Early-effectiveness of unilateral biportal endoscopic laminectomy in treatment of two-level lumbar spinal stenosis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Yuhong ¹ , FENG Bo ² , SU Weiliang ¹ , LIU Dong ³ ,  HU Peng ¹ , LU Huaiwang ¹ , GENG Xiaopeng ¹

1. Department of Spinal Surgery, Binzhou Medical University Hospital, Binzhou Shandong, 256603, P. R. China;
2. Department of Neurology, Binzhou Medical University Hospital, Binzhou Shandong, 256603, P. R. China;
3. Department of Traumatic Orthopedics, Binzhou Medical University Hospital, Binzhou Shandong, 256603, P. R. China;

Corresponding author：

HU Peng, Email: qyhupeng@163.com

Keywords：

Unilateral biportal endoscopy technique; lumbar spinal stenosis; decompression; effectiveness

DOI：

10.7507/1002-1892.202302014

Video：

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Objective To analyze the early effectiveness of unilateral biportal endoscopy (UBE) laminectomy in the treatment of two-level lumbar spinal stenosis (LSS). Methods The clinical data of 98 patients with two-level LSS treated with UBE between September 2020 and December 2021 were retrospectively analyzed. There were 53 males and 45 females with an average age of 59.9 years (range, 32-79 years). Among them, there were 56 cases of mixed spinal stenosis, 23 cases of central spinal canal stenosis, and 19 cases of nerve root canal stenosis. The duration of symptoms was 1.5- 10 years, with an average of 5.4 years. The operative segments were L_{2, 3} and L_{3, 4} in 2 cases, L_{3, 4} and L_{4, 5} in 29 cases, L_{4, 5} and L_5, S₁ in 67 cases. All patients had different degrees of low back pain, among of which 76 cases were with unilateral lower extremity symptoms and 22 cases were with bilateral lower extremity symptoms. There were 29 cases of bilateral decompression in both segments, 63 cases of unilateral decompression in both segments, and 6 cases of unilateral decompression and bilateral decompression of each segment. The operation time, intraoperative blood loss, total incision length, hospitalization stay, ambulation time, and related complications were recorded. Visual analogue scale (VAS) score was used to assess the low back and leg pain before operation and at 3 days, 3 months after operation, and at last follow-up. The Oswestry disability index (ODI) was used to evaluate the functional recovery of lumbar spine before operation and at 3 months and last follow-up after operation. Modified MacNab criteria was used to evaluate clinical outcomes at last follow-up. Imaging examinations were performed before and after operation to measure the preservation rate of articular process, modified Pfirrmann scale, disc height (DH), lumbar lordosis angle (LLA), and cross-sectional area of the canal (CAC), and the CAC improvement rate was calculated. Results All patients underwent surgery successfully. The operation time was (106.7±25.1) minutes, the intraoperative blood loss was (67.7±14.2) mL, and the total incision length was (3.2±0.4) cm. The hospitalization stay was 8 (7, 9) days, and the ambulation time was 3 (3, 4) days. All the wounds healed by first intention. Dural tear occurred in 1 case during operation, and mild headache occurred in 1 case after operation. All patients were followed up 13-28 months with an average of 19.3 months, and there was no recurrence or reoperation during the follow-up. At last follow-up, the preservation rate of articular process was 84.7%±7.3%. The modified Pfirrmann scale and DH were significantly different from those before operation (P<0.05), while the LLA was not significantly different from that before operation (P=0.050). The CAC significantly improved (P<0.05), and the CAC improvement rate was 108.1%±17.8%. The VAS scores of low back pain and leg pain and ODI at each time point after operation significantly improved when compared with those before operation, and the differences between each time points were significant (P<0.05). According to the modified MacNab criteria, 63 cases were excellent, 25 cases were good, and 10 cases were fair, with an excellent and good rate of 89.8%. Conclusion UBE laminectomy is a safe and effective technique with little trauma and fast recovery for two-level LSS and the early effectiveness is satisfactory.

