Objective This study evaluates surgical strategies based on preoperative computed tomography (CT) findings during unilateral biportal endoscopic (UBE) surgery for thoracic ossification of the ligamentum flavum (OLF) with dural ossification.
Methods This retrospective study included patients undergoing posterior thoracic laminectomy via UBE surgery to treat symptomatic thoracic stenosis due to OLF. Clinical outcomes were assessed using visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) scores, alongside analyses of preoperative CT and intraoperative videos for dural ossification characteristics.
Results A total of 34 patients participated, showing significant improvements in VAS and JOA scores postoperatively. All focal dural ossifications exhibiting the tram-track sign were effectively excised without significant dural defects. The circumferential floating technique was employed for cases with the bridge sign, whereas wide excision was warranted for those with the comma sign.
Conclusion UBE surgery effectively manages progressive thoracic OLF associated with dural ossification. Preoperative CT imaging is essential for assessing dural involvement and guiding surgical techniques. Microscopic surgery is recommended for inexperienced surgeons requiring wide dural excision.
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Neurospine 2023;20(3):931-939. Published online September 30, 2023
Objective This study aimed to evaluate the treatment of spinal stenosis with spondylolisthesis using bilateral-contralateral unilateral biportal endoscopic (UBE) decompression to minimize facet joint damage.
Methods We retrospectively evaluated 42 patients with grade 1 spondylolisthesis who underwent bilateral-contralateral UBE decompression between July 2018 and September 2019. To identify segmental instability, static and dynamic images from preoperative and postoperative procedures and final follow-up radiographs were reviewed. Lateral radiograph slippage ratio, sagittal motion, and facet joint preservation were evaluated. Clinical assessments were conducted using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria.
Results The average final follow-up period was 26.5 ± 1.3 months. The average preoperative slip percentage was 15.70% ± 5.25%, which worsened to 18.80% ± 5.41% at the final follow-up (p < 0.005). The facet joint preservation rate was 95.6% ± 4.1% on the contralateral side. Improvements in the VAS scores (leg pain: from 7.9 ± 2.2 to 3.1 ± 0.7; p < 0.005; back pain: from 7.2 ± 3.0 to 2.8 ± 1.0; p < 0.005) were observed at the final follow-up. The mean preoperative ODI was 26.19 ± 3.42, which improved to 9.6 ± 1.0 (p < 0.005). Thirteen patients exhibited delayed focal segmental instability following decompression. Despite the absence of symptoms or improvement with conservative treatment in the majority of patients with delayed instability, two patients required fusion surgery to address the instability. Additionally, 2 patients developed facet synovial cysts, while 2 experienced spinous process fractures.
Conclusion Bilateral decompression with a contralateral UBE approach could be an effective and alternative treatment method to reduce instability in spinal stenosis with grade 1 spondylolisthesis.
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Objective Advanced biportal endoscopic surgery techniques can be used to treat thoracic myelopathy secondary to ossification of the ligamentum flavum (OLF). This case series elaborates on a feasible biportal endoscopic technique for thoracic OLF removal and evaluates clinical and radiological outcomes.
Methods A biportal endoscopic posterior thoracic laminectomy was performed to remove the thoracic OLF. Surgical techniques have evolved from inside-out piecemeal removal methods to outside-in en bloc removal methods. Preoperative computed tomography was performed to analyze dural ossification and OLF types. Intraoperative videos were reviewed to observe dural ossification and to determine the surgical method. Neurological outcomes were assessed using the Japanese Orthopaedic Association (JOA) score.
Results Clinical symptoms and neurological function improved markedly after surgery (JOA score, preoperative: 12.6 ± 1.0, final follow-up: 15.6 ± 1.2). The mean operation time per segment was not short (106.6 ± 38 minutes). At early experience stages, inside-out piecemeal decompression was used and it caused intraoperative spinal cord injury. However, outside-in en bloc decompression technique did not induce neural complications. Postoperative segmental instability and correlated mechanical back pain were not observed.
Conclusion The biportal endoscopic posterior thoracic approach is an attractive surgical option to treat thoracic spondylotic myelopathy secondary to OLF. Piecemeal inside-out decompression can induce irreversible spinal cord injury, especially in the early experience stages. Outside-in decompression is more efficient and safer than inside-out pattern procedures by minimizing dural manipulation. Nonetheless, this technique is technically demanding and should only be performed in selected patients after acquiring abundant experience with endoscopic spine surgeries.
