Objective To evaluate early postoperative mobility after lumbar decompression using real-time location system (RTLS)-derived objective metrics and to explore differences in mobility patterns between biportal endoscopic decompression and open decompression.
Methods This retrospective cohort study included 323 patients who underwent lumbar decompression for degenerative lumbar spinal stenosis between March 2020 and May 2024. RTLS sensors embedded in wristbands continuously recorded patient mobility during postoperative days (PODs) 1–4. Primary RTLS-derived outcomes included total walking distance, mean walking speed, and active movement ratios (top 20% and top 50%). Between-group comparisons were performed using nonparametric tests. Propensity score matching and multivariable median quantile regression adjusting for age, American Society of Anesthesiologists physical status, and preoperative mobility were conducted.
Results RTLS identified differences in early postoperative activity patterns between surgical approaches. In adjusted analyses, activity-intensity–based metrics, particularly the top 20% activity ratio, remained significantly higher in the biportal endoscopic decompression group across multiple PODs. Subgroup analyses demonstrated minimal differences after single-level decompression, whereas activity-based differences were more frequently observed in multilevel procedures.
Conclusion RTLS-based continuous monitoring detected differences in early postoperative activity patterns following lumbar decompression. These findings support the role of RTLS as an objective tool for assessing early functional recovery in spine surgery.
Objective Unilateral biportal endoscopic (UBE) spine surgery is a minimally invasive technique that uses continuous irrigation to improve visualization and control bleeding. Effective water pressure management is crucial for patient safety, particularly at the cervical and thoracic levels where spinal cord injury risk is higher. However, real-time pressure monitoring remains underexplored. This study evaluates the impact of real-time water pressure monitoring on safety during UBE surgery.
Methods A prospective study was conducted involving 20 patients undergoing UBE lumbar spine surgery. Patients were divided into 2 groups based on the irrigation system: gravity-based or infusion pump. Real-time water pressure was monitored using a digital sensor throughout surgery. Each procedure was categorized into 3 phases: phase I, working space preparation; phase II, laminectomy; phase III, flavectomy, dura exposure, and discectomy. Data was analyzed according to the type of irrigation system and surgical phase.
Results The mean water pressure in the surgical field during UBE spine surgery was 17.98± 8.07 mmHg, with no significant differences between surgical phases. However, the infusion pump system maintained significantly lower mean pressure (12.10±3.51 mmHg) compared to the gravity-based system (23.86±6.97 mmHg, p=0.001). The infusion pump system consistently maintained a significantly lower mean water pressure compared to the gravity-based system.
Conclusion Real-time water pressure monitoring during UBE surgery enhances safety by enabling improved control of pressure within the surgical field. Both the gravity-based and infusion pump systems safely maintained working space pressure, with the pump system showing significantly lower pressure levels.
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Mazda Farshad, Jana Felicitas Schader, Alexandra Stauffer, Carl Moritz Zipser, Najmeh Kheram, José Miguel Spirig, Marie-Rosa Fasser, Jonas Widmer, Vincent Hagel
Neurospine 2025;22(2):583-591. Published online June 30, 2025
Objective Endoscopic spine surgery implies possibly severe complications of the central nervous system, from headache to seizures and autonomic dysreflexia. These adverse events might be due to increased intracranial pressure (ICP), presumably induced by increased spinal intra-/epidural pressure caused by fluid irrigation. This study was designed to perform interlaminar endoscopic lumbar discectomy (IELD) at different irrigation fluid settings while monitoring its effect on intra-/epidural and ICPs, with and without dural tears.
Methods Spinal intradural pressures were measured by introducing catheters through a sacral approach to human cadavers’ lumbar, thoracic, and cervical levels. Additionally, an epidural probe was placed at L3–4. ICP was measured by an intraventricular probe. IELD was performed at L3–4, and the effect of varying irrigation pressures by different endoscopic pump systems and gravity-based irrigation on intra-/epidural and ICP pressures was measured before and after durotomy at L3–4.
