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 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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Objective This study aimed to evaluate the clinical and radiological outcomes of unilateral laminotomy for bilateral decompression (ULBD) using biportal endoscopic spinal surgery (BESS) in patients with central canal stenosis, with and without low-grade degenerative lumbar spondylolisthesis (DLS).
Methods A retrospective observational study was conducted on 170 patients who underwent BESS-ULBD between 2015 and 2018, with at least 2 years of follow-up. Patients were categorized into 2 groups: group A (68 patients) with central stenosis and low-grade DLS and group B (102 patients) with central stenosis alone. Clinical outcomes were assessed using the visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and Modified MacNab criteria. Radiological assessments included sagittal translation measurements on dynamic flexion-extension radiographs.
Results Both groups significantly improved clinical outcomes at the final follow-up (p<0.05). Group A’s mean VAS scores improved from 3.8±2.4 to 1.9±2.0 for back pain and from 6.4±1.8 to 2.3±2.0 for leg pain. In group B, back pain improved from 3.9±2.5 to 1.7±1.9, and leg pain from 6.6±2.0 to 2.2±2.2. ODI scores also improved significantly in both groups. Radiological evaluation showed no significant changes in sagittal translation postoperatively, indicating preserved spinal stability. Both groups had comparable clinical outcomes, with no major complications reported.
Conclusion BESS-ULBD is a safe and effective minimally invasive option for managing central canal stenosis, with or without low-grade DLS. This technique provides substantial symptom relief, preserves spinal stability, and presents a promising alternative to more invasive fusion procedures in carefully selected patients.
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Objective This study aimed to determine the rates, causes, and predictive factors of readmissions at different periods following spine surgery, up to 180 days.
Methods This study utilized data from the 2018 to 2019 Nationwide Readmissions Database and included four postoperative periods: 0 to 7 days, 8 to 30 days, 31 to 90 days, and 91 to 180 days. The causes of readmissions and potential predictive factors were systematically identified. All analyses were performed for each period.
Results For the 180,281 patients (mean age, 65.4 years) included, 2.4% were readmitted between 0 and 7 days, 3.5% between 8 and 30 days, 3.7% between 31 and 90 days, and 4.3% between 91 and 180 days (cumulative rates: 2.4%, 5.9%, 9.3%, and 12.1%, respectively). The causes of readmissions varied across different periods: surgical site-related causes predominated within the first 30 days, whereas nonsurgical site-related causes were more prevalent from 31 to 180 days; other surgical care complication (e.g., infection) was the most prevalent cause between 0 and 7 days (10.7%) and between 8 and 30 days (29.2%), while spondylopathies/spondyloarthropathy (e.g., spinal stenosis) were the leading causes between 31 and 90 days (12.6%) and between 91 and 180 days (17.5%). The predictive factors associated with readmissions also varied across different periods. For example, patients who underwent fusion was associated with a decreased risk of readmissions between 31 and 180 days (e.g., between 91 and 180 days: odds ratio [OR], 0.79; 95% confidence interval [CI], 0.72–0.86; p<0.001), rather than between 0 and 30 days (e.g., between 0 and 7 days: OR, 0.99; 95% CI, 0.90–1.08; p=0.81).
Conclusion About 6% of patients with lumbar spinal stenosis who underwent spine surgery were readmitted within 30 days and 12% by 180 days. The causes of readmissions and predictive factors varied by period, providing valuable insights for quality improvement efforts and the burden of readmission reductions.
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Objective This study aimed to compare the clinical and comprehensive radiological outcomes of 3 types of endoscopic decompression surgery: unilateral biportal endoscopic lumbar decompression (UBELD), microendoscopic laminotomy (MEL), and percutaneous endoscopic lumbar decompression (PELD).