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Objective We compared the midterm clinical and radiological outcomes between 2 types of full endoscopic posterior cervical foraminotomy, including conventional posterior endoscopic cervical foraminotomy (PECF) and modified inclined technique for PECF.
Methods One of the 2 types of PECF surgery was performed for defined cervical foraminal stenosis. The foraminal expansion ratio and facet resection rate and foraminal stenosis grade were measured using magnetic resonance imaging. Visual analogue scale (VAS) scores for neck and arm pain, neck disability index, MacNab criteria, operation time, hospital stay, and complications, including postoperative dysesthesia, were assessed. Clinical and radiological parameters were compared between the 2 surgical groups.
Results There were 49 and 46 patients in the PECF and modified-PECF groups, respectively. The modified-PECF group showed significantly higher expansion of distal foraminal diameter and foraminal height, and a lower facet resection rate compared to PECF group (in all, p < 0.001). The modified-PECF group displayed significantly lower VAS score for neck pain at 1 day and 1 week after surgery and lower arm pain VAS score after 6-month follow-up (p = 0.002, p = 0.001, p = 0.002, respectively).
Conclusion Compared with the PECF, the modified inclined technique has radiologic benefits, including enhanced facet joint preservation, restoration of the natural course of nerve roots, and prevention of restenosis by expanding the superior articular process base, especially in grade 2 foraminal stenosis. Furthermore, the modified inclined technique significantly improved the postoperative VAS score for neck pain within the 1-week follow-up and that of arm pain after 6-month follow-up.
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Objective The aim of this study was to compare the clinical and radiologic outcomes of 3 types of minimally invasive posterior cervical foraminotomy (PCF): uniportal endoscopic surgery, biportal endoscopic surgery, and microsurgery.
Methods Between January 2019 to January 2020, PCF was performed using 3 different approaches to treat foraminal stenosis. The foraminal expansion rate, facet resection rate, and surgical foraminal approach angle were measured using magnetic resonance imaging. Visual analogue scale (VAS) scores for neck and arm pain, neck disability index (NDI), MacNab criteria, operation time, hospital stay, and complications were assessed. Clinical and radiologic parameters were compared among the 3 surgical groups.
Results There were 38, 30, and 50 patients in the uniportal endoscopy, biportal endoscopy, and microscopy groups, respectively. Microscopy group displayed significantly higher foraminal expansion compared to uniportal endoscopy group (p = 0.001). Facet resection rates and inclination angle for facet joint undercutting were significantly different among the 3 groups. Uniportal endoscopy group had the highest inclination angle and the least facet resection. On the 6 months and final follow-up, VAS scores and NDI were significantly lower in the uniportal endoscopy group than in the microscopy group (p = 0.000).
Conclusion All 3 types of PCF displayed favorable clinical outcomes and sufficient expansion of the midforaminal area. Two endoscopy groups showed a significantly higher inclination angle for undercutting the facet joint and a lower facet resection rate than the microscopy group. Reduced facet joint resection using an inclinatory approach did not interfere with sufficient foraminal expansion and enhanced the clinical result after 6 months of follow-up.
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Biportal endoscopic transforaminal lumbar interbody fusion (TLIF) may have advantages of minimally invasive fusion surgery as well as those of endoscopic surgery. The purpose of this study was to present the biportal endoscopic TLIF technique along with video presentations and a review of the literature on this technique. Basically, the biportal endoscopic TLIF technique is similar to minimally invasive TLIF with a tubular retractor. There were 2 options in the biportal endoscopic TLIF procedures. The first was the insertion of one long TLIF cage and the other was the insertion of 2 short posterior lumbar interbody fusion (PLIF) cages. After the interbody fusion procedures, percutaneous pedicles screw fixation was performed. Biportal endoscopic TLIF achieved complete neural decompression through laminectomy and facetectomy like conventional TLIF. Endplate preparation was performed completely under a clear and magnified endoscopic view. It was also feasible to insert a large TLIF cage or 2 cages for PLIF without exiting nerve root injury. Biportal endoscopic TLIF might have the advantages of endoscopic surgery as well as minimally invasive fusion surgery. Direct neural decompression, endplate preparation under endoscopic guidance, and the insertion of a large TLIF cage or 2 PLIF cages may be the merits of biportal endoscopic lumbar fusion procedures.
