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

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.

Comparative Evaluation of Postoperative Epidural Hematoma after Lumbar Microendoscopic Laminotomy: The Utility of Ultrasonography versus Magnetic Resonance Imaging

Introduction

Postoperative spinal epidural hematoma (PSEH) is a severe complication of spinal surgery that necessitates accurate and timely diagnosis. This study aimed to assess the accuracy of ultrasonography as an alternative diagnostic tool for PSEH after microendoscopic laminotomy (MEL) for lumbar spinal stenosis, comparing it with magnetic resonance imaging (MRI).

Methods

A total of 65 patients who underwent MEL were evaluated using both ultrasound- and MRI-based classifications for PSEH. Intra- and interrater reliabilities were analyzed. Furthermore, ethical standards were strictly followed, with spine surgeons certified by the Japanese Orthopaedic Association performing evaluations.

Results

Among the 65 patients, 91 vertebral segments were assessed. The intra- and interrater agreements for PSEH classification were almost perfect for both ultrasound (κ=0.824 [95% confidence interval (CI) 0.729-0.918] and κ=0.810 [95% CI 0.712-0.909], respectively) and MRI (κ=0.839 [95% CI 0.748-0.931] and κ=0.853 [95% CI 0.764-0.942], respectively). The results showed high concordance between ultrasound- and MRI-based classifications, validating the reliability of ultrasound in postoperative PSEH evaluation.

Conclusions

This study presents a significant advancement by introducing ultrasound as a precise and practical alternative to MRI for PSEH evaluation. The comparable accuracy of ultrasound to MRI, rapid bedside assessments, and radiation-free nature make it valuable for routine postoperative evaluations. Despite the limitations related to specific surgical contexts and clinical outcome assessment, the clinical potential of ultrasound is evident. It offers clinicians a faster, cost-effective, and repeatable diagnostic option, potentially enhancing patient care. This study establishes the utility of ultrasound in evaluating postoperative spinal epidural hematomas after MEL. With high concordance to MRI, ultrasound emerges as a reliable, practical, and innovative tool, promising improved diagnostic efficiency and patient outcomes. Further studies should explore its clinical impact across diverse surgical scenarios.

Comparing the Efficacy and Safety of Unilateral Biportal Endoscopic Decompression with Percutaneous Endoscopic Lumbar Decompression for Lumbar Degenerative Diseases: A Meta-Analysis

OBJECTIVE

Unilateral biportal endoscopic decompression (UBED) offers the advantages of minimal tissue damage, operational flexibility, and clear visualization, positioning it as an innovative and minimally invasive endoscopic technique. Nevertheless, the clinical evidence supporting the use of UBED in the treatment of degenerative lumbar diseases is limited and conflicting.

METHODS

As of October 1, 2023, a comprehensive search was conducted across databases including Web of Science, PubMed, Embase, and the Cochrane Library to identify all published studies on minimally invasive UBED for the treatment of degenerative lumbar diseases. Data pertaining to patient demographics, fluoroscopy time, operative duration, intraoperative hemorrhage, hospitalization length, visual analog scale (VAS) score for back and leg pain, MacNab criteria, Oswestry Disability Index (ODI), and complication rates were extracted. The Newcastle-Ottawa scale was utilized to assess the quality.

RESULTS

Twelve articles were included, involving 816 patients. The back VAS score (95% confidence interval [CI]: -0.09-0.07, P = 0.75), MacNab criteria (95% CI: 0.52-2.3, P = 0.82), fluoroscopy time (95% CI: -7.03 to -0.4, P = 0.08), and the incidence of complications (95% CI: 0.5-1.73, P = 0.82) were not significantly different, while the leg VAS score (95% CI: 0.01-0.18, P = 0.03), ODI score (95% CI: -1.03 to -0.09, P = 0.02), operation time (95% CI: 5.76-20.62, P = 0.0005), hospitalization length (95% CI: 0.41-2.76, P = 0.008), and intraoperative hemorrhage (95% CI: 21.92-72.44, P = 0.0003) were significantly different.

CONCLUSIONS

UBED offers superiority in ODI, flexibility, and visual field clarity. Conversely, percutaneous endoscopic lumbar decompression presents advantages in terms of operation duration, blood loss, hospitalization length, and leg VAS score. These factors should be thoroughly considered when selecting a surgical approach.

Unilateral biportal endoscopic lumbar interbody fusion (ULIF) versus endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in the treatment of lumbar spinal stenosis along with intervertebral disc herniation: a retrospective analysis

OBJECTIVE

This study aims to compare the clinical effects and imaging data of patients who underwent endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) with those who received unilateral biportal endoscopic lumbar interbody fusion (ULIF).

METHODS

A retrospective analysis was conducted on the clinical data of 69 patients presenting with typical intermittent claudication and signs and symptoms indicative of unilateral lower extremity nerve root compression, meeting inclusion criteria between April 2022 and June 2022. Among the cohort, 35 patients underwent ULIF group, while 34 patients underwent Endo-TLIF group. We compared perioperative parameters, including intraoperative blood loss, duration of hospital stay, and operation time between the two groups. Pre-operative and post-operative changes in the height and cross-sectional area of the target intervertebral space were also compared between the groups. Finally, we evaluated bone graft size and interbody fusion rates at 6 and 12 months post-surgery using the Brantigan scoring system.