Methods Patients with single-level lumbar spinal stenosis without instability were included in this multicenter retrospective study. Visual analogue scale (VAS) scores for each extremity, VAS back pain, and Japanese Orthopaedic Association (JOA) scores at preoperative and postoperative 1st, 6th, and 12th months were used as clinical outcome measures. In order to compare the radiological results of the patients, bilateral superior articular distance (SAD), bilateral lateral recess height (LR height), bilateral lateral recess angle (LR angle), and cross-sectional spinal canal area values were measured.
Results Eighty patients in the UBELD group, 73 patients in the MEL group, and 62 patients in the PELD group were included in the study. There was a statistically significant improvement in VAS scores and JOA scores in all groups compared to the preoperative period. At the 12th month postoperatively, the highest lateral decompression values on the approach side were determined as MEL (SAD: 4.1 mm, LR angle: 38.8°, LR height: 4.0 mm), followed by UBELD (SAD: 3.6 mm, LR angle: 36.2°, LR height: 3.3 mm) and PELD (SAD: 3.0 mm, LR angle: 21.7°, LR height: 2.3 mm), respectively. For the contralateral side, the highest lateral recess decompression values were listed as UBELD > MEL > PELD.
Conclusion Effective decompression can be performed using all endoscopic techniques in lumbar spinal stenosis. However lateral recess decompression values were found to be better in UBELD and MEL techniques, compared to PELD.
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The main aim of this video article is to demonstrate the combined use of O-arm navigation and unilateral biportal endoscopy (UBE) to manage far-out syndrome (FOS). In FOS there is entrapment and compression of the fifth lumbar nerve beyond the foramen and between L5 transverse process and the sacral ala at the lumbosacral junction. Conventional microscopic decompression using a paraspinal approach had been the gold standard for its management. However, the surgery is technically challenging due to the deep location of the pathology and intricate anatomy of extraforaminal space. There have been some published reports of unsatisfactory outcomes with microscopic decompression for FOS. We decided to integrate navigation with UBE to increase precision for the management of FOS. A 70-year-old female presented to us with chief complaint of left lower limb radiculopathy since 1 year. She also complained of numbness and paresthesias in her left leg and foot. She was unable to walk for more than 10 minutes due to pain. Her magnetic resonance imaging scan revealed compression of left L5 nerve root in the extraforaminal region. UBE decompression via paraspinal approach was performed for her under O-arm navigation. She experienced immediate relief of her symptoms in the postoperative period. O-arm-navigation-guided UBE is an effective and safer alternative to microsurgical decompression for the management of FOS. This video demonstrates the step-by-step implementation of O-arm navigation with endoscopy and its precise execution.
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This article aims to demonstrate the uniportal full endoscopic surgery for treating complex anterior and posterior spinal pathology at the T1–2 level, offering a invasive, accessible, stable, and versatile approach to challenging anatomical situations. Uniportal full endoscopic surgery is one of the most minimally invasive spinal surgeries, utilizing slim, elongated, and compact instruments that provide access to lesions from any angle and distance. This characteristic makes the technique especially suitable for hard, such as the T1–2 level, where traditional approaches may be limited or difficult. We present the case of a 39-year-old male patient (height, 187 cm; weight, 130 kg) who developed myelopathy due to a hard disc herniation and ossification of the ligamentum flavum at the T1–2 leading to paraparesis, which was more severe on the left side. An anterior approach was challenging due to the anatomical constraints at the T1–2 level, as well as the patient’s body size. A posterior access via the interlaminar approach facilitated the removal of the ossified ligamentum flavum. However, to the anterior lesion remained problematic without spinal cord retraction. Using the uniportal full endoscope, we were able to approach both anterior and posterior lesions through an incision 8 cm lateral to the midline, allowing for the treatment of the entire 270° arc of the pathology. The slim and elongated nature of the full endoscope enabled effective decompression without exerting pressure on the spinal cord, providing access from any angle and distance. This technique can be applied to a variety of cases involving difficult-to-access spinal.
