Unilateral biportal endoscopy-assisted decompression strategy for lateral lumbar spinal stenosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

XU Xuyang ¹ ,  ZHANG Zhiqiang ² , WANG Zijie ¹ , ZHANG Liang ² , CAI Jun ² , FENG Xinmin ² , DING Yu ¹ , ZHANG Yi ¹

1. Medical College, Yangzhou University, Yangzhou Jiangsu, 225001, P. R. China;
2. Department of Orthopedics, Northern Jiangsu People’s Hospital Affiliated to Yangzhou University, Yangzhou Jiangsu, 225001, P. R. China;

Corresponding author：

ZHANG Zhiqiang, Email: 18051060808@163.com

Keywords：

Lumbar spinal stenosis; lateral lumbar spinal stenosis; unilateral biportal endoscopy; decompression surgery; surgical approach

DOI：

10.7507/1002-1892.202502068

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Objective To explore decompression strategies for lateral lumbar spinal stenosis under unilateral biportal endoscopy (UBE) assistance. Methods A clinical data of 86 patients with lateral lumbar stenosis treated with UBE-assisted intervertebral decompression between September 2022 and December 2023 was retrospectively analyzed. There were 42 males and 44 females with an average age of 63.6 years (range, 45-79 years). The disease duration ranged from 6 to 14 months (mean, 8.5 months). Surgical levels included L_{2, 3} in 3 cases, L_{3, 4} in 26 cases, L_{4, 5} in 42 cases, and L₅, S₁ in 15 cases. According to Lee's grading system, there were 21 cases of grade 1, 36 cases of grade 2, and 29 cases of grade 3 for lumbar spinal stenosis. Based on the location of stenosis and clinical symptoms, the 33 cases underwent interlaminar approach, 7 cases underwent interlaminar approach with auxiliary third incision, 26 cases underwent contralateral inclinatory approach, and 20 cases paraspinal approach, and corresponding decompression procedures were performed. Visual analogue scale (VAS) score was used to evaluate lower back/leg pain before operation and at 1 and 3 months after operation, while Oswestry disability index (ODI) was used to evaluate spinal function. At 3 months after operation, the effectiveness was evaluated using the modified MacNab evaluation criteria. The spinal stenosis and decompression were evaluated based on Lee grading criteria using lumbar MRI before operation and 3 months after operation. Results All procedures were successfully completed with mean operation time of 95.14 minutes (range, 57-166 minutes). Dural tears occurred in 2 cases treated with interlaminar approach with auxiliary third incision. All incisions healed by first intention. All patients were followed up 3-10 months (mean, 5.9 months). The clinical symptoms of the patients were relieved to varying degrees. The VAS scores and ODI of lower back and leg pain at 1 and 3 months after operation significantly improved compared to preoperative levels (P<0.05), and the indicators at 3 months significantly improved than that at 1 month (P<0.05). According to the modified MacNab evaluation criteria, the effectiveness at 3 months after operation was rated as excellent in 52 cases, good in 21 cases, and poor in 13 cases, with the excellent and good rate of 84.9%. No lumbar instability detected on flexion-extension X-ray films during follow-up. The Lee grading of lateral lumbar stenosis at 3 months after operation showed significant improvement compared to preoperative grading (P<0.05). Conclusion For lateral lumbar spinal stenosis, UBE-assisted decompression of the spinal canal requires the selection of interlaminar approach, interlaminar approach with auxiliary third incision, contralateral inclinatory approach, and paraspinal approach based on preoperative imaging findings and clinical symptoms to achieve better effectiveness.

