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Original Article
NASS/Neurospine Endoscopic Spine Surgery Special Issue
Objective There is a lack of literature on indirect decompression in uniportal endoscopic posterolateral transforaminal lumbar interbody fusion (EPTLIF). Our aim is to evaluate the dimensions of the spinal canal and contralateral foramen before and after EPTLIF.
Methods This is a retrospective study of patients who underwent EPTLIF in a tertiary spine centre over a 2-year period. The cross-sectional area of the spinal canal and the contralateral foramen at the level of fusion were measured on magnetic resonance imaging scan at 1-day postoperation and at the final follow-up. Patients were grouped according to the decompression performed as per the clinician’s judgement.
Results One hundred fifty-two levels of fusion were performed in 120 patients. There was a statistically significant clinical improvement in visual analogue scale and Oswestry Disability Index scores postoperation. The measurements of the spinal canal area were 106.0 mm2, 138.8 mm2, and 195.5 mm2; while contralateral foraminal area were 73.2 mm2, 104.4 mm2, and 120.7 mm2 at preoperation, 1-day postoperation, and at the final follow-up, respectively (p < 0.001). For the subgroup analyses, spinal canal area measurements for the bilateral decompression cohort (n = 35) were 57.0 mm2, 123.9 mm2, and 191.8 mm2; for the ipsilateral decompression cohort (n = 42) were 89.3 mm2, 128.9 mm2, 183.3 mm2; and for the cohort without any decompression and only cage inserted (n = 75) were 138.3 mm2, 151.2 mm2, and 204.1 mm2 (p < 0.001). Contralateral foraminal area measurements were 73.3 mm2, 106.4 mm2 and 120.4 mm2 in the bilateral decompression cohort; 69.5 mm2, 99.0 mm2, 116.9 mm2 in the ipsilateral decompression cohort; and 75.1 mm2, 106.5 mm2, 122.9 mm2 in the cohort without any decompression (p < 0.001).
Conclusion Indirect decompression of both the spinal canal and the contralateral foramen can be achieved via EPTLIF. Decompression on an asymptomatic contralateral side is not necessary.
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In the first phase of development of lumbar endoscopic spine surgery, the focus was on removal of soft disc material through the working corridor of Kambin’s triangle using transforaminal endoscopic lumbar discectomy. With the introduction of the interlaminar approach and increased interest from both industry and surgeons, there has been an exponential development of endoscopic surgical equipment and a corresponding expansion of endoscopic techniques. Endoscopic treatment strategies are applied to conditions ranging from contained prolapsed intervertebral discs to noncontained migrated herniated discs, hard calcified discs, spinal stenosis in the central or lateral recess and the foraminal and extraforaminal region, and other combinations of degenerative conditions requiring decompression or fusion surgery. The further expansion of endoscopic surgical management involving complicated spinal cases and the final quartet of trauma, infections, tumors, and possibly deformities could be the future stage of endoscopic spine surgery development. This article covers the full range of current treatment strategies and presents possible future developments of endoscopic spine surgery for the management of lumbar spinal conditions.
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Minimally invasive spinal surgery in particular lumbar endoscopic unilateral laminotomy with bilateral decompression becomes popular as it can be performed with regional anesthesia, soft tissue damages are minimized as endoscopic visualization and instruments can be brought close to operating area bypassing much of the intervening soft tissues for sufficient spinal decompression with ligamentum flavum resection despite less bony resection compared to open surgery. Overall, when well executed, it preserves spinal stability. Outside-in technique of decompression is also known as over the top decompression in minimally invasive literature. It involves maintaining deep layer of ligamentum flavum integrity till satisfactory bony decompression is achieved. Deep layer of ligamentum flavum is removed as final step of decompression. Preservation of the deep layer of ligamentum flavum protects the neural elements, allowing drills and sharp equipment to be used safely to perform bony decompression.In this study, we demonstrate the technical details of outside-in approach lumbar endoscopic unilateral laminotomy with bilateral decompression (LE-ULBD). LE-ULBD Outside-in Technique is an effective and safe procedure in relieving lumbar spinal stenosis with favorable results with a follow-up for more than 1 year.
