Objective To analyze the early effectiveness of unilateral biportal endoscopy (UBE) laminectomy in the treatment of two-level lumbar spinal stenosis (LSS). Methods The clinical data of 98 patients with two-level LSS treated with UBE between September 2020 and December 2021 were retrospectively analyzed. There were 53 males and 45 females with an average age of 59.9 years (range, 32-79 years). Among them, there were 56 cases of mixed spinal stenosis, 23 cases of central spinal canal stenosis, and 19 cases of nerve root canal stenosis. The duration of symptoms was 1.5- 10 years, with an average of 5.4 years. The operative segments were L2, 3 and L3, 4 in 2 cases, L3, 4 and L4, 5 in 29 cases, L4, 5 and L5, S1 in 67 cases. All patients had different degrees of low back pain, among of which 76 cases were with unilateral lower extremity symptoms and 22 cases were with bilateral lower extremity symptoms. There were 29 cases of bilateral decompression in both segments, 63 cases of unilateral decompression in both segments, and 6 cases of unilateral decompression and bilateral decompression of each segment. The operation time, intraoperative blood loss, total incision length, hospitalization stay, ambulation time, and related complications were recorded. Visual analogue scale (VAS) score was used to assess the low back and leg pain before operation and at 3 days, 3 months after operation, and at last follow-up. The Oswestry disability index (ODI) was used to evaluate the functional recovery of lumbar spine before operation and at 3 months and last follow-up after operation. Modified MacNab criteria was used to evaluate clinical outcomes at last follow-up. Imaging examinations were performed before and after operation to measure the preservation rate of articular process, modified Pfirrmann scale, disc height (DH), lumbar lordosis angle (LLA), and cross-sectional area of the canal (CAC), and the CAC improvement rate was calculated. Results All patients underwent surgery successfully. The operation time was (106.7±25.1) minutes, the intraoperative blood loss was (67.7±14.2) mL, and the total incision length was (3.2±0.4) cm. The hospitalization stay was 8 (7, 9) days, and the ambulation time was 3 (3, 4) days. All the wounds healed by first intention. Dural tear occurred in 1 case during operation, and mild headache occurred in 1 case after operation. All patients were followed up 13-28 months with an average of 19.3 months, and there was no recurrence or reoperation during the follow-up. At last follow-up, the preservation rate of articular process was 84.7%±7.3%. The modified Pfirrmann scale and DH were significantly different from those before operation (P<0.05), while the LLA was not significantly different from that before operation (P=0.050). The CAC significantly improved (P<0.05), and the CAC improvement rate was 108.1%±17.8%. The VAS scores of low back pain and leg pain and ODI at each time point after operation significantly improved when compared with those before operation, and the differences between each time points were significant (P<0.05). According to the modified MacNab criteria, 63 cases were excellent, 25 cases were good, and 10 cases were fair, with an excellent and good rate of 89.8%. ConclusionUBE laminectomy is a safe and effective technique with little trauma and fast recovery for two-level LSS and the early effectiveness is satisfactory.
Objective To analyze the learning curve of unilateral biportal endoscopic lumbar interbody fusion (UBE-LIF). Methods Fifty-five patients with single-segment lumbar degenerative disease treated with UBE-LIF between December 2020 and February 2022 were selected as the research subjects. The patients were grouped according to the operation sequence, the first 27 cases were in the early group, and the last 28 cases were in the late group. There was no significant difference between the two groups in age, gender, disease type, and surgical segment distribution (P>0.05). The operation time, the amount of hemoglobin loss (the difference between 1 day before operation and 3 days after operation), the hospital stay after operation, and the incidence of perioperative complications were recorded; the learning curve of UBE-LIF was analyzed by log-curve regression analysis. Results All the operations were successfully completed without changing to other operations. The operation time, the amount of hemoglobin loss, and hospital stay in the early group were significantly more than those in the late group (P<0.05). Complications occurred in 2 cases (7.4%) in the early group, including 1 case of dural tear during operation and 1 case of epidural hematoma after operation, and 1 case (3.6%) with transient radiculitis in the late group. There was no significant difference in the incidence of complications between the two groups (P=0.518) . The log-curve regression analysis showed that the operation time decreased significantly with the increase of the number of patients (P<0.05). The operation time tended to be stable after the surgeon completed 17 cases. ConclusionFor single-level lumbar degenerative disease, the operation time of UBE-LIF can decrease gradually with the increase of the number of patients, and tend to be stable after 17 cases.
