Complications in Minimally Invasive Cervical Spine Surgery - Tubular, Uniportal, and Biportal Endoscopic Surgery (2013-2024): A Proportional Meta-Analysis.

Study Design:Technical report.Objectives:Dural tear is one of the most common complications of endoscopic spine surgery. Although endoscopic dural repair of the durotomy area may be difficult, we successfully repaired the dural tear area using nonpenetrating clips during biportal endoscopic surgery. We introduce the surgical technique of dural repair using nonpenetrating titanium clips in biportal endoscopic spine surgery and report its clinical outcome.Methods:We retrospectively reviewed and analyzed 5 patients who were treated via primary dural repair using nonpenetrating titanium clips during biportal endoscopic lumbar surgery. The 2 methods of dural clipping and repair include 2 or 3 portals. We analyzed radiological parameters such as cerebrospinal fluid collection as well as clinical parameters, including postoperative clinical outcomes.Results:Five patients underwent biportal endoscopic dural repair using nonpenetrating clips. Incidental durotomy was successfully repaired using nonpenetrating titanium clips in all 5 patients. No cerebrospinal fluid collection was detected in the postoperative magnetic resonance images. Clinically, preoperative symptoms improved significantly after surgery (P < .05).Conclusions:We repaired the dural tear area completely using nonpenetrating titanium vascular anastomosis clips in biportal endoscopic lumbar surgery. Dural repair via clipping method may be an effective alternative for incidental durotomy.

Study DesignSystematic Review and Meta-analysis.ObjectivesLumbar degenerative disease (LDD) is prevalent among aging adults. While tubular retraction is a widely used minimally invasive approach, biportal endoscopic spine surgery has emerged as a potential alternative. This systematic review and meta-analysis compares the clinical outcomes of tubular retraction and biportal endoscopy for decompression procedures (discectomy, laminectomy, laminotomy) and transforaminal lumbar interbody fusion (TLIF) in LDD patients.MethodsA systematic review and meta-analysis of comparative studies was conducted per PRISMA guidelines. A comprehensive search of PubMed, Embase, and Scopus identified relevant studies published before October 7, 2024. Data were analyzed using a random-effects model to assess Oswestry Disability Index (ODI), visual analog scale (VAS) scores for back and leg pain, complication rates, operative time, and length of stay at preoperative, ≤2-weeks postoperative, and ≥1-year postoperative time points.ResultsA total of 772 patients were included (400 tubular, 372 biportal). Biportal endoscopic surgery was associated with a lower complication rate (10.73% vs 15.94%; P < .001) and lower ≤2-week postoperative VAS back pain (2.70 ± 0.27 vs 3.55 ± 0.49; P < .001) relative to tubular spine surgery. Biportal decompression had a lower complication rate (15.13% vs 22.34%; P = .006) but similar patient-reported outcomes. Biportal TLIF had longer operative times (189.93 ± 25.90 vs 145.1 ± 14.90 min; P = .026) but lower complication rates (6.33% vs 9.55%; P = .026) and ≥1-year VAS leg pain (1.88 ± 0.29 vs 2.02 ± 0.26; P < .001).ConclusionsBiportal endoscopy for LDD had lower complication rates and similar patient-reported outcomes relative to tubular retraction, though longer operative times in TLIF subanalysis. Future studies are necessary to validate findings and guide patient-specific decision-making.