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Novel anatomical landmark guided puncture method in L4/L5 spine posterior interlaminar endoscopic surgery: a technical note and case series Bin Zheng, Tiepeng Han, Yan Liang, Haiying Liu, Panfeng Yu Frontiers in Surgery.2025;[Epub] CrossRef
Global Trends and Hotspots of Minimally Invasive Surgery in Lumbar Spinal Stenosis: A Bibliometric Analysis Dacheng Sang, Jinyang Guo, Hanlu Meng, Luofei Zhang, Hongpeng Sang Journal of Pain Research.2024; Volume 17: 117. CrossRef
Uniportal endoscopic lumbar decompression: Interlaminar and transforaminal techniques and outcomes Dean C. Perfetti, Peter B. Derman Seminars in Spine Surgery.2024; 36(1): 101080. CrossRef
Finite element analysis of endoscopic cross-overtop decompression for single-segment lumbar spinal stenosis based on real clinical cases Yiwei Ding, Hanshuo Zhang, Qiang Jiang, Tusheng Li, Jiang Liu, Zhengcao Lu, Guangnan Yang, Hongpeng Cui, Fengtong Lou, Zhifeng Dong, Mei Shuai, Yu Ding Frontiers in Bioengineering and Biotechnology.2024;[Epub] CrossRef
Efficacy of PE-PLIF with a novel ULBD approach for lumbar degeneration diseases: a large-channel endoscopic retrospective study Yichi Zhou, Chuankun Zhou, Qingbo Li, Lei Cai, Bowen Kou, Weizhi Fang, Zhi Yao, Mengcheng Wei, Shishuang Zhang, Weijun Liu Journal of Orthopaedic Surgery and Research.2024;[Epub] CrossRef
Evaluation of Safe Insertion Angles for Spinal Needles and Safe Intensity of the Holmium:YAG Laser during Percutaneous Laser Disc Ablations in Feline Cadavers Zhenglin Piao, Young-ung Kim, Jongchan Ko, Jumjae Lee, Daeyoung Choi, Namsoo Kim Veterinary Sciences.2024; 11(7): 325. CrossRef
Comparison of endoscopic decompression to open laminectomy in patients with thoracic ossified ligamentum flavum – a systematic review and meta-analysis Vishal Kumar, Parth Bansal, Vivek P. Ksheerasagar, Sarvdeep Singh Dhatt Neurosurgical Review.2024;[Epub] CrossRef
Does Routine Post-Operative Use of Drainage in Minimally Invasive Lumbar Spine Surgery Offer Better Results? Alexandros Moniakis, Niels Pacheco-Barrios, Esteban Quiceno, Amna Hussein, Annie Pico, Ebtesam Abdulla, Isabel L. Bauer, Kristin Nosova, Monis Ahmed Khan, Dara S. Farhadi, Michael Prim, Ali Baaj Journal of Spine Practice.2024; 3(2): 52. CrossRef
Complications of Unilateral Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis: A Systematic Review of the Literature and Meta‐analysis of Single‐arm Studies Bin Wang, Peng He, Xiowei Liu, Zhengfang Wu, Bin Xu Orthopaedic Surgery.2023; 15(1): 3. CrossRef
Remodeling of Epidural Fluid Hematoma after Uniportal Lumbar Endoscopic Unilateral Laminotomy with Bilateral Decompression: Comparative Clinical and Radiological Outcomes with a Minimum Follow-up of 2 Years Pang Hung Wu, Hyeun Sung Kim, Giovanni Grasso, Jin Woo An, Myeonghun Kim, Inkyung Lee, Jong Seon Park, Jun Hyoung Lee, Sangsoo Kang, Jeongshik Lee, Yeonjin Yi, Jun Hyung Lee, Jun Hwan Park, Jae Hyeon Lim, Il-Tae Jang Asian Spine Journal.2023; 17(1): 118. CrossRef
