has a steep learning curve and surgical outcome is strongly dependent on the surgeon's skillfulness. A solid surgical technique requires reproducibility and ensured safety in addition to surgical outcomes. In this review article, how to improve ESS was investigated by grafting novel technologies such as navigation, robotics, and 3-dimensional and ultraresolution visualization.

Early Career Challenges in Setting Up an Endoscopic Spine Surgery Practice

After the completion of an endoscopic spinal surgery fellowship, the next challenge for the newly minted consultant is to set up a viable and sustainable endoscopic practice. A successful practice of endoscopic spine surgery is dependent on several factors, such as anesthetic support; surgical expertise; support for provision and maintenance of endoscopic equipment; cost of equipment; administrative and nursing support; postoperative care services to optimize patients' outcome and satisfaction; patients' ideas, concerns, and expectations, as well as continuing medical education. In this article, a perspective is given on the early career challenges that a fellowship-trained endoscopic surgeon may encounter in the period leading to first successful endoscopic spinal surgery.

Microscopic decompressive laminectomy versus percutaneous endoscopic decompressive laminectomy in patients with lumbar spinal stenosis: protocol for a systematic review and meta-analysis

INTRODUCTION

Lumbar spinal stenosis (LSS) is a common lumbar degenerative disease in the elderly, usually requiring surgery if conservative treatment fails. Microscopic decompressive laminectomy (MDL) and percutaneous endoscopic decompressive laminectomy (PEDL) have been widely used to treat LSS. This study aims to provide a protocol for the evaluation and comparison of the efficacy, safety and applicability between MDL and PEDL.

METHODS AND ANALYSIS

We will search for randomised controlled trials (RCTs) comparing MDL and PEDL for treating LSS from inception to December 2019 in the following databases: PubMed, The Cochrane Library, Web of Science, Embase and China Biology Medicine. The quality of included studies will be assessed using the risk of bias tool recommended by the Cochrane Handbook 5.2.0. Subsequently, a meta-analysis will be performed using RevMan 5.3 software.

ETHICS AND DISSEMINATION

Given the nature of this study, no ethical approval will be required. The protocol will be disseminated via a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020164765.

Biportal endoscopic discectomy for high-grade migrated lumbar disc herniation

OBJECTIVE

Although endoscopic procedures for lumbar disc herniation have improved greatly and offer many advantages, the indications are limited mostly to nonmigrated or low-grade migrated disc herniation. Endoscopic application in migrated disc herniation cases is still challenging and technically demanding. The goal in this study was to determine the feasibility of biportal endoscopic discectomy for removal of high-grade migrated disc herniation.

METHODS

A retrospective review was performed in 262 patients who had undergone biportal endoscopic discectomy after the diagnosis of lumbar herniated disc. According to preoperative MRI findings, disc herniation was classified into 5 zones based on the direction and distance from the disc space. Patients were divided into 2 groups-a high-grade migration group and a low-grade migration group. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI), visual analog scale (VAS), and modified Macnab criteria, and those outcomes and operation time were compared between the 2 groups.

RESULTS

There were 10 patients with "high-grade up," 8 with "low-grade up," 98 with disc-level, 102 with "low-grade down," and 44 with "high-grade down" herniation, thereby yielding 54 patients in the high-grade group and 208 in the low-grade group. Demographic data for the 2 groups showed no significant difference. There was no significant difference between the 2 groups in ODI, VAS, and modified Macnab criteria. Operation time between the 2 groups was not significantly different (60.74 vs 65.63 minutes, p > 0.05).

CONCLUSIONS

Biportal endoscopic discectomy can be effective for high-grade migrated lumbar disc herniation with no prolonged operation time and satisfactory clinical outcomes.

Ten-Step Biportal Endoscopic Transforaminal Lumbar Interbody Fusion Under Computed Tomography-Based Intraoperative Navigation: Technical Report and Preliminary Outcomes in Mexico

BACKGROUND

The principal advantage of intraoperative spinal navigation is the ease of screw placement. However, visualization and the integration of navigation can be explored with the use of navigation-guided full-endoscopic techniques.

OBJECTIVE

To describe the stepwise intraoperative navigation-assisted unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) technique and to present our preliminary results in a Mexican population.

METHODS

A 10-step summary of the UBE-TLIF operative technique was described, and the clinical and radiological results are presented and analyzed.

RESULTS

A total of 7 patients were treated. We observed the value of integrating navigation and endoscopic visualization when decompression had to be performed.

CONCLUSION

Together, intraoperative navigation and direct visualization through the endoscope may be a useful surgical tool for surgeons with experience in endoscopic spinal surgery.