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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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Neurospine 2024;21(4):1190-1198. Published online December 31, 2024
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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Objective To describe the full-endoscopic lumbar foraminoplasty with midline skin incision (FEFM) and lateral recess decompression procedure and to report its clinical outcomes at the 1-year follow-up.
Methods Consecutive patients with lumbar foraminal and/or lateral recess stenosis who underwent FEFM procedures were retrospectively reviewed. Clinical outcomes were evaluated with a visual analogue scale (VAS) of back and leg pain and Oswestry Disability Index (ODI) up to 1 year postoperatively. The complications and recurrence rate were also recorded.
Results A total of 30 cases (51 levels) were included (L3–4, 6 cases [11.8%]; L4–5, 23 [45.1%]; L5–S1, 22 cases [43.1%]). VAS scores collected at preoperative, postoperative day 1, 3 months, 6 months, and 1 year were 9.16, 1.7, 1.36, 1.3, and 1.43, respectively. The ODI scores collected at preoperative, postoperative 3 months, 6 months, and 1 year were 46.63, 11.5, 10.66, and 10.46, respectively (p<0.05). The mean operation time was 88.7 minutes (range, 45–152 minutes). The length of hospital stay was 1.21 days (range, 1–3 days). No immediate complications were identified, and no patients experienced a recurrence of symptoms requiring revision surgery.
Conclusion FEFM is an effective procedure for treating foraminal and/or lateral recess stenosis. It demonstrates the capability to decompress both bilateral foraminal and lateral recess stenosis through a single-entry point.
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Objective The unilateral biportal endoscopic posterior cervical foraminotomy (UBE-PCF) has been recently adopted for unilateral radiating arm pain due to cervical herniated intervertebral disc or foraminal stenosis. We systematically meta-analyzed clinical outcomes and complications of the UBE-PCF and compared them with those of full-endoscopic PCF (FE-PCF).
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 This study aims to overcome challenges in lumbar spine imaging, particularly lumbar spinal stenosis, by developing an automated segmentation model using advanced techniques. Traditional manual measurement and lesion detection methods are limited by subjectivity and inefficiency. The objective is to create an accurate and automated segmentation model that identifies anatomical structures in lumbar spine magnetic resonance imaging scans.
Methods Leveraging a dataset of 539 lumbar spinal stenosis patients, the study utilizes the residual U-Net for semantic segmentation in sagittal and axial lumbar spine magnetic resonance images. The model, trained to recognize specific tissue categories, employs a geometry algorithm for anatomical structure quantification. Validation metrics, like Intersection over Union (IOU) and Dice coefficients, validate the residual U-Net’s segmentation accuracy. A novel rotation matrix approach is introduced for detecting bulging discs, assessing dural sac compression, and measuring yellow ligament thickness.
Results The residual U-Net achieves high precision in segmenting lumbar spine structures, with mean IOU values ranging from 0.82 to 0.93 across various tissue categories and views. The automated quantification system provides measurements for intervertebral disc dimensions, dural sac diameter, yellow ligament thickness, and disc hydration. Consistency between training and testing datasets assures the robustness of automated measurements.
Conclusion Automated lumbar spine segmentation with residual U-Net and deep learning exhibits high precision in identifying anatomical structures, facilitating efficient quantification in lumbar spinal stenosis cases. The introduction of a rotation matrix enhances lesion detection, promising improved diagnostic accuracy, and supporting treatment decisions for lumbar spinal stenosis patients.
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Objective Hypertrophy ligamentum flavum (LFH) is a common cause of lumbar spinal stenosis, resulting in significant disability and morbidity. Although long noncoding RNAs (lncRNAs) have been associated with various biological processes and disorders, their involvement in LFH remains not fully understood.
Methods Human ligamentum flavum samples were analyzed using lncRNA sequencing followed by validation through quantitative real-time polymerase chain reaction. To explore the potential biological functions of differentially expressed lncRNA-associated genes, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were performed. We also studied the impact of lncRNA PARD3-AS1 on the progression of LFH in vitro.