RESULTS

The ULIF group had significantly shorter operative times compared to the Endo-TLIF group (P < 0.05). Conversely, the Endo-TLIF group exhibited significantly shorter hospital stays compared to the ULIF group (P < 0.05). However, there were no significant differences in intraoperative bleeding between the two groups (P > 0.05). Furthermore, both groups exhibited postoperative increases in vertebral canal volume compared to baseline (P < 0.05), with no significant difference in the change in the cross-sectional area of the target intervertebral space between the two surgical methods (P > 0.05). Interbody fusion rates were comparable between the two groups at both 6 and 12 months after surgery (P > 0.05). Lastly, the ULIF group had a significantly larger area of bone graft than the Endo-TLIF group (P < 0.05).

CONCLUSION

In summary, the ULIF technique, as a novel spinal endoscopy approach, is a safer and more effective minimally invasive surgical method for addressing lumbar spinal stenosis and intervertebral disc herniation in patients. Both surgical methods have their own advantages and drawbacks. With the development of technology and related instruments, the limitations of both techniques can be mitigated for to a certain extent, and they can be applied by more doctors in diverse medical fields in the future.

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.

How I do it: the biportal endoscopic inclined-ipsilateral technique to decompress the lumbar lateral recess

BACKGROUND

Various full-endoscopic techniques have been developed to reach the lateral recess of the lumbar spine. However, specialized surgical tools, including expensive spinal endoscopic systems, and a steeper learning curve to mastering the technique are required.

METHOD

We present a novel target-addressed unilateral biportal endoscopic technique to reach directly the lumbar lateral recess, particularly useful at L4-L5 and L5-S1. The technique follows an inclined-ipsilateral trajectory to preserve the lateral extension of ligamentum flavum and the facet joint as much as possible.

CONCLUSION

This technique was associated with all the advantages of minimally invasive decompressive procedures and outstanding outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Comparative Study of Unilateral Biportal Endoscopic Decompression and Percutaneous Transforaminal Endoscopic Decompression for Geriatric Patients with Lumbar Lateral Recess Stenosis

Purpose

The purpose of this research was to compare the efficacy of unilateral biportal endoscopic decompression (UBE) and percutaneous transforaminal endoscopic decompression (PTED) in the treatment of elderly patients with single-level lumbar lateral recess stenosis (LRS).

Materials and Methods

Data from January 2020 to March 2022 were analyzed. Thirty-eight patients in the PTED group and thirty-nine patients in the UBE group completed the minimum 12-month follow-up. The demographic data and perioperative outcomes were reviewed. Clinical outcomes were evaluated using the VAS for back and leg pain, the Oswestry Disability Index (ODI), and the modified MacNab criteria.

Results

Both groups of patients completed surgery and a one-year follow-up. There was no significant difference between the two groups in demographics data. UBE has the advantage in operative duration and X-ray time; as far as incision length, blood loss, and drainage volume are concerned, PTED is advantageous. Under the modified MacNab criteria, UBE exhibited a good-to-excellent rate similar to that of PTED (84.6% vs 81.6%, P>0.05). There were no significant differences at any point in time between UBE and PTED with respect to ODI, VAS, or back pain scores (P>0.05). UBE and PTED did not differ significantly in terms of complications.

Conclusion

Both PTED and UBE achieved favorable outcomes in single-level LRS. For operative time and X-ray times, UBE is more advantageous, while PTED offers better estimates of blood loss, incision length, and drainage volume.

Clinical comparison of percutaneous transforaminal endoscopic discectomy and unilateral biportal endoscopic discectomy for single-level lumbar disc herniation

Purpose

To compare the clinical outcomes of percutaneous transforaminal endoscopic discectomy (PTED) and unilateral biportal endoscopic discectomy (UBE) for the treatment of single-level lumbar disc herniation (LDH).

Materials and methods

From January 2020 to November 2021, 62 patients with single-level LDH were retrospectively reviewed. All patients underwent spinal surgeries at the Affiliated Hospital of Chengde Medical University and Beijing Tongren Hospital, Capital Medical University. Among them, 30 patients were treated with UBE, and 32 were treated with PTED. The patients were followed up for at least one year. Patient demographics and perioperative outcomes were reviewed before and after surgery. The Oswestry Disability Index (ODI), visual analog scale (VAS) for back pain and leg pain, and modified MacNab criteria were used to evaluate the clinical outcomes. x-ray examinations were performed one year after surgery to assess the stability of the lumbar spine.

Results

The mean ages in the UBE and PTED groups were 46.7 years and 48.0 years, respectively. Compared to the UBE group, the PTED group had better VAS scores for back pain at 1 and 7 days after surgery (3.06 ± 0.80 vs. 4.03 ± 0.81, P < 0.05; 2.81 ± 0.60 vs. 3.70 ± 0.79, P < 0.05). The UBE and PTED groups demonstrated significant improvements in the VAS score for leg pain and ODI score, and no significant differences were found between the groups at any time after the first month (P > 0.05). Although the good-to-excellent rate of the modified MacNab criteria in the UBE group was similar to that in the PTED group (86.7% vs. 87.5%, P > 0.05), PTED was advantageous in terms of the operation time, estimated blood loss, incision length, and length of postoperative hospital stay.

Conclusions

Both UBE and PTED have favorable outcomes in patients with single-level LDH. However, PTED is superior to UBE in terms of short-term postoperative back pain relief and perioperative quality of life.