Results Intradural pressure at L3–4 correlated linearly with increasing irrigation pressure, irrespective of the used pump system (median pressure increase at 100-mmHg irrigation pressure: system I: 7 mmHg, r=0.94, p=0.002; system II: 7 mmHg, r=0.89, p=0.017) or gravity (8 mmHg, r=0.93, p=0.242). This effect was also seen intradurally at the thoracic/cervical spine, epidural, and intracranial level, and was even more pronounced with the maneuver of outflow-occlusion and a dural tear present.
Conclusion While performing IELD, pump pressures correlated linearly to intra-/epidural pressures and ICPs. Pressures did not rise to concerningly high levels without outflow-occlusion, even with increased pump pressures. In the presence of a dural tear, higher pump pressures exacerbated by occlusion may lead to deleterious intradural and ICP elevations.
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Objective The upper lumbar region has distinctive anatomical characteristics that contribute to the challenges of performing discectomy. We introduce far-lateral transforaminal unilateral biportal endoscopic (UBE) lumbar discectomy for central or paracentral disc herniations in the upper lumbar region.
Methods We conducted retrospective review of the patients who underwent a far-lateral transforaminal UBE lumbar discectomy at our institution from January 2018 to September 2024. The electronic medical records, operative records, and radiologic images of the patients were reviewed.
Results A total of 27 patients underwent far-lateral transforaminal UBE lumbar discectomy for central or paracentral disc herniations in the upper lumbar region. The patient had a mean age of 54.0 ± 13.7 years. Operation was performed at the L1–2 level in 3 patients (11.1%), L2–3 in 9 patients (33.3%), and L3–4 in 15 patients (55.6%). The patients were followed-up for a mean of 27.7 ± 19.3 months. The Oswestry Disability Index was significantly decreased from 36.3 ± 6.8 preoperatively to 3.7 ± 3.3 at last follow-up (p < 0.001). The visual analogue scale (VAS) back was significantly decreased from 7.8 ± 0.9 preoperatively to 3.1 ± 0.6 postoperative day 2 (p < 0.001). The VAS leg was significantly decreased from 8.1 ± 0.8 preoperatively to 2.3 ± 0.7 postoperative day 2 (p < 0.001).
Conclusion The far-lateral transforaminal UBE lumbar discectomy would be a viable surgical option for upper lumbar disc herniations.
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Objective To analyze costs and cost-effectiveness of transforaminal endoscopic thoracic discectomy (TETD) for the treatment of symptomatic thoracic disc herniation (TDH) and compare it with open microdiscectomy (MD).
Methods This retrospective cohort study included patients who underwent TETD or MD for symptomatic TDH and had a minimum follow-up of 1 year. Cost analysis included direct costs (primary and secondary hospital costs), indirect costs (lost wages due to work absence), total costs (direct + indirect), and cost-effectiveness (cost per quality-adjusted life year [QALY] and incremental cost-effectiveness ratio [ICER]). Clinical outcomes included patient-reported outcome measures (Oswestry Disability Index [ODI], 36-item Short Form health survey [SF-36]), QALY gained, and reoperation and readmission rates at 1 year. TETD and MD groups were compared for outcome measures.
Results A total of 111 patients (57 TETD, 54 MD) were included. The direct ($6,270 TETD vs. $7,410 MD, p < 0.01), indirect costs ($1,250 TETD vs. $1,450 MD, p < 0.01), total costs ($7,520 TETD vs. $8,860 MD, p < 0.01), and cost per QALY ($31,333 TETD vs. $44,300 MD, p < 0.01) were significantly lower for TETD compared to MD. ICER of TETD was found to be -$33,500. At 1 year, TETD group showed significantly greater improvement in ODI (46% vs. 36%, p < 0.01) and SF-36 (64% vs. 53%, p < 0.01) and significantly greater QALY gained (0.24 vs. 0.2, p < 0.01) compared to MD group. No significant difference was found in reoperation and readmission rates.
Conclusion TETD demonstrated significantly better clinical outcomes, lower overall costs, and better cost-effectiveness than MD in appropriately selected patients of symptomatic TDH.
