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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of Unilateral Biportal Endoscopy Decompression and Microscopic Decompression Effectiveness in Lumbar Spinal Stenosis Treatment: A Systematic Review and Meta-analysis

This study aimed to compare the safety and effectiveness between unilateral biportal endoscopy (UBE) technique and microscopic decompression (MD) technique in lumbar spinal stenosis treatment. PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, and other databases were used to conduct extensive literature searches. RevMan ver. 5.3 software was used for the statistical analysis. Eleven studies were included with 930 patients, including 449 patients in the UBE group and 521 in the MD group. Both techniques revealed similar operative times at -1.77 minutes (95% confidence interval [CI], -7.59 to 4.05 minutes; p =0.55), the postoperative dural expansion area at -1.27 (95% CI, -19.30 to 16.77; p =0.89), the postoperative complications at 0.76 (95% CI, 0.47 to 1.22; p =0.26), the preoperative Visual Analog Scale (VAS) for leg pain, and the last follow-up (>12 months) VAS for leg pain at -0.04 (95% CI, -0.14 to 0.06; p =0.47), the preoperative Oswestry Disability Index (ODI), and the last follow-up (>12 months) ODI scores at -0.18 (95% CI, -0.76 to 0.40; p =0.54), and patient satisfaction (the modified MacNab score) at 1.15 (95% CI, 0.54 to 2.42; p =0.72). However, intraoperative bleeding was lower following the UBE technique at -52.78 mL (95% CI, -93.47 to -12.08 mL; p =0.01) and was shorter following the UBE technique at -3.06 (95% CI, -3.84 to -2.28; p <0.01). UBE and MD technology have no significant differences in efficacy or safety in the treatment of patients with lumbar spinal stenosis based on this meta-analysis. However, the UBE technique has less intraoperative bleeding and a shorter hospital stay. It has a slight advantage and is a better surgical option than the MD technique. It can be an alternative minimally invasive spinal surgery method.

Oblique Lumbar Interbody Fusion with Selective Biportal Endoscopic Posterior Decompression for Multilevel Lumbar Degenerative Diseases

Oblique lumbar interbody fusion is a minimally invasive procedure for treating degenerative lumbar disease. Its advantages include correcting coronal and sagittal spinal alignment and indirect neural decompression. However, achieving a successful outcome is limited in some patients who need direct decompression for central canal lesions including hard stenotic lesions (endplate or facet articular osteophytes and ossification of posterior longitudinal ligaments) and sequestration of the disk. Biportal endoscopic spinal surgery is a minimally invasive technique, which directly decompresses the lesion. By taking advantage of two procedures, in a longlevel lumbar lesion, alignment correction and direct decompression can be both achieved. Herein, the authors introduce multilevel lumbar fusion through oblique lumbar interbody fusion and selective direct decompression through biportal endoscopic spinal surgery and discuss the surgical indications, surgical pitfalls, and recommendations for application. Consequently, it is regarded as a minimally invasive interbody fusion method for patients with multilevel lumbar degenerative degeneration.

Biportal endoscopic versus microscopic discectomy for lumbar herniated disc: a randomized controlled trial

BACKGROUND CONTEXT

Biportal endoscopic discectomy has been frequently performed in recent years and has shown acceptable clinical outcomes. However, evidence regarding its efficacy and safety remains limited.

PURPOSE

This study aimed to compare the clinical efficacy and safety of biportal endoscopic with that of open microscopic discectomy in patients with single-level herniated lumbar discs.

STUDY DESIGN

Prospective, randomized, multicenter, open-label, assessor-blind, non-inferiority controlled trial.

PATIENT SAMPLE

Sixty-four participants suffering from low back and leg pain with a single-level herniated lumbar disc and required discectomy.

OUTCOME MEASURES

Outcomes were assessed with the use of patient-reported outcome measures (PROMs), visual analog scale (VAS) pain score for surgical site, low back and lower extremity, Oswestry Disability Index (ODI) for lumbar disabilities, European Quality of Life-5 Dimensions value for quality of life, and painDETECT for neuropathic pain. Surgery-related outcomes such as hospital stay, operation time, and opioid usage were collected. Adverse events occurring during the follow-up period were also noted.