Objective To investigate the effectiveness of unilateral biportal endoscopic discectomy (UBED), percutaneous endoscopic lumbar discectomy (PELD), and traditional fenestration discectomy (FD) in the treatment of lumbar disc herniation (LDH). Methods The clinical data of 347 LDH patients who met the selection criteria and underwent discectomy between January 2017 and December 2021 were retrospectively analyzed. They were divided into FD group (160 cases), PELD group (86 cases), and UBED group (101 cases) according to operation methods. There was no significant difference in gender, age, surgical level distribution, disease duration, and preoperative visual analogue scale (VAS) score and Oswestry disability index (ODI) between groups (P>0.05). The operation time, hospitalization stay, treatment cost, and incidence of surgery-related complications were recorded and compared between groups. The patients’ pain and functional recovery were evaluated by VAS score and ODI before and after operation. Results The operation time of FD group was significantly shorter than that of PELD group and UBED group, and the hospitalization stay was significantly longer than that of PELD group and UBED group (P<0.05); there was no significant difference between PELD group and UBED group (P>0.05). The treatment cost in UBED group was significantly higher than that in PELD group, and in PELD group than in FD group (P<0.05). All the patients were followed up 6-24 months, with an average of 14.6 months. VAS score of lower extremity and ODI in 3 groups significantly improved after operation when compared with that before operation (P<0.05). At 1 day after operation, VAS score of lower extremity of UBED group was significantly better than that in PELD group and FD group (P<0.05), but there was no significant difference between PELD group and FD group (P>0.05). There was no significant difference in VAS scores of lower extremity between the 3 groups at 1 and 3 months after operation (P>0.05). The difference of ODI before and after operation in FD group and UBED group was slightly better than that in PELD group (P<0.05), and there was no significant difference between FD group and UBED group (P>0.05). Incidence of surgery-related complications in FD group (20.0%) was significantly higher than that in PELD group (12.8%) and UBED group (6.9%), and PELD group was significantly higher than UBED group (P<0.05). All the incision infection occurred in FD group (12 cases), symptomatic disc cyst and myeloid hypertension-like occurred in 1 case each in PELD group.Conclusion UBED, PELD, and FD have similar effectiveness on lower extremity pain in early LDH. Compared with FD, UBED and PELD have the advantage of shorter hospitalization stay and fewer complications.
The current unilateral biportal endoscopy (UBE) technique was originated from Argentina and developed in South Korea, which was rapidly growing and popularizing in China. The adoption of spinal endoscopy, using small cameras placed inside body with continuous water irrigation, providing better surgical field with less tissue dissection and quicker recovery for patients. As with other disciplines, the use of spinal endoscopy in spinal surgery will become increasingly widespread. UBE technique will promote the popularization of spinal endoscopy in China with monoportal endoscopy technique. At the same time, biportal endoscopy has better expansibility, the application of accessory incision may provide solution for more complicated spinal disease. Chinese spine surgeon should better understand the trends in spinal endoscopy, seize the opportunity of the rapidly evolving in spinal healthcare, and to promote the popularization of UBE across the globe.