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Unilateral biportal endoscopic lumbar interbody fusion assisted by intraoperative O-arm total navigation for lumbar degenerative disease: A retrospective study Xinle Huang, Junfeng Gong, Huan Liu, Zegang Shi, Wenkai Wang, Shuai Chen, Xiaobing Shi, Changqing Li, Yu Tang, Yue Zhou Frontiers in Surgery.2022;[Epub] CrossRef
Commentary on “Endoscopic Transforaminal Lumbar Interbody Fusion – Technical note” Junseok Bae Journal of Spinal Surgery.2022; 9(4): 240. CrossRef
The Future of Minimally Invasive Spine Surgery Dong Hwa Heo, Yoon Ha, Seung Yi, Hungtae Chung Neurology India.2022; 70(Suppl 2): S104. CrossRef
Clinical Results and Complications of Endoscopic Lumbar Interbody Fusion for Lumbar Degenerative Disease: A Meta-Analysis Dong Hwa Heo, Dong Chan Lee, Hyeun Sung Kim, Choon Keun Park, Hungtae Chung World Neurosurgery.2021; 145: 396. CrossRef
Modified far lateral endoscopic transforaminal lumbar interbody fusion using a biportal endoscopic approach: technical report and preliminary results Dong Hwa Heo, Jin Hwa Eum, Jae Young Jo, Hungtae Chung Acta Neurochirurgica.2021; 163(4): 1205. CrossRef
Surgical treatment of senile spinal diseases Dal-Sung Ryu, Seung-Hwan Yoon Journal of the Korean Medical Association.2021; 64(3): 191. CrossRef
Unilateral Biportal Endoscopy for Decompression of Extraforaminal Stenosis at the Lumbosacral Junction: Surgical Techniques and Clinical Outcomes Man-Kyu Park, Sang-Kyu Son, Weon Wook Park, Seung-Hyun Choi, Dae Young Jung, Dong Han Kim Neurospine.2021; 18(4): 871. CrossRef
Recent Trends and Changes in the Endoscopic Spinal Surgery Dong Hwa Heo, Dong Chan Lee, Hyeun Sung Kim, Hungtae Chung Journal of Minimally Invasive Spine Surgery and Technique.2021; 6(Suppl 1): S81. CrossRef
Biportal Endoscopic Lumbar Interbody Fusion: Review of Current Evidence and the Literature Man-Kyu Park, Sang-Kyu Son Journal of Minimally Invasive Spine Surgery and Technique.2021; 6(Suppl 1): S171. CrossRef
Endoscopic Lumbar Interbody Fusion and Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Degenerative Diseases: A Systematic Review and Meta-Analysis Yuanqiao Kou, Jianjun Chang, Xiaoming Guan, Qiang Chang, Haoyu Feng World Neurosurgery.2021; 152: e352. CrossRef
Biportal endoscopic unilateral laminotomy with bilateral decompression for the treatment of cervical spondylotic myelopathy Jiyeon Kim, Dong Hwa Heo, Dong Chan Lee, Hung Tae Chung Acta Neurochirurgica.2021; 163(9): 2537. CrossRef
Contralateral sublaminar approach for decompression of the combined lateral recess, foraminal, and extraforaminal lesions using biportal endoscopy: a technical report Ji Yeon Kim, Dong Hwa Heo Acta Neurochirurgica.2021; 163(10): 2783. CrossRef
Evaluation of Two Methods (Inside-Out/Outside-In) Inferior Articular Process Resection for Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion: Technical Note Hyeun-Sung Kim, Pang-Hung Wu, Jin-Woo An, Yeon-Jin Lee, Jun-Hyung Lee, Myeong-Hun Kim, Inkyung Lee, Jong-Sung Park, Jun-Hyung Lee, Jun-Hwan Park, Il-Tae Jang Brain Sciences.2021; 11(9): 1169. CrossRef
Lumbar Interbody Fusion: Techniques, Pearls and Pitfalls Young-Hoon Kim, Kee-Yong Ha, Kee-Won Rhyu, Hyung-Youl Park, Chang-Hee Cho, Hun-Chul Kim, Hyo-Jin Lee, Sang-Il Kim Asian Spine Journal.2020; 14(5): 730. CrossRef
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