Citation： ZHANG Yuhong, FENG Bo, SU Weiliang, LIU Dong, HU Peng, LU Huaiwang, GENG Xiaopeng. Early-effectiveness of unilateral biportal endoscopic laminectomy in treatment of two-level lumbar spinal stenosis. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(6): 706-712. doi: 10.7507/1002-1892.202302014 Copy

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.	张睿, 吴思滨, 张金虎. 腰后路减压植骨融合内固定术治疗老年性多节段腰椎管狭窄症的临床观察. 中国医学创新, 2023, 20(1): 35-38.
3.	刘建军, 朱斌, 陈磊, 等. 单边双通道内镜下椎管减压术和椎板间扩大开窗术治疗腰椎侧隐窝狭窄症的疗效比较. 中华医学杂志, 2022, 102(11): 801-807.
4.	蒋小红, 王辉, 郑亚东, 等. 两种椎体间融合术治疗双节段腰椎管狭窄的比较. 中国矫形外科杂志, 2021, 29(21): 1934-1938.
5.	Tan B, Yang QY, Fan B, et al. Decompression via unilateral biportal endoscopy for severe degenerative lumbar spinal stenosis: A comparative study with decompression via open discectomy. Front Neurol, 2023, 14: 1132698. doi: 10.3389/fneur.2023.1132698.
6.	Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976), 2007, 32(1): 1-8.
7.	Ahn Y. A historical review of endoscopic spinal discectomy. World Neurosurg, 2021, 145: 591-596.
8.	Kim N, Jung SB. Percutaneous unilateral biportal endoscopic spine surgery using a 30-degree arthroscope in patients with severe lumbar spinal stenosis: A technical note. Clin Spine Surg, 2019, 32(8): 324-329.
9.	Aygun H, Abdulshafi K. Unilateral biportal endoscopy versus tubular microendoscopy in management of single level degenerative lumbar canal stenosis: A prospective study. Clin Spine Surg, 2021, 34(6): E323-E328.
10.	Schizas C, Theumann N, Burn A, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine (Phila Pa 1976), 2010, 35(21): 1919-1924.
11.	Griffith JF, Wang YX, Antonio GE, et al. Modified Pfirrmann grading system for lumbar intervertebral disc degeneration. Spine (Phila Pa 1976), 2007, 32(24): E708-E712.
12.	许伟, 李智斐, 余伟波, 等. 精准定位内镜减压治疗多节段腰椎管狭窄症. 中国矫形外科杂志, 2022, 30(1): 5-10.
13.	Ito Z, Shibayama M, Nakamura S, et al. Clinical comparison of unilateral biportal endoscopic laminectomy versus microendoscopic laminectomy for single-level laminectomy: A single-center, retrospective analysis. World Neurosurg, 2021, 148: e581-e588.
14.	Hung SF, Liao JC, Tsai TT, et al. Comparison of outcomes between indirect decompression of oblique lumbar interbody fusion and MIS-TLIF in one single-level lumbar spondylosis. Sci Rep, 2021, 11(1): 12783. doi: 10.1038/s41598-021-92330-9.
15.	Diebo BG, Varghese JJ, Lafage R, et al. Sagittal alignment of the spine: What do you need to know? Clin Neurol Neurosurg, 2015, 139: 295-301.
16.	李子全, 余可谊, 王以朋, 等. 经皮椎间孔入路脊柱内镜下单侧减压治疗腰椎管狭窄症临床疗效及非手术侧下肢症状观察研究. 中国修复重建外科杂志, 2019, 33(7): 831-836.
17.	Zaina F, Tomkins-Lane C, Carragee E, et al. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev, 2016, 2016(1): CD010264. doi: 10.1002/14651858.CD010264.pub2.
18.	张海鸿, 孙正义, 闵坤山, 等. 单节段与双节段腰椎管狭窄对马尾神经影响的实验研究. 中国脊柱脊髓杂志, 1999, (3): 24-26, 64.
19.	Ghogawala Z, Benzel EC, Amin-Hanjani S, et al. Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative Grade Ⅰ spondylolisthesis. J Neurosurg Spine, 2004, 1(3): 267-272.
20.	Untch C, Liu Q, Hart R. Segmental motion adjacent to an instrumented lumbar fusion: the effect of extension of fusion to the sacrum. Spine (Phila Pa 1976), 2004, 29(21): 2376-2381.