1.	Katz JN, Zimmerman ZE, Mass H, et al. Diagnosis and management of lumbar spinal stenosis: a review. JAMA, 2022, 327(17): 1688-1699.
2.	Jensen RK, Jensen TS, Koes B, et al. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. Eur Spine J, 2020, 29(9): 2143-2163.
3.	Hathi K, Bigney E, Richardson E, et al. Minimally invasive vs. open surgery for lumbar spinal stenosis in patients with diabetes—A canadian spine outcomes and research network study. Global Spine J, 2023, 13(6): 1602-1611.
4.	Li X, Liu J, Liu Z. Comparison of the results of open PLIF versus UBE PLIF in lumbar spinal stenosis: postoperative adjacent segment instability is lesser in UBE. J Orthop Surg Res, 2023, 18(1): 543. doi: 10.1186/s13018-023-04038-3.
5.	Dhar UK, Menzer EL, Lin M, et al. Open laminectomy vs. minimally invasive laminectomy for lumbar spinal stenosis: a review. Front Surg, 2024, 11: 1357897. doi: 10.3389/fsurg.2024.1357897.
6.	汤玮, 丁兆利, 潘伟, 等. 内镜与开放双侧减压治疗老年腰椎管狭窄症. 中国矫形外科杂志, 2024, 32(16): 1520-1524.
7.	Park DK, Weng C, Zakko P, et al. Unilateral biportal endoscopy for lumbar spinal stenosis and lumbar disc herniation. JBJS Essent Surg Tech, 2023, 13(2): e22.00020. doi: 10.2106/JBJS.ST.22.00020.
8.	Zhu C, Cheng W, Wang D, et al. A helpful third portal for unilateral biportal endoscopic decompression in patients with cervical spondylotic myelopathy: A technical note. World Neurosurgery, 2022, 161: 75-81.
9.	Tian D, Zhu B, Liu J, et al. Contralateral inclinatory approach for decompression of the lateral recess and same-level foraminal lesions using unilateral biportal endoscopy: A technical report. Frontiers in Surgery, 2022, 9: 959390. doi: 10.3389/fsurg.2022.959390.
10.	Park SC, Kang MS, Yang JH, et al. How I do it: biportal endoscopic paraspinal approach for recurrent lumbar disc herniation following percutaneous endoscopic lumbar discectomy. Acta Neurochirurgica, 2022, 164(11): 3057-3060.
11.	王玉, 孔清泉, 陈仲强. 再议腰椎管狭窄症. 中国修复重建外科杂志, 2019, 33(7): 789-794.
12.	Chiarotto A, Maxwell LJ, Ostelo RW, et al. Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: A systematic review. J Pain, 2019, 20(3): 245-263.
13.	Fairbank JC, Pynsent PB. The Oswestry disability index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
14.	Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg (Am), 1971, 53(5): 891-903.
15.	Park HJ, Kim SS, Lee YJ, et al. Clinical correlation of a new practical MRI method for assessing central lumbar spinal stenosis. Br J Radiol, 2013, 86(1025): 20120180. doi: 10.1259/bjr.20120180.
16.	Lee CK, Rauschning W, Glenn W. Lateral lumbar spinal canal stenosis: classification, pathologic anatomy and surgical decompression. Spine, 1988, 13(3): 313-320.
17.	汪文龙, 刘正, 吴四军, 等. 单侧双通道内镜下减压治疗腰椎管狭窄症的早期疗效观察. 中国脊柱脊髓杂志, 2021, 31(10): 911-918.
18.	Tang Z, Tan J, Shen M, et al. Comparative efficacy of unilateral biportal and percutaneous endoscopic techniques in unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis. BMC Musculoskelet Disord, 2024, 25(1): 713. doi: 10.1186/s12891-024-07825-z.
19.	Tan L, Tang R, Rong L, et al. The third channel-assisted unilateral biportal endoscopic technique for lumbar spinal stenosis combined with contralateral disc herniation. J Vis Exp, 2023. doi: 10.3791/65262.
20.	Li W, Han J, Xin Q, et al. Finite element mechanical analysis of ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery. J Orthop Surg Res, 2023, 18(1): 979. doi: 10.1186/s13018-023-04476-z.
21.	Kang MS, Hwang JY, Park SM, et al. Comparison of biportal endoscopic and microscopic tubular paraspinal approach for foraminal and extraforaminal lumbar disc herniation. J Neurosurg Spine, 2024, 41(4): 473-482.
22.	Park MK, Son SK, Park WW, et al. Unilateral biportal endoscopy for decompression of extraforaminal stenosis at the lumbosacral junction: Surgical techniques and clinical outcomes. Neurospine, 2021, 18(4): 871-879.
23.	Chen R, Shi B, Zheng X, et al. Anatomic study and clinical significance of the dorsal meningovertebral ligaments of the thoracic dura mater. Spine (Phila Pa 1976), 2015, 40(10): 692-698.