Objective To evaluate the effectiveness of spinal canal decompression assisted by unilateral biportal endoscopy (UBE) and percutaneous uniplanar pedicle screw internal fixation in the treatment of lumbar burst fractures with neurological symptoms. Methods Between June 2021 and December 2022, 10 patients with single level lumbar burst fracture with neurological symptoms were treated with spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw internal fixation. There were 7 males and 3 females with an average age of 43.1 years (range, 21-57 years). The injured vertebrae located at L1 in 2 cases, L2 in 4 cases, L3 in 3 cases, and L4 in 1 case. There were 7 cases of AO type A3 fractures and 3 cases of AO type A4 fractures. The total operation time, the time of operation under endoscopy, and complications were recorded. Pre- and post-operative visual analogue scale (VAS) score and American Spinal Injury Association (ASIA) scale (grading A-E corresponding to assigning 1-5 points for statistical analysis) were used to evaluate effectiveness. X-ray film and CT were performed to observe the fracture healing, and the ratio of anterior vertebral body height, Cobb angle, and rate of spinal canal invasion were measured to evaluate the reduction of fracture.Results All operations was successfully completed, and the spinal canal decompression and the bone fragment in spinal canal reduction completed under the endoscopy. Total operation time was 119 minutes on average (range, 95-150 minutes), and the time of operation under endoscopy was 46 minutes on average (range, 35-55 minutes). There was no complication such as dural sac, nerve root, or blood vessel injury during operation. All incisions healed by first intention. All patients were followed up 18.7 months on average (range, 10-28 months). The VAS score after operation significantly decreased when compared with that before operation (P<0.05), and further improved at last follow-up (P<0.05). The ASIA scale after operation significantly improved when compared with that before operation (P<0.05), and there was no significant difference (P>0.05) in the ASIA scale between at 1 week after operation and at last follow-up. The imaging examination showed that the screw position was good and the articular process joint was preserved. During follow-up, there was no loosening, fracture, or fixation failure of the internal fixation. The ratio of anterior vertebral body height and Cobb angle significantly improved, the rate of spinal canal invasion significantly decreased after operation (P<0.05), and without significant loss of correction during the follow-up (P>0.05). Conclusion Spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw fixation is a feasible minimally invasive treatment for lumbar burst fractures with neurological symptoms, which can effectively restore the vertebral body sequence, as well as relieve the compression of spinal canal, and improve the neurological function.
Objective To investigate the effectiveness of the unilateral biportal endoscopy (UBE) technique in the treatment of high-grade migrated lumbar disc herniation (LDH). Methods Between January 2020 and February 2021, 23 cases of high-grade migrated LDH were treated with discectomy via UBE. There were 14 males and 9 females, with a mean age of 48.7 years (range, 32-76 years). All patients had low back and leg pain. The disease duration ranged from 2 months to 7 years (median, 13 months). Lesion segments were L3, 4 in 2 cases, L4, 5 in 15 cases, and L5, S1 in 6 cases. The operation time, intraoperative blood loss, the time when the patients started to move off the floor, and postoperative complications were recorded. The effectiveness was evaluated using the visual analogue scale (VAS) score, the modified Oswestry disability index (ODI), and the modified MacNab criteria. Results All operations were completed successfully, and no complication such as dural tear, epidural hematoma, nerve injury, or vascular injury occurred. The operation time ranged from 53 to 96 minutes, with an average of 71.0 minutes. The intraoperative blood loss ranged from 32 to 56 mL, with an average of 39.3 mL. All patients were removed the drainage tube and wore a lumbar brace to move off the floor around 1 to 2 days after operation. All patients were followed up 3-12 months after operation, with an average of 5.7 months. The VAS scores of low back pain and leg pain and the modified ODI at all postoperative time points were lower than those before operation, and the differences were significant (P<0.05). The differences were significant (P<0.05) when comparing the above indexes between the time points after operation. At last follow-up, the effectiveness was evaluated according to the modified MacNab criteria, and 17 cases were excellent, 4 cases were good, and 2 cases were fair, with an excellent and good rate of 91.3%. There was no recurrence of LDH during follow-up. ConclusionDiscectomy via UBE is an effective method for the treatment of high-grade migrated LDH because of its flexibility, clear view, and wide range of intraoperative exploration, which can effectively reduce the risk of residual nucleus pulposus after operation.