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Endoscopic spine surgery (ESS) is growing in popularity worldwide. An expanding body of literature demonstrates rapid functional recovery with reduced morbidity compared to open techniques. Both full endoscopic spine surgery, or uniportal endoscopy, and unilateral biportal endoscopy (UBE) can be employed in conjunction with various navigation and enabling technologies for assistance with localization of anatomic orientation and assessment of the intraoperative target spinal pathology. This review article describes various navigation technologies in ESS, including 2-dimensional (2D) fluoroscopic imaging, 2D fluoroscopic navigation, 3-dimensional C-arm navigation, augmented reality, and spinal robotics. Employment of enabling navigation and emerging technology with the registration of patient-specific anatomy enables clear delineation of anatomic landmarks and facilitation of a successful procedure. Additionally, avoidance of common pitfalls during use of navigation systems in ESS is discussed in this review.
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Objective This study aims to investigate the anatomical relationship among the nerve roots, intervertebral space, pedicles, and intradural rootlets of the cervical spine for improving operative outcomes and exploring neuroventral decompression approach in posterior endoscopic cervical discectomy (PECD).
Methods Cervical computed tomography myelography imaging data from January 2021 to May 2023 were collected, and the RadiAnt DICOM Viewer Software was employed to conduct multiplane reconstruction. The following parameters were recorded: width of nerve root (WN), nerve root-superior pedicle distance (NSPD), nerve root-inferior pedicle distance (NIPD), and the relationship between the intervertebral space and the nerve root (shoulder, anterior, and axillary). Additionally, the descending angles between the spinal cord and the ventral (VRA) and dorsal (DRA) rootlets were measured.
Results The WN showed a gradual increase from C4 to C7, with measurements notably larger in men compared to women. The NSPD decreased gradually from the C2–3 to the C5–6 levels. However, the NIPD showed an opposite level-related change, notably larger than the NSPD at the C4–5, C5–6, and C7–T1 levels. Furthermore, significant differences in NIPD were observed between different age groups and genders. The incidence of the anterior type exhibited a gradual decrease from the C2–3 to the C5–6 levels. Conversely, the axillary type exhibited an opposite level-related change. Additionally, the VRA and DRA decreased as the level descended, with measurements significantly larger in females.
Conclusion A prediction of the positional relationship between the intervertebral space and the nerve root is essential for the direct neuroventral decompression in PECD to avoid damaging the neural structures. The axillary route of the nerve root offers a safer and more effective pathway for performing direct neuroventral decompression compared to the shoulder approach.
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This video aims to describe an endoscopic surgical approach for accessing difficult to reach pathology such as disc herniations after previous surgery. The relatively small size of endoscopic instruments facilitates significant freedom of movement inside the spinal canal. The authors have experience with interlaminar approaches for contralateral pathology such as disc herniations, recurrent disc herniations, spinal stenosis, and facet cysts. The advantages of starting from the opposite side of the canal in a revision situation include the ability to establish a clear plane between the dura and the borders of the canal and visualize the disc from a different angle than the index operation. Contralateral approaches to residual or recurrent herniations can be performed with an “over the top” technique, navigating dorsal to the thecal sac to reach the far side of the canal. In the associated video we demonstrate a novel technique, a contralateral transaxillary endoscopic approach to a recurrent disc herniation at the L5–S1 level in a young male collegiate wrestler. In our experience, we have found this particular approach to be useful in patients with an early take off of the S1 nerve root which creates a large axillary window. In several instances this technique has allowed us to inspect the area of the reherniation from both the axilla and over the top of the thecal sac. This particular patient has a large recurrence 2 years after an open microscopic hemilaminotomy and discectomy. In this instance, an approach was chosen that navigates dorsal to the S1 nerve root and ventral to the thecal sac, starting on the opposite side of the spinal canal from the herniation. This approach is described as a contralateral interlaminar transaxillary discectomy.