21.	Jiang HW, Chen CD, Zhan BS, et al. Unilateral biportal endoscopic discectomy versus percutaneous endoscopic lumbar discectomy in the treatment of lumbar disc herniation: a retrospective study. J Orthop Surg Res, 2022, 17(1): 30. doi: 10.1186/s13018-022-02929-5.
22.	舒鹏, 王智伟, 陈刚. 单侧双通道脊柱内镜下经椎间孔腰椎椎体间融合术治疗单节段Ⅰ、Ⅱ度腰椎滑脱症近期疗效分析. 中国修复重建外科杂志, 2022, 36(10): 1207-1212.
23.	Choi CM, Chung JT, Lee SJ, et al. How I do it? Biportal endoscopic spinal surgery (BESS) for treatment of lumbar spinal stenosis. Acta Neurochir (Wien), 2016, 158(3): 459-463.
24.	Xie X, Zhang G, Liu N. Clinical effect of unilateral biportal endoscopy in the treatment of lumbar diseases: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne, 2022, 17(1): 61-68.
25.	胡宇童, 付豪, 杨东方, 等. 单侧双通道内镜下减压与全椎板切除减压融合内固定治疗重度腰椎管狭窄症的对比研究. 中华医学杂志, 2022, 102(41): 3281-3287.
26.	张海龙, 贺石生, 顾广飞, 等. 通道辅助下多节段腰椎管狭窄症的微创治疗. 中国微创外科杂志, 2014, 14(3): 238-242.
27.	Naserkhaki S, Jaremko JL, El-Rich M. Effects of inter-individual lumbar spine geometry variation on load-sharing: Geometrically personalized Finite Element study. J Biomech, 2016, 49(13): 2909-2917.
28.	Ahuja S, Moideen AN, Dudhniwala AG, et al. Lumbar stability following graded unilateral and bilateral facetectomy: A finite element model study. Clin Biomech (Bristol, Avon), 2020, 75: 105011. doi: 10.1016/j.clinbiomech.2020.105011.
29.	Teo EC, Lee KK, Qiu TX, et al. The biomechanics of lumbar graded facetectomy under anterior-shear load. IEEE Trans Biomed Eng, 2004, 51(3): 443-449.
30.	房格, 王永峰, 原杰, 等. 联合CT参数评估大通道内镜治疗单节段腰椎管狭窄症的安置空间及疗效分析. 中国微创外科杂志, 2022, 22(10): 808-813.
31.	Kim JE, Choi DJ, Park EJJ, et al. Biportal endoscopic spinal surgery for lumbar spinal stenosis. Asian Spine J, 2019, 13(2): 334-342.
32.	Sairyo K, Goel VK, Masuda A, et al. Biomechanical rationale of endoscopic decompression for lumbar spondylolysis as an effective minimally invasive procedure—a study based on the finite element analysis. Minim Invasive Neurosurg, 2005, 48(2): 119-122.
33.	苏保辉, 栾素娴, 孙良智, 等. 单侧双通道内镜治疗双节段腰椎管狭窄症. 中国矫形外科杂志, 2022, 30(16): 1508-1511.
34.	Hong SW, Choi KY, Ahn Y, et al. A comparison of unilateral and bilateral laminotomies for decompression of L₄-L₅ spinal stenosis. Spine (Phila Pa 1976), 2011, 36(3): E172-E178.
35.	Zhang L, Miao HX, Wang Y, et al. Limited unilateral decompression and pedicle screw fixation with fusion for lumbar spinal stenosis with unilateral radiculopathy: A retrospective analysis of 25 cases. J Korean Neurosurg Soc, 2015, 58(1): 65-71.
36.	芦怀旺, 胡鹏, 田霖, 等. 腰椎管狭窄症单侧双通道内镜下单侧与双侧减压比较. 中国矫形外科杂志, 2022, 30(18): 1643-1647.
37.	王志军, 王建峰, 杨斌, 等. 中央椎管狭窄椎间孔镜单侧与双侧减压融合比较. 中国矫形外科杂志, 2021, 29(5): 399-403.
38.	Park HJ, Kim SK, Lee SC, et al. Dural tears in percutaneous biportal endoscopic spine surgery: Anatomical location and management. World Neurosurg, 2020, 136: e578-e585.
39.	Lee HG, Kang MS, Kim SY, et al. Dural injury in unilateral biportal endoscopic spinal surgery. Global Spine J, 2021, 11(6): 845-851.
40.	Kim W, Kim SK, Kang SS, et al. Pooled analysis of unsuccessful percutaneous biportal endoscopic surgery outcomes from a multi-institutional retrospective cohort of 797 cases. Acta Neurochir (Wien), 2020, 162(2): 279-287.