ObjectiveTo summarize the characteristics of the learning curve and the occurrence of postoperative adverse events during the development of unilateral biportal endoscopy (UBE) technique by comparing the clinical data of early and late patients treated with UBE technique. Methods All patients who underwent single-level UBE technique between April 1, 2020 and December 31, 2021 were selected as the research subjects. According to the surgical options, all patients were allocated into 3 groups: unilateral decompression and discectomy (UDD) group, unilateral laminotomy for bilateral decompression (ULBD) group, and lumbar intervertebral fusion (LIF) group. The first 60 cases from each group were extracted and ranked orderly. The endoscopic operation time, the times of fluoroscopy during non-internal fixation implantation, the postoperative hospital stay, the drainage volume, the decrease of hemoglobin, the decrease of hematocrit, and the adverse events were collected. In each group, the patients were allocated into early and late cases according to the operation sequence. The first 30 cases of each group were classified as early cases, and the last 30 cases as late cases. Statistical analysis was performed on the above observation indicators between the early and late cases, and a scatter plot of relevant data changes was drawn to observe the change trend. Results Compared with the early cases, the endoscopic operation time and the times of fluoroscopy during non-internal fixation implantation of late cases in each group were significantly lower (P<0.05); the postoperative hospital stay of late cases in LIF group was significantly shorter (P<0.05); the decreased values of hemoglobin and hematokrit of late cases in ULBD group and LIF group were significantly lower (P<0.05); the postoperative drainage volume of late cases in ULBD group significantly decreased (P<0.05). The endoscopic operation time and the times of fluoroscopy during non-internal fixation implantation of 3 groups showed a significant downward trend. The adverse events occurred in 3 early cases and 1 late case of the UDD group, in 6 and 3 cases of the UBLD group, and 8 and 3 cases of the LIF group, respectively. The difference was not significant between the early and late cases (P>0.05). Conclusion In the early practice of UBE technique, there is a high incidence of complication, and the surgical trauma is relatively large, which is related to the lack of understanding of the UBE technique characteristics and insufficient surgical experience. With the proficiency of surgical techniques and accumulation of experience, the operation time and the incidence of postoperative adverse events were significantly reduced.
Objective To investigate the relationships between the bony structures, nerve, and indentations of ligamentum flavum of the upper lumbar spine by using CT three-dimensional reconstruction technique, in order to guide the unilateral biportal endoscopy (UBE) technique via contralateral approach in the treatment of upper lumbar disc herniation (ULDH). Methods Twenty-one ULDH patients who were admitted between June 2019 and July 2021 and met the selection criteria were selected as the research subjects. There were 12 males and 9 females with an average age of 62.1 years (range, 55-72 years). The disease duration was 1-12 years (mean, 5.7 years). There was 1 case of L1, 2, 4 cases of L2, 3, and 16 cases of L3, 4. The CT myelography data of T12-S3 segment was saved in DICOM format and imported into Mimics21.0 software for three-dimensional reconstruction. The relationship between the intersection (point Q) of spinous process and the inferior margin of lamina, the indentation of superior margin of ligamentum flavum, the inferior margin of nerve root origin, intervertebral space, and foramen were observed. The Mimics21.0 software was used to create a 3-mm-diameter cylinder to simulate the UBE channel and measure its abduction angle (∠b1), as well as measure the following lumbar vertebra-related indicators: in L1,2-L3,4 segments, the vertical distance from the point Q to the inferior margin of the contralateral lumbar pedicle of the same lumbar vertebra (a1), the superior margin of the contralateral pedicle of the lower lumbar vertebra (a2), the lower endplate of the same lumbar vertebra (a3), the upper endplate of the lower lumbar vertebra (a4); the vertical distance from the lower endplate of lumbar vertebra to the inferior margin of the lumbar pedicle (c1), the vertical distance from the upper endplate of the lower lumbar vertebra to the superior margin of the lumbar pedicle (c2); the vertical distance from the inferior margin of the nerve root origin to the superior margin (d1) and the inferior margin (d2) of the lumbar pedicle, respectively; the vertical distance from the intersection (point P) of the indentation of superior margin of ligamentum