Results In the LFH tissues when compared to that in the nonhypertrophic ligamentum flavum (LFN) tissues, a total of 1,091 lncRNAs exhibited differential expression, with 645 upregulated and 446 downregulated. Based on GO analysis, the differentially expressed transcripts primarily participated in metabolic processes, organelles, nuclear lumen, cytoplasm, protein binding, nucleic acid binding, and transcription factor activity. Moreover, KEGG pathway analysis indicated that the differentially expressed lncRNAs were associated with the hippo signaling pathway, nucleotide excision repair, and nuclear factor-kappa B signaling pathway. The expression of PARD3-AS1, RP11-430G17.3, RP1-193H18.3, and H19 was confirmed to be consistent with the sequencing analysis. Inhibition of PARD3-AS1 resulted in the suppression of fibrosis in LFH cells, whereas the overexpression of PARD3-AS1 promoted fibrosis in LFH cells in vitro.
Conclusion This study identified distinct expression patterns of lncRNAs that are linked to LFH, providing insights into its underlying mechanisms and potential prognostic and therapeutic interventions. Notably, PARD3-AS1 appears to play a significant role in the pathophysiology of LFH.
Objective To introduce a technique of laminotomy using a common trephine to enlarge the interlaminar space at L4/5 segment for interlaminar endoscopic lumbar discectomy (IELD) and report the anatomical basis of this procedure, technical details, as well as primary clinical outcomes of a consecutive patient cohort with L4/5 lumbar disc herniation (LDH).
Methods On anteroposterior fluoroscopy, the intersection of the medial edge of the inferior articular process and the inferior endplate of L4 vertebra was taken as the target. Using a common trephine, laminotomy was performed to remove a big portion of the posterior wall of the canal under the guidance of endoscopy. From June 2018 to December 2021, the consecutive patients who underwent L4/5 IELD were prospectively studied. Clinical outcomes were assessed at the day before surgery, 1 day, 1 month, 3 months, 12 months after surgery, and the last follow-up. Numerical Rating Scale, Roland-Morris Disability Questionnaire (RMDQ), and MacNab criteria were used to evaluate back and leg pain, the quality of life, and clinical efficacy, respectively.
Results There were 64 men and 44 women, with an age of 50.3 ± 14.9 years. The operating time was 74.54 ± 17.42 minutes. The mean follow-up time was 32.7 ± 18.6 months (range, 12–64 months). The complications of IELD included numbness, neck pain, and recurrence. Both leg pain (6.2 ± 1.9 vs. 1.8 ± 0.8, p < 0.001) and back pain (3.1 ± 2.3 vs. 1.7 ± 0.9, p < 0.001) quickly improved after this procedure and maintained (1.1 ± 1.5, 1.1 ± 1.3) at final follow-up. Physical disability due to back pain, as assessed using RMDQ, was improved remarkably after surgery (15.0 ± 5.8 vs. 2.9 ± 4.1, p < 0.001). In addition, MacNab outcome grade was evaluated as good-to-excellent in 96 cases (88.9%).
Conclusion A convenient technique of laminotomy using a common trephine was proposed for the L4/5 IELD. It can efficiently enlarge the interlaminar entry to perform endoscopic discectomy. This procedure is particularly suitable for treating LDH with concomitant lumbar spinal stenosis and migrated herniated disc.
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Objective To investigate risk factors associated with postoperative restenosis after full endoscopic lumbar foraminotomy (FELF) in patients with lumbar foraminal stenosis (LFS).
Methods A single-center, retrospective case-control study was conducted on patients diagnosed with foraminal stenosis who underwent FELF between August 2019 and April 2022. The study included 56 patients, comprising 18 cases and 38 controls. Clinical data, radiologic assessments, and surgical types were compared between the groups. The cutoff values of radiologic parameters that differentiate the 2 groups were investigated.
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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