Comparision of biportal endoscopic and microscopic decompression in treatment of lumbar spinal stenosis: A comparative study protocol

BACKGROUND

Microscopic bilateral decompression (MBD) has been suggested as an alternative to open laminectomy and fusion. Recently, percutaneous biportal endoscopic decompression (PBED) has begun to attract attention. The purpose of this retrospective study was to evaluate postoperative pain, functional disability, symptom reduction and satisfaction, and specific surgical parameters between the MBD and PBED techniques in patients with lumbar spinal stenosis (LSS).

METHODS

A retrospective review of LSS patients performed with MBD or PBED technique between May 2015 and June 2018 was conducted. Institutional review board approval in People's Hospital of Ningxia Hui Nationality Autonomous Region was obtained prior to conducting chart review and analysis. We received informed consent from all patients before surgery. The primary outcomes assessed were the preoperative to postoperative changes in leg/back pain and disability/function, patient satisfaction with the procedure, and postoperative quality of life. The secondary outcomes including duration of postoperative hospital stay, time to mobilization, postoperative analgesic use, complication rates, and baseline patient characteristics were prospectively collected.

RESULTS

The hypothesis was that the PBED technique would achieve better clinical outcomes as compared to the MBD technique in LSS.

Biportal endoscopic decompression vs. microscopic decompression for lumbar canal stenosis: A systematic review and meta-analysis

Lumbar decompressive surgery is the gold standard treatment for lumbar spinal stenosis. Minimally invasive surgical techniques have been introduced with the aim of reducing the morbidity associated with open surgery. The purpose of the present study was to systematically search the literature and perform a meta-analysis of studies comparing the outcomes between biportal endoscopic technique and microscopic technique for lumbar canal stenosis decompression. A comprehensive search of the PubMed, Google Scholar, Web of Science, Embase and the Cochrane Library databases was performed to identify relevant articles up to 15th of December 2019. Eligible studies were retrieved, data were extracted by two authors independently and risks of bias were assessed. A total of six studies involving 438 patients were selected for review. The results of the pooled analysis indicated similar operative times [mean difference (MD), -3.41; 95% CI, -10.78-3.96; P<0.36], similar complications (MD, 0.70; 95% CI, 0.33-1.46; P=0.34), similar visual analogue scale scores for back and leg pain at the time of the final follow-up and similar Oswestry disability indexes (MD, -0.28; 95% CI, -1.25-0.69; P=0.58) for the two procedures. In conclusion, biportal endoscopic technique is a viable alternative to microscopic technique for lumbar canal stenosis decompression with similar operative time, clinical outcomes and complications.

Lumbar decompression and lumbar interbody fusion in the treatment of lumbar spinal stenosis: A systematic review and meta-analysis

BACKGROUND

The goal of this study was to review relevant randomized controlled trials in order to determine the efficacy of decompression and lumbar interbody fusion in the treatment of lumbar spinal stenosis.

METHOD

Using appropriate keywords, we identified relevant studies in PubMed, the Cochrane library, and Embase. Key pertinent sources in the literature were also reviewed, and all articles published through July 2019 were considered for inclusion. For each study, we assessed odds ratios, mean difference, and 95% confidence interval to assess and synthesize outcomes.

RESULT

Twenty-one randomized controlled trials were eligible for this meta-analysis with a total of 3636 patients. Compared with decompression, decompression and fusion significantly increased length of hospital stay, operative time and estimated blood loss. Compared with fusion, decompression significantly decreased operative time, estimated blood loss and overall visual analogue scale (VAS) scores. Compared with endoscopic decompression, microscopic decompression significantly increased length of hospital stay, and operative time. Compared with traditional surgery, endoscopic discectomy significantly decreased length of hospital stay, operative time, estimated blood loss, and overall VAS scores and increased Japanese Orthopeadic Association score. Compared with TLIF, MIS-TLIF significantly decreased length of hospital stay, and increased operative time and SF-36 physical component summary score. Compared with multi-level decompression and single level fusion, multi-level decompression and multi-level fusion significantly increased operative time, estimated blood loss and SF-36 mental component summary score and decreased Oswestry disability index score. Compared with decompression, decompression with interlaminar stabilization significantly decreased operative time and the score of Zurich claudication questionnaire symptom severity, and increased VAS score.

CONCLUSION

Considering the limited number of included studies, we still need larger-sample, high-quality, long-term studies to explore the optimal therapy for lumbar spinal stenosis.

Intervertebral Disc Diseases PART 2: A Review of the Current Diagnostic and Treatment Strategies for Intervertebral Disc Disease

With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases.

Biportal endoscopic versus microscopic lumbar decompressive laminectomy in patients with spinal stenosis: a randomized controlled trial

BACKGROUND CONTEXT

Biportal endoscopic decompressive laminectomy is a widely performed procedure and shows acceptable clinical outcomes. However, the evidence regarding the advantages of biportal endoscopic surgery is weak, a randomized controlled trial is therefore warranted.