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. 张睿, 吴思滨, 张金虎. 腰后路减压植骨融合内固定术治疗老年性多节段腰椎管狭窄症的临床观察. 中国医学创新, 2023, 20(1): 35-38.
3. 刘建军, 朱斌, 陈磊, 等. 单边双通道内镜下椎管减压术和椎板间扩大开窗术治疗腰椎侧隐窝狭窄症的疗效比较. 中华医学杂志, 2022, 102(11): 801-807.
4. 蒋小红, 王辉, 郑亚东, 等. 两种椎体间融合术治疗双节段腰椎管狭窄的比较. 中国矫形外科杂志, 2021, 29(21): 1934-1938.
5. Tan B, Yang QY, Fan B, et al. Decompression via unilateral biportal endoscopy for severe degenerative lumbar spinal stenosis: A comparative study with decompression via open discectomy. Front Neurol, 2023, 14: 1132698. doi: 10.3389/fneur.2023.1132698.
6. Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976), 2007, 32(1): 1-8.
7. Ahn Y. A historical review of endoscopic spinal discectomy. World Neurosurg, 2021, 145: 591-596.
8. Kim N, Jung SB. Percutaneous unilateral biportal endoscopic spine surgery using a 30-degree arthroscope in patients with severe lumbar spinal stenosis: A technical note. Clin Spine Surg, 2019, 32(8): 324-329.
9. Aygun H, Abdulshafi K. Unilateral biportal endoscopy versus tubular microendoscopy in management of single level degenerative lumbar canal stenosis: A prospective study. Clin Spine Surg, 2021, 34(6): E323-E328.
10. Schizas C, Theumann N, Burn A, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine (Phila Pa 1976), 2010, 35(21): 1919-1924.
11. Griffith JF, Wang YX, Antonio GE, et al. Modified Pfirrmann grading system for lumbar intervertebral disc degeneration. Spine (Phila Pa 1976), 2007, 32(24): E708-E712.
12. 许伟, 李智斐, 余伟波, 等. 精准定位内镜减压治疗多节段腰椎管狭窄症. 中国矫形外科杂志, 2022, 30(1): 5-10.
13. Ito Z, Shibayama M, Nakamura S, et al. Clinical comparison of unilateral biportal endoscopic laminectomy versus microendoscopic laminectomy for single-level laminectomy: A single-center, retrospective analysis. World Neurosurg, 2021, 148: e581-e588.
14. Hung SF, Liao JC, Tsai TT, et al. Comparison of outcomes between indirect decompression of oblique lumbar interbody fusion and MIS-TLIF in one single-level lumbar spondylosis. Sci Rep, 2021, 11(1): 12783. doi: 10.1038/s41598-021-92330-9.
15. Diebo BG, Varghese JJ, Lafage R, et al. Sagittal alignment of the spine: What do you need to know? Clin Neurol Neurosurg, 2015, 139: 295-301.
16. 李子全, 余可谊, 王以朋, 等. 经皮椎间孔入路脊柱内镜下单侧减压治疗腰椎管狭窄症临床疗效及非手术侧下肢症状观察研究. 中国修复重建外科杂志, 2019, 33(7): 831-836.
17. Zaina F, Tomkins-Lane C, Carragee E, et al. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev, 2016, 2016(1): CD010264. doi: 10.1002/14651858.CD010264.pub2.
18. 张海鸿, 孙正义, 闵坤山, 等. 单节段与双节段腰椎管狭窄对马尾神经影响的实验研究. 中国脊柱脊髓杂志, 1999, (3): 24-26, 64.
19. Ghogawala Z, Benzel EC, Amin-Hanjani S, et al. Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative Grade Ⅰ spondylolisthesis. J Neurosurg Spine, 2004, 1(3): 267-272.
20. Untch C, Liu Q, Hart R. Segmental motion adjacent to an instrumented lumbar fusion: the effect of extension of fusion to the sacrum. Spine (Phila Pa 1976), 2004, 29(21): 2376-2381.
21. Jiang HW, Chen CD, Zhan BS, et al. Unilateral biportal endoscopic discectomy versus percutaneous endoscopic lumbar discectomy in the treatment of lumbar disc herniation: a retrospective study. J Orthop Surg Res, 2022, 17(1): 30. doi: 10.1186/s13018-022-02929-5.