1. Katz JN, Zimmerman ZE, Mass H, et al. Diagnosis and management of lumbar spinal stenosis: a review. JAMA, 2022, 327(17): 1688-1699.
2. Jensen RK, Jensen TS, Koes B, et al. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. Eur Spine J, 2020, 29(9): 2143-2163.
3. Hathi K, Bigney E, Richardson E, et al. Minimally invasive vs. open surgery for lumbar spinal stenosis in patients with diabetes—A canadian spine outcomes and research network study. Global Spine J, 2023, 13(6): 1602-1611.
4. Li X, Liu J, Liu Z. Comparison of the results of open PLIF versus UBE PLIF in lumbar spinal stenosis: postoperative adjacent segment instability is lesser in UBE. J Orthop Surg Res, 2023, 18(1): 543. doi: 10.1186/s13018-023-04038-3.
5. Dhar UK, Menzer EL, Lin M, et al. Open laminectomy vs. minimally invasive laminectomy for lumbar spinal stenosis: a review. Front Surg, 2024, 11: 1357897. doi: 10.3389/fsurg.2024.1357897.
6. 汤玮, 丁兆利, 潘伟, 等. 内镜与开放双侧减压治疗老年腰椎管狭窄症. 中国矫形外科杂志, 2024, 32(16): 1520-1524.
7. Park DK, Weng C, Zakko P, et al. Unilateral biportal endoscopy for lumbar spinal stenosis and lumbar disc herniation. JBJS Essent Surg Tech, 2023, 13(2): e22.00020. doi: 10.2106/JBJS.ST.22.00020.
8. Zhu C, Cheng W, Wang D, et al. A helpful third portal for unilateral biportal endoscopic decompression in patients with cervical spondylotic myelopathy: A technical note. World Neurosurgery, 2022, 161: 75-81.
9. Tian D, Zhu B, Liu J, et al. Contralateral inclinatory approach for decompression of the lateral recess and same-level foraminal lesions using unilateral biportal endoscopy: A technical report. Frontiers in Surgery, 2022, 9: 959390. doi: 10.3389/fsurg.2022.959390.
10. Park SC, Kang MS, Yang JH, et al. How I do it: biportal endoscopic paraspinal approach for recurrent lumbar disc herniation following percutaneous endoscopic lumbar discectomy. Acta Neurochirurgica, 2022, 164(11): 3057-3060.
11. 王玉, 孔清泉, 陈仲强. 再议腰椎管狭窄症. 中国修复重建外科杂志, 2019, 33(7): 789-794.
12. Chiarotto A, Maxwell LJ, Ostelo RW, et al. Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: A systematic review. J Pain, 2019, 20(3): 245-263.
13. Fairbank JC, Pynsent PB. The Oswestry disability index. Spine (Phila Pa 1976), 2000, 25(22): 2940-2952.
14. Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg (Am), 1971, 53(5): 891-903.
15. Park HJ, Kim SS, Lee YJ, et al. Clinical correlation of a new practical MRI method for assessing central lumbar spinal stenosis. Br J Radiol, 2013, 86(1025): 20120180. doi: 10.1259/bjr.20120180.
16. Lee CK, Rauschning W, Glenn W. Lateral lumbar spinal canal stenosis: classification, pathologic anatomy and surgical decompression. Spine, 1988, 13(3): 313-320.
17. 汪文龙, 刘正, 吴四军, 等. 单侧双通道内镜下减压治疗腰椎管狭窄症的早期疗效观察. 中国脊柱脊髓杂志, 2021, 31(10): 911-918.
18. Tang Z, Tan J, Shen M, et al. Comparative efficacy of unilateral biportal and percutaneous endoscopic techniques in unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis. BMC Musculoskelet Disord, 2024, 25(1): 713. doi: 10.1186/s12891-024-07825-z.
19. Tan L, Tang R, Rong L, et al. The third channel-assisted unilateral biportal endoscopic technique for lumbar spinal stenosis combined with contralateral disc herniation. J Vis Exp, 2023. doi: 10.3791/65262.
20. Li W, Han J, Xin Q, et al. Finite element mechanical analysis of ipsilateral approach and contralateral approach in unilateral bilateral endoscopic spine surgery. J Orthop Surg Res, 2023, 18(1): 979. doi: 10.1186/s13018-023-04476-z.
21. Kang MS, Hwang JY, Park SM, et al. Comparison of biportal endoscopic and microscopic tubular paraspinal approach for foraminal and extraforaminal lumbar disc herniation. J Neurosurg Spine, 2024, 41(4): 473-482.
22. Park MK, Son SK, Park WW, et al. Unilateral biportal endoscopy for decompression of extraforaminal stenosis at the lumbosacral junction: Surgical techniques and clinical outcomes. Neurospine, 2021, 18(4): 871-879.
23. Chen R, Shi B, Zheng X, et al. Anatomic study and clinical significance of the dorsal meningovertebral ligaments of the thoracic dura mater. Spine (Phila Pa 1976), 2015, 40(10): 692-698.

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