METHODS

All participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic (biportal group) or microscopic discectomy (microscopy group). The primary outcome was the difference in ODI scores at 12-months post surgically based on a modified intention-to-treat strategy, with a non-inferiority margin of 12.8 points. The secondary outcomes included PROMs, surgery-related outcomes, and adverse events.

RESULTS

The ODI score at the 12-month follow-up was 11.97 in the microscopy group and 13.89 in the biportal group (mean difference, 1.92; 95% confidence interval [CI], -3.50 to 7.34), showing the non-inferiority of biportal group. The results for the secondary outcomes were similar to those for the primary outcome. Creatinine phosphokinase ratios were low in the biportal group. Early surgical site pain was slightly lower in the biportal group (mean difference of VAS pain score at 48-hr, -0.98; 95% CI, -1.77 to -0.19). Adverse events including reoperation showed no significant difference between the groups.

CONCLUSION

Biportal endoscopic discectomy was non-inferior to microscopic discectomy over a 12 month period. Biportal endoscopic discectomy is suggested to be a relatively safe and effective surgical technique with the slight advantage of reduced muscle damage. However, the clinical implications of surgical site pain should be carefully considered.

Comparison of clinical and radiological outcomes of full-endoscopic versus microscopic lumbar decompression laminectomy for the treatment of lumbar spinal stenosis: a systematic review and meta-analysis

BACKGROUND

To determine the clinical and radiological outcomes of full-endoscopic (FE) versus microscopic (MI) lumbar decompression laminectomy in the treatment of lumbar spinal stenosis (LSS), we performed a meta-analysis to explore the best choice for patients with LSS requiring surgical relief.

METHODS

Literature searches of the PubMed, the Cochrane Library, Embase, Medline, Embase, and Web of Science databases were performed. The searches covered all indexed studies published between 2008 and 2020, using keywords identifying the patient group (lumbar spine stenosis) and the interventions (full-endoscopic lumbar decompression laminectomy and microscopic lumbar decompression laminectomy). A total of 1,727 patients were included in 10 studies. The primary outcomes of the analysis were visual analogue scale (VAS) scores for leg and back pain, and Oswestry Disability Index (ODI) score.

RESULTS

The meta-analysis of the VAS score for low back pain showed that in the first 24 hours postoperatively, participants who underwent FE had better pain control than those who underwent MI [FE: mean difference (MD) =-0.78, 95% confidence interval (CI): -1.11, -0.45; MI: MD =-1.53, 95% CI: -1.94, -1.12]. In all subgroup analyses, the VAS score for back pain was lower in the FE group than in the MI group (MD =-0.71, 95% CI: -0.96, -0.47). Regarding the VAS score for leg pain, the FE group had a significantly lower score than the MI group in the first 24 hours (Total: MD =-1.02, 95% CI: -1.31, -0.73). The meta-analysis demonstrated that the FE group had a significantly lower ODI score than the MI group (MD =-1.03, 9% CI: -1.54, -0.51). At 6 months, the MI group had a significantly lower score than the FE group (MD =1.09, 95% CI: 0.53, 1.64), but at 12 months, the FE group had a significantly lower score than the MI group (MD =-2.40, 95% CI: -3.12, -1.67).

DISCUSSION

Compared to MI decompression, the FE decompression method resulted in better pain control in the early postoperative period, both in the lower back and legs, as well as shorter operative and shorter hospitalization times.

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.

Bi-portal Arthroscopic Spinal Surgery (BASS) with 30° arthroscopy for far lateral approach of L5-S1 - Technical note

Background context

Lumbar foraminal stenosis or extraforaminal stenosis is a common cause of spinal cord radiculopathy. Recently, several authors have introduced an endoscopy-based spinal surgery technique.

Purpose

The study aimed to introduce far lateral approach of biportal arthroscopic technique using 30° arthroscopy for foraminal decompression of L5-S1.

Study design

Technical note.

Patient sample

12 consecutive patients.

Outcome measures

The leg VAS with modified Macnab criteria was measured.

Result

The leg VAS improved from VAS 7.5 to 1.8.

Conclusion

Far lateral approach of BASS with 30° arthroscopy is an alternative method that can decompress foraminal stenosis minimally invasively.