Ambulatory uniportal versus biportal endoscopic unilateral laminotomy with bilateral decompression for lumbar spinal stenosis—cohort study using a prospective registry Pang Hung Wu, Brian Zhao Jie Chin, Peng Lee, Chang Yi Woon, Hyeun Sung Kim, Rajeesh George, Shuxun Lin, Yu-Heng Gamaliel Tan European Spine Journal.2023; 32(8): 2726. CrossRef
Complications and Management of Endoscopic Spinal Surgery Chang Il Ju, Seung Myung Lee Neurospine.2023; 20(1): 56. CrossRef
Clinical Results and Review of Techniques of Thoracic Endoscopic Unilateral Laminotomy with Bilateral Decompression (TE-ULBD) Using the Outside-In Technique for Thoracic Ossified Ligamentum Flavum Hyeun Sung Kim, Pang Hung Wu, Il-Tae Jang Journal of Minimally Invasive Spine Surgery and Technique.2023; 8(1): 74. CrossRef
Radiological Outcomes of Unilateral Laminotomy for Bilateral Decompression in Lumbar Spinal Stenosis With and Without Discectomy Hyun-Seo Cho, Se-Hoon Kim, Jeong Su Han, Bum-Joon Kim World Neurosurgery.2023; 175: e1307. CrossRef
Narrative Review of Pathophysiology and Endoscopic Management of Basivertebral and Sinuvertebral Neuropathy for Chronic Back Pain Hyeun Sung Kim, Pang Hung Wu, Il-Tae Jang Journal of Korean Neurosurgical Society.2023; 66(4): 344. CrossRef
Full-endoscopic bilateral over-the-top decompression in lumbar central stenosis: surgical technique and outcomes Christoph J. Siepe, Anna-Lena Bridts, Mohamed Ayman, Daniel Sauer, Christoph Mehren European Spine Journal.2023; 32(8): 2918. CrossRef
Consecutive Case Series of Uniportal Full‐endoscopic Unilateral Laminotomy for Bilateral Decompression in Lumbar Spinal Stenosis: Relationship between Decompression Range and Functional Outcomes Haining Tan, Lingjia Yu, Xuehu Xie, Ning Liu, Guoqiang Zhang, Xiang Li, Yong Yang, Bin Zhu Orthopaedic Surgery.2023; 15(12): 3153. CrossRef
Overview and Prevention of Complications During Biportal Endoscopic Lumbar Spine Surgery Sang Yoon Lee, Dong Ah Shin, Seong Yi, Yoon Ha, Keung Nyun Kim, Chang Kyu Lee Journal of Minimally Invasive Spine Surgery and Technique.2023; 8(2): 145. CrossRef
Ten-step minimally invasive slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation Siegfried J. Adelhoefer, Jessica Berger, Catherine Mykolajtchuk, Jaskeerat Gujral, Blake I. Boadi, Brian Fiani, Roger Härtl BMC Musculoskeletal Disorders.2023;[Epub] CrossRef
Technical feasibility of combined uniportal unilateral laminotomy with bilateral decompression and interlaminar lumbar discectomy surgery for cauda equina syndrome due to lower lumbar disc herniation Wu Pang Hung, Rohit Akshay Kavishwar, Hyeun Sung Kim, Brian Zhao Jie Chin North American Spine Society Journal (NASSJ).2023; 16: 100290. CrossRef
Unilateral laminotomy with bilateral spinal canal decompression: systematic review of outcomes and complications Nizar Algarni, Mohamed Al-Amoodi, Yousef Marwan, Rakan Bokhari, Abdullah Addar, Abdullah Alshammari, Abdulrahman Alaseem, Waleed Albishi, Ibrahim Alshaygy, Fahad Alabdullatif BMC Musculoskeletal Disorders.2023;[Epub] CrossRef