flavum and the medial margin of the lumbar pedicle to the superior margin (e1) and the inferior margin (e2) of the lumbar pedicle, respectively; the horizontal distance from the lateral margin of the dural mater (f1) and the narrowest part of the lumbar isthmus (f2) to the facet joint space, respectively. Thirteen of the patients included in the study chose the UBE surgery via contralateral approach. There were 8 males and 5 females with an average age of 63.3 years (range, 55-71 years). The disease duration was 2-12 years, with an average of 6.2 years. There were 3 cases of L2, 3 and 10 cases of L3, 4. The perioperative complications and surgical decompression were recorded. And the effectiveness were evaluated by visual analogue scale (VAS) score, Oswestry disability index (ODI), and short form-36 health survey (SF-36) score. Results The imaging results showed that there was no significant difference in a1, a3, a4, e1, e2, f1, and f2 between segments (P>0.05), and there were significant differences (P<0.05) in a2 and c2 between L1, 2 and L3, 4 segments, in ∠b1 and d2 between L1, 2, L2, 3 segments and L3, 4 segments, and in c1 and d1 between L1, 2 and L2, 3, L3, 4 segments. The 87.30% (110/126) of point Q of L1, 2-L3, 4 segments corresponded to the inferior articular process, and 78.57% (99/126) of the lower endplate corresponded to the level of the isthmus. All 13 patients completed the UBE surgery via contralateral approach, and none were converted to open surgery. All patients were followed up 12-17 months (mean, 14.6) months. The VAS score of low back pain and leg pain, ODI, and SF-36 score at 6 and 12 months after operation significantly improved when compared with those before operation (P<0.05), and further improved at 12 months after operation when compared with 6 months after operation (P<0.05). The imaging review results showed that the herniated disc was removed and the dura mater was decompressed adequately. Conclusion The point Q, the superior margin of ligamentum flavum, and lumbar pedicle can be used as the markers for the treatment of ULBD with UBE surgery via contralateral approach, making the procedure safer, more precise, and more effective.
Objective To investigate the safety and effectiveness of unilateral biportal endoscopy (UBE) technique in the treatment of single-segment thoracic ossification of ligamentum flavum (TOLF). Methods Between August 2020 and December 2021, 11 patients with single-segment TOLF were treated with UBE technique. There were 6 males and 5 females, with an average of 58.2 years (range, 49-72 years). The responsible segment was T6, 7 in 1 case, T7, 8 in 1 case, T8, 9 in 2 cases, T9, 10 in 2 cases, T10, 11 in 2 cases, and T11, 12 in 3 cases. Imaging examination showed that the ossification were located on the left side in 4 cases, on the right side in 3 cases, and on bilateral sides in 4 cases. The main clinical symptoms were chest and back pain or lower limb pain, all accompanied by lower limb numbness and fatigue. The disease duration ranged from 2 to 28 months (median, 17 months). The operation time, postoperative hospital stay, and complications were recorded. Visual analogue scale (VAS) score was used to evaluate the chest and back pain and low limb pain, and Oswestry disability index (ODI) and Japanese Orthopedic Association (JOA) score were used to evaluate functional recovery before operation and at 3 days, 1 month, 3 months after operation, and last follow-up. The anteroposterior diameter of the coronal spinal canal was measured by CT before and after operation to evaluate the effect of surgical decompression. Results All operations were successfully completed. The operation time was 50-105 minutes, with an average of 80.0 minutes. No postoperative complication such as dural sac tear, cerebrospinal fluid leakage, spinal nerve injury, or infection occurred. The postoperative hospital stay was 2-5 days, with an average of 3.1 days. All incisions healed by first intention. All patients were followed up 6-22 months, with an average of 14.8 months. CT measurement at 3 days after operation showed that the anteroposterior diameter of the spinal canal was (8.63±1.61) mm, which was significantly larger than that before operation [(3.67±1.37) mm] (t=−12.181, P<0.001). The VAS score of chest and back pain and lower limb pain and ODI at each time point after operation were significantly lower than those before operation (P<0.05). The above indexes were further improved after operation, except that there was no significant difference between at 3 months after operation and at last follow-up (P>0.05), the differences between other time points were significant (P<0.05). There was no recurrence during the follow-up period. Conclusion UBE technique is a safe and effective method to treat single-segment TOLF, but its long-term effectiveness needs to be further studied.