PURPOSE

To compare the clinical efficacies of biportal endoscopic and microscopic decompressive laminectomy in patients with lumbar spinal stenosis.

STUDY DESIGN

Randomized controlled trial.

PATIENT SAMPLE

Sixty-four participants suffering from low back and leg pain with single-level lumbar spinal stenosis who required decompressive laminectomy.

OUTCOME MEASURES

Outcomes were assessed with the use of patient-reported outcome measures, visual analog scale (VAS) score for low back and lower extremity radiating pain, Oswestry disability index (ODI), European Quality of Life-5 Dimensions (EQ-5D) score, and painDETECT for neuropathic pain. Surgery-related outcomes including operation time, length of hospital stay, postoperative drainage, and serum creatine phosphokinase were evaluated. Perioperative (<30 days) and late (1-12 months) complications were also noted.

METHODS

All participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic or microscopic decompressive laminectomy. The primary outcome was the ODI score at 12 months after surgery based on a modified intention-to-treat strategy. The secondary outcomes included VAS score for low back and lower extremity radiating pain, ODI scores, EQ-5D score, and painDETECT score. There were no sources of funding and no conflicts of interest associated with this study.

RESULTS

There was no significant difference between groups in the mean ODI score at 12 months after surgery (30 in the microscopy vs. 29 in the biportal endoscopy group, p=.635). There were also no significant differences in low back and lower extremity pain VAS scores, ODI, EQ-5D scores, and painDETECT scores at the 3-, 6-, or 12-month follow-up. Operation time, length of hospital stay, serum creatine phosphokinase, and perioperative complications, such as durotomies and symptomatic hematoma, showed no significant differences between the groups; however, one participant underwent additional revision surgery 9 months after the index surgery in the microscopy group.

CONCLUSIONS

Despite the study design limitation of relatively short duration of follow-up, this trial suggests that biportal endoscopic decompressive laminectomy is an alternative to and offers similar clinical outcomes as microscopic open surgery in patients with symptomatic lumbar spinal stenosis.

Full-endoscopic (bi-portal or uni-portal) versus microscopic lumbar decompression laminectomy in patients with spinal stenosis: systematic review and meta-analysis

BACKGROUND

Lumbar stenosis causes pain in the lower lumbar spine and lower extremities and reduces the patient's quality of life and walking ability. Thus, these conditions are common surgical indications for spinal stenosis. Previous reports have shown satisfactory clinical outcomes of the full-endoscopic (FE) and MI technique decompressive laminectomy for lumbar stenosis. However, they still remain controversial.

OBJECTIVE

We conducted a systematic review and meta-analysis to compare the postoperative outcomes between FE (bi-portal or uni-portal) and MI technique decompressive laminectomy for lumbar stenosis.

METHOD

We searched all comparative studies that compared postoperative outcomes (operative time, VAS for back and leg pain, ODI in 3 months and last follow-up) of full-endoscopic (bi-portal or uni-portal) and microscopic technique decompressive laminectomy for lumbar stenosis from the PubMed and Scopus databases up to October 16, 2019.

RESULTS

Nine of 1107 studies (five comparative studies and four RCT) (N = 994 patients) were eligible; all studies were included in pooling of FE and MI decompression. Five and three studies were included in pooling of bi-portal endoscopic, uni-portal endoscopic and MI decompression. All three techniques were compared in one study. Eight, nine, seven, eight, five, seven, eight and nine studies were included in pooling of VAS for back, leg, ODI in 3 months and last follow-up and operative time, respectively. The UMD of VAS for back, leg, ODI in 3 months and last follow-up of FE group was - 0.63 (95% CI - 1.15, - 0.12), - 0.15 (- 0.42, 0.11), - 2.06 (- 3.76, - 0.39), - 0.07 (- 0.22, 0.08), - 0.16 (- 0.29, - 0.03), - 0.20 (- 1.20, 0.81) scores and - 3.00 (- 12.25, 6.25) minutes when compared to MI in lumbar stenosis. In terms of complication, FE was lower risk of 0.62 (0.40, 0.96) times when compared to MI. After subgroup analysis, BESS had significant lower back and leg pain within 3 months when compared to MI group, while uni-portal FE had significant lower leg pain in the last follow-up and complication when compared to MI group. There had no difference in ODI and operative time between two groups.

CONCLUSION

FE had statistically significant lower back pain, lower leg pain and lower risk of having complications when compared to MI decompression in lumbar stenosis, while there is no difference in ODI and operative time between both groups. Comparing to MI, BESS had better early postoperative back pain while uni-portal FE had better leg pain and risk of having complications. Larger, prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient.

LEVEL OF EVIDENCE

III.