Objective Spinal stenosis is a prevalent condition; however, the optimal surgical treatment for central lumbar stenosis remains controversial. This study compared the clinical outcomes and radiological parameters of 3 surgical methods: unilateral laminectomy bilateral decompression with unilateral biportal endoscopy (ULBD-UBE), conventional subtotal laminectomy (STL), and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).
Methods This retrospective study included 86 patients, divided into ULBD-UBE (n=34), STL (n=24), and MIS-TLIF (n=28) groups. We evaluated demographics and perioperative factors and assessed clinical outcomes using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and neurogenic intermittent claudication (NIC). Radiological parameters assessed included lumbar lordosis, L4S1 Cobb angle (L4S1), T12S1 Cobb angle (T12S1), increased cross-sectional dural area (CSA), dynamic angulation (DA), dynamic slip (DS), and development of postoperative instability.
Results The ULBD-UBE group showed a significantly shorter hospital stay duration and operation time and reduced blood loss than the other groups (p<0.001). ULBD-UBE group showed a trend towards greater VAS and ODI improvement at 1 month and postoperative NIC symptom relief. Radiologically, MIS-TLIF group exhibited lower postoperative DA and DS (p<0.001), indicating higher postoperative stability. Postoperative instability was lower in the ULBD-UBE group (2.9%) than in the STL group (16.7%) and similar to the MIS-TLIF group (0.0%) (p=0.028). The CSA was highest in the MIS-TLIF group (295.5%) compared to that in the other groups (ULBD-UBE, 216.3%; STL, 245.2%) (p<0.001).
Conclusion Compared to other procedures, ULBD-UBE is a safe, effective, and viable surgical procedure for treating lumbar central stenosis.
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Objective To compare the safety profiles of biportal endoscopic spinal surgery (BESS) and microscopic spinal surgery (MSS) for lumbar disc herniation and spinal stenosis by analyzing the associated adverse events.
Methods We pooled data from 2 prospective randomized controlled trials involving 220 patients (110 in each group) who underwent single-level lumbar surgery. Participants aged 20–80 years with radiating pain due to lumbar disc herniation or spinal stenosis were included in this study. Adverse events were recorded and analyzed over a 12-month follow-up period.
Results The overall adverse event rates were 9.1% (10 of 110) in the BESS group and 17.3% (19 of 110) in the MSS group, which were not statistically significantly different (p=0.133). Notably, wound dehiscence occurred in 8.2% of MSS cases but in none of the BESS cases. Both groups showed similarly low rates of complications, such as dural tears, epidural hematoma, and nerve root injury. The most common adverse event in the BESS group was recurrent disc herniation (2.7%), whereas that in the MSS group was wound dehiscence (8.2%).
Conclusion BESS demonstrated a safety profile comparable to that of MSS for the treatment of lumbar disc herniation and spinal stenosis, with a trend towards fewer overall complications. BESS offers particular advantages in terms of reducing wound-related complications. These findings suggest that BESS is a safe alternative to conventional MSS and potentially offers the benefits of a minimally invasive approach without compromising patient safety.
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Methods We systematically searched the PubMed, Embase, and Web of Science until February 29, 2024. Clinical outcomes and complications of the UBE-PCF and FE-PCF were collected and analyzed using the fixed-effect or random-effects model. Clinical outcomes of the UBE-PCF were compared with minimal clinically important difference (MCID) following PCF to evaluate the efficacy of UBE-PCF.
Results Ten studies were included in the meta-analysis. In the random-effects meta-analysis, the Neck Disability Index (NDI), visual analogue scale (VAS) neck, and VAS arm were significantly decreased after the UBE-PCF (p<0.001). The improvement of NDI, VAS neck, and VAS arm were significantly higher than MCID (p<0.05). The improvement of NDI, VAS neck, and VAS arm were not significantly different between the UBE-PCF and FE-PCF (p>0.05). Overall incidence of complications of the UBE-PCF was 6.2% (24 of 390). The most common complication was dura tear (2.1%, 8 of 390). The incidence in overall complications was not significantly different between the UBE-PCF and FE-PCF (p=0.813).