Objective To compare the clinical and radiological outcomes of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) and minimally invasive tubular TLIF (MT-TLIF) in treatment of lumbar degenerative diseases. Methods A clinical data of 75 patients with lumbar degenerative diseases, who met the selection criteria between August 2019 and August 2020, was retrospectively analyzed, including 35 patients in the UBE- TLIF group and 40 patients in the MT-TLIF group. There was no significant difference in general data such as gender, age, body mass index, disease type and duration, and surgical segment between the two groups (P>0.05), which was comparable. The operation time, intraoperative blood loss, hemoglobin (Hb) before operation and at 1 day after operation, the length of hospital stay, incidence of complications, and visual analogue scale (VAS) score of low back and leg pain, Oswestry Disability Index (ODI), Short-Form 36 Health Survey Scale (SF-36 scale), intervertebral disc height (IDH), sagittal Cobb angle, lumbar lordosis (LL), and the intervertebral fusion were compared between the two groups. Results Compared with MT-TLIF group, UBE-TLIF group had significantly longer operation time but less intraoperative blood loss and shorter length of hospital stay (P<0.05). The Hb levels in both groups decreased at 1 day after operation, but there was no significant difference in the difference before and after operation between the two groups (P>0.05). All patients were followed up, and the follow-up time was (14.7±2.5) months in the UBE-TLIF group and (15.0±3.4) months in the MT-TLIF group, with no significant difference (t=0.406, P=0.686). In both groups, the VAS score of low back pain, VAS score of leg pain, SF-36 scale, and ODI after operation significantly improved when compared with those before operation (P<0.05). There was no significant difference between 1 month after operation and last follow-up (P>0.05). There was no significant difference in the VAS score of low back pain, VAS score of leg pain, and SF-36 scale between the two groups before and after operation (P>0.05). At 1 month after operation, the ODI in the UBE-TLIF group was significantly better than that in the MT-TLIF group (P<0.05). At 1 month after operation, IDH, Cobb angle, and LL in both groups recovered when compared with those before operation (P<0.05), and were maintained until last follow-up (P>0.05). There was no significant difference in the IDH, Cobb angle, and LL between the two groups at each time point (P>0.05). Thirty-three cases (89.2%) in the UBE-TLIF group and 35 cases (87.5%) in the MT-TLIF group achieved fusion, and the difference was not significant (χ2=0.015, P=0.901). In the UBE-TLIF group, 1 case of intraoperative dural tear and 1 case of postoperative epidural hematoma occurred, with an incidence of 5.7%. In the MT-TLIF group, 1 case of intraoperative dural tear, 1 case of postoperative epidural hematoma, and 1 case of superficial infection of the surgical incision occurred, with an incidence of 7.5%. There was no significant difference in the incidence of complications between the two groups (χ2=1.234, P=1.000). Conclusion Compared with MT-TLIF, UBE-TILF can achieve similar interbody fusion in the treatment of lumbar degenerative diseases, and has the advantages of smaller incision, less bleeding, and shorter length of hospital stay.