22. 舒鹏, 王智伟, 陈刚. 单侧双通道脊柱内镜下经椎间孔腰椎椎体间融合术治疗单节段Ⅰ、Ⅱ度腰椎滑脱症近期疗效分析. 中国修复重建外科杂志, 2022, 36(10): 1207-1212.
23. Choi CM, Chung JT, Lee SJ, et al. How I do it? Biportal endoscopic spinal surgery (BESS) for treatment of lumbar spinal stenosis. Acta Neurochir (Wien), 2016, 158(3): 459-463.
24. Xie X, Zhang G, Liu N. Clinical effect of unilateral biportal endoscopy in the treatment of lumbar diseases: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne, 2022, 17(1): 61-68.
25. 胡宇童, 付豪, 杨东方, 等. 单侧双通道内镜下减压与全椎板切除减压融合内固定治疗重度腰椎管狭窄症的对比研究. 中华医学杂志, 2022, 102(41): 3281-3287.
26. 张海龙, 贺石生, 顾广飞, 等. 通道辅助下多节段腰椎管狭窄症的微创治疗. 中国微创外科杂志, 2014, 14(3): 238-242.
27. Naserkhaki S, Jaremko JL, El-Rich M. Effects of inter-individual lumbar spine geometry variation on load-sharing: Geometrically personalized Finite Element study. J Biomech, 2016, 49(13): 2909-2917.
28. Ahuja S, Moideen AN, Dudhniwala AG, et al. Lumbar stability following graded unilateral and bilateral facetectomy: A finite element model study. Clin Biomech (Bristol, Avon), 2020, 75: 105011. doi: 10.1016/j.clinbiomech.2020.105011.
29. Teo EC, Lee KK, Qiu TX, et al. The biomechanics of lumbar graded facetectomy under anterior-shear load. IEEE Trans Biomed Eng, 2004, 51(3): 443-449.
30. 房格, 王永峰, 原杰, 等. 联合CT参数评估大通道内镜治疗单节段腰椎管狭窄症的安置空间及疗效分析. 中国微创外科杂志, 2022, 22(10): 808-813.
31. Kim JE, Choi DJ, Park EJJ, et al. Biportal endoscopic spinal surgery for lumbar spinal stenosis. Asian Spine J, 2019, 13(2): 334-342.
32. Sairyo K, Goel VK, Masuda A, et al. Biomechanical rationale of endoscopic decompression for lumbar spondylolysis as an effective minimally invasive procedure—a study based on the finite element analysis. Minim Invasive Neurosurg, 2005, 48(2): 119-122.
33. 苏保辉, 栾素娴, 孙良智, 等. 单侧双通道内镜治疗双节段腰椎管狭窄症. 中国矫形外科杂志, 2022, 30(16): 1508-1511.
34. Hong SW, Choi KY, Ahn Y, et al. A comparison of unilateral and bilateral laminotomies for decompression of L₄-L₅ spinal stenosis. Spine (Phila Pa 1976), 2011, 36(3): E172-E178.
35. Zhang L, Miao HX, Wang Y, et al. Limited unilateral decompression and pedicle screw fixation with fusion for lumbar spinal stenosis with unilateral radiculopathy: A retrospective analysis of 25 cases. J Korean Neurosurg Soc, 2015, 58(1): 65-71.
36. 芦怀旺, 胡鹏, 田霖, 等. 腰椎管狭窄症单侧双通道内镜下单侧与双侧减压比较. 中国矫形外科杂志, 2022, 30(18): 1643-1647.
37. 王志军, 王建峰, 杨斌, 等. 中央椎管狭窄椎间孔镜单侧与双侧减压融合比较. 中国矫形外科杂志, 2021, 29(5): 399-403.
38. Park HJ, Kim SK, Lee SC, et al. Dural tears in percutaneous biportal endoscopic spine surgery: Anatomical location and management. World Neurosurg, 2020, 136: e578-e585.
39. Lee HG, Kang MS, Kim SY, et al. Dural injury in unilateral biportal endoscopic spinal surgery. Global Spine J, 2021, 11(6): 845-851.
40. Kim W, Kim SK, Kang SS, et al. Pooled analysis of unsuccessful percutaneous biportal endoscopic surgery outcomes from a multi-institutional retrospective cohort of 797 cases. Acta Neurochir (Wien), 2020, 162(2): 279-287.

Chinese Journal of Reparative and Reconstructive Surgery

Early-effectiveness of unilateral biportal endoscopic laminectomy in treatment of two-level lumbar spinal stenosis

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