Conclusion We found that the UBE-PCF significantly improved clinical outcomes. Regarding clinical outcomes and complications, the UBE-PCF and FE-PCF were not significantly different. Therefore, the UBE-PCF would be an advantageous surgical option comparable to FE-PCF for unilateral radiating arm pain.
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Objective Endoscopic spine surgery is an emerging technique of minimally invasive spine surgery. However, headache, seizure, and autonomic dysreflexia are possible irrigation-related complications following full-endoscopic lumbar discectomy (FELD). Pressure elevation through fluid irrigation may contribute to these adverse events. A validated experimental model to investigate parameters for guideline definition is lacking. This study aimed to create an experimental setting for FELD with pressure assessments to prove the concept of repeatable and sensitive measurement of intracranial, intra- and epidural pressures during spine endoscopy.
Methods To measure intradural pressure, catheters were introduced through a sacral approach and advanced to lumbar, thoracic, and cervical levels in human cadavers. Similarly, lumbar epidural and intracranial probes were placed. The dural sac was filled with Ringer solution to a physiologic pressure of 15 cmH2O. Lumbar endoscopy was performed on 3 human cadavers at the L3–4 level. Pressure changes were measured continuously at all sites and the effects of backflow-occlusion were monitored.
Results Reproducibility of the experimental model was validated with catheters at the correct locations and stable compartmental pressure baselines at all levels for 3 specimens (mean±standard deviation: 1.3±2.9 mmHg, 9.0±2.0 mmHg, 6.0±1.2 mmHg, respectively). Pressure increase could be detected sensitively by closing the system with backflow-occlusion.
Conclusion An experimental setup for feasible, repeatable, and precise pressure measurement during FELD in a human cadaveric setup has been developed. This allows investigation of the effects of endoscopic techniques and pump pressures on intra-, epidural and intracranial pressure and enables ranges of safe pump pressures per clinical situations.
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Methods To achieve this goal, we integrated an endoscope system into a manipulator and conducted precision bone machining using a neurosurgical drill, recording the grinding resistance values across 3 axes. Our study encompassed 2 core tasks: linear grinding, such as laminectomy, and cylindrical grinding, such as foraminotomy, with each task yielding unique measurement data.
Results In linear grinding, we observed a proportional increase in grinding resistance values in the machining direction with acceleration. This observation suggests that 3-axis resistance measurements are a valuable tool for gauging and predicting deep cortical penetration. However, problems occurred in cylindrical grinding, and a significant error of 10% was detected. The analysis revealed that multiple factors, including the tool tip efficiency, machining speed, teaching methods, and deflection in the robot arm and jig joints, contributed to this error.
Conclusion We successfully measured the resistance exerted on the tool tip during bone machining with a robotic arm across 3 axes. The resistance ranged from 3 to 8 Nm, with the measurement conducted at a processing speed approximately twice that of manual surgery performed by a surgeon. During the simulation of foraminotomy under endoscopic grinding conditions, we encountered a -10% error margin.
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Results No significant difference in age, sex distribution, or presence of adjacent segment disease or grade I spondylolisthesis was observed between the groups. Cases had a higher degree of disc wedging angle (DWA) (3.0° ± 1.1° vs. 0.5° ± 1.4°, p < 0.001), larger coronal Cobb angle (CCA) (8.8° ± 5.1° vs. 4.7° ± 2.5°, p = 0.004), and smaller segmental lumbar lordosis (SLL) than controls (11.0 ± 7.4 vs. 18.0 ± 5.4, p = 0.001). Optimal cutoff values for DWA, CCA, and SLL were estimated as 1.8°, 7.9°, and 17.1°, respectively. A significant difference in surgical types was observed between cases and controls (p = 0.004), with the case group having a higher distribution of patients undergoing discectomy in addition to TELF.
Conclusion The study identified potential risk factors for restenosis after FELF in patients with LFS, including higher DWA, larger CCA, smaller SLL angle. We believe that discectomy should be perform with caution during FELF, as it can lead to subsequent restenosis.
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