Remodeling Pattern of Spinal Canal after Full Endoscopic Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: One Year Repetitive MRI and Clinical Follow-Up Evaluation Hyeun-Sung Kim, Pang-Hung Wu, Giovanni Grasso, Jin-Woo An, Myeonghun Kim, Inkyung Lee, Jong-Seon Park, Jun-Hyoung Lee, Sangsoo Kang, Jeongshik Lee, Yeonjin Yi, Jun-Hyung Lee, Jun-Hwan Park, Jae-Hyeon Lim, Il-Tae Jang Diagnostics.2022; 12(4): 793. CrossRef
Comparative Clinical and Radiographic Cohort Study: Uniportal Thoracic Endoscopic Laminotomy With Bilateral Decompression by Using the 1-Block Resection Technique and Thoracic Open Laminotomy With Bilateral Decompression for Thoracic Ossified Ligamentum F Hyeun Sung Kim, Pang Hung Wu, Ji-Yeon Kim, Yeon Jin Lee, Dae Hwan Kim, Jun Hyung Lee, Jun Bok Jeon, Il-Tae Jang Operative Neurosurgery.2022; 22(6): 391. CrossRef
Percutaneous Endoscopic Posterior Lumbar Interbody Fusion with Unilateral Laminotomy for Bilateral Decompression Vs. Open Posterior Lumbar Interbody Fusion for the Treatment of Lumbar Spondylolisthesis Li-Ming He, Jia-Rui Li, Hao-Ran Wu, Qiang Chang, Xiao-Ming Guan, Zhuo Ma, Hao-Yu Feng Frontiers in Surgery.2022;[Epub] CrossRef
Fully Endoscopic 360° Decompression for Central Lumbar Spinal Stenosis Combined with Disc Herniation: Technical Note and Preliminary Outcomes of 39 Cases Shengwei Meng, Derong Xu, Shuo Han, Guanghui Li, Yan Wang, Yanqing Shen, Kai Zhu, Antao Lin, Ruiting Wang, Xuexiao Ma, Chuanli Zhou Journal of Pain Research.2022; Volume 15: 2867. CrossRef
Uniportal thoracic endoscopic decompression using one block resection technique for thoracic ossified ligamentum flavum technical report Pang Hung Wu, Hyeun Sung Kim, Ji-Yeon Kim, Yeon Jin Lee, Dae Hwan Kim, Jun Hyung Lee, Jun Bok Jeon, Il-Tae Jang Interdisciplinary Neurosurgery.2021; 23: 100963. CrossRef
Research Tendency in Lumbar Spinal Stenosis over the Past Decade: A Bibliometric Analysis Ömer Faruk Kiliçaslan, Vugar Nabi, Fatma Yardibi, Mehmet Ali Tokgöz, Özkan Köse World Neurosurgery.2021; 149: e71. CrossRef
Anatomical Importance of Inner Ligamentum Flavum Parameters for Successful Endoscopic Lumbar Decompression Surgery Ji Yeon Kim, Hyeun Sung Kim, Pang Hung Wu, Il-Tae Jang Journal of Minimally Invasive Spine Surgery and Technique.2021; 6(1): 26. CrossRef
Overview of Tips in Overcoming Learning Curve in Uniportal and Biportal Endoscopic Spine Surgery Pang Hung Wu, Hyeun Sung Kim, Dae Jung Choi, Yu-Heng Tan Gamaliel Journal of Minimally Invasive Spine Surgery and Technique.2021; 6(Suppl 1): S84. CrossRef
Clinical Results And Review of Techniques of Lumbar Endoscopic Unilateral Laminotomy With Bilateral Decompression (LE-ULBD) for Lumbar Stenosis Hyeun Sung Kim, Pang Hung Wu, Il-Tae Jang Journal of Minimally Invasive Spine Surgery and Technique.2021; 6(Suppl 1): S117. CrossRef
How I do it? Uniportal full endoscopic pseudoarthrosis release of left L5/S1 Bertolotti’s syndrome under intraoperative computer tomographic guidance in an ambulatory setting Pang Hung Wu, Matthew Sebastian, Hyeun Sung Kim, Gamaliel Tan Yu Heng Acta Neurochirurgica.2021; 163(10): 2789. CrossRef
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