This study was the first comprehensive systematic review and meta-analysis to compare clinical outcomes between conventional open surgery and biportal endoscopy for decompression and fusion of lumbar degenerative disease. Although conventional open spine surgery has been the standard approach for decades, biportal endoscopy has gained attention as a minimally invasive alternative with potential surgical outcome benefits. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we performed a systematic review and meta-analysis including eight comparative studies on open and biportal endoscopic spine surgery. A comprehensive search of PubMed, Embase, and Scopus identified studies that reported outcomes, such as the Oswestry Disability Index (ODI), Visual Analog Scale (VAS) scores for back and leg pain, complication rates, operative time, and hospital stay. Data were analyzed using a random effects model to evaluate the effect size between the two approaches. We analyzed 414 open and 383 biportal endoscopic lumbar surgical procedures. The open group had a mean age of 61.0 years and comprised 42.0% men, whereas the biportal group had a mean age of 59.8 years and comprised 46.7% men. Compared with open spine surgery, biportal surgery was associated with a significantly longer operative time but shorter length of hospital stay and similar preoperative VAS scores, ODI score, and postoperative outcomes at <1 month and >1 year. Fusion subgroup analysis showed significantly lower VAS score for back pain with biportal surgery than with open surgery, but the other measures were comparable. Despite its longer operative time, biportal endoscopy led to shorter hospital stay and similar long-term pain and disability outcomes, compared with open spine surgery. Given the significant improvement in short-term leg pain relief after fusion procedures, biportal endoscopic spine surgery is a potential minimally invasive alternative to open surgery that warrants further study.

BackgroundPrevalent endoscopic spine surgeries have shown limitations especially in spinal stenosis (Ahn in Neurosurgery 75(2):124–133, 2014). Biportal endoscopic surgery is introduced to manage central and foraminal stenosis with its wide range of access angle and clear view.MethodsThe authors provide an introduction of this technique followed by a description of the surgical anatomy with discussion on its indications and advantages. In particular, tricks to avoid complications are also presented.ConclusionsEffective circumferential and focal decompression were achieved in most cases without damage to the spinal structural integrity with preservation of muscular and ligamentous attachments. The biportal endoscopic spinal surgery (BESS) may be safely used as an alternative minimally invasive procedure for lumbar spinal stenosis (Figs. 1 and 2).Electronic supplementary materialThe online version of this article (doi:10.1007/s00701-015-2670-7) contains supplementary material, which is available to authorized users.

Review. Unilateral Biportal Endoscopy (UBE) is a minimally invasive surgery that is gaining recognition and being employed in clinical practice. Nevertheless, the precise method for determining UBE portals' location varies depending on the originator's preferences or the anatomical structure's proximity to the portal positions. Consequently, the relationship among UBE portals' locations is messy. This study aims to elaborate on the specific portal localization and explore the positional association and commonality among different UBE approaches' portals. The following keywords are used to search in the PubMed, Ovid, Web of Science, ScienceDirect, SpringerLink, Scopus, CNKI, and Wanfang database: "Biportal endoscopic spinal surgery", "Two portal endoscopic spinal surgery", "Percutaneous biportal endoscopic decompression", "Unilateral biportal endoscopy", "Irrigation endoscopic discectomy", "UBE" and "BESS". After screening, 29 pieces of literature are included. The study summarizes different UBE approach portal localizations, categorized by fusion or non-fusion surgery and pathological classification. The study presents an inaugural method for categorizing the lumber into four surgical intervals based on bone landmarks and assigns different UBE approaches to the appropriate intervals based on their characteristics, making the selection of UBE surgical approaches' portal locations more flexible. Additionally, the study provides an overview of the indications, complications, and distinct benefits associated with each interval, further refining the novel UBE portal interval localization method. The study clarifies the interrelationship and commonality between the portals of different UBE approaches and proposes a new UBE portal interval localization method to enhance surgeons' understanding and proficiency in UBE procedures.

Complications of Unilateral Biportal Endoscopic Lumbar Discectomy: A Systematic Review

There are many types of minimally invasive lumbar interbody fusion procedures. Among them is the recently introduced biportal endoscopic lumbar interbody fusion surgery. Biportal endoscopic transforaminal lumbar interbody fusion (TLIF) might combine the advantages of minimally invasive TLIF and endoscopic spine approaches. However, clinical evidence in support of biportal endoscopic TLIF remains insufficient. A comprehensive review of English-language literature on biportal endoscopic lumbar interbody fusion was performed. Articles on biportal endoscopic TLIF in PubMed, the Cochrane Library, and Web of Science were searched using the terms "unilateral biportal endoscopy," "biportal endoscopic spine surgery," "transforaminal," and "lumbar interbody fusion" as well as their combinations. The clinical and radiological outcomes of biportal endoscopic TLIF were analyzed and are summarized here. The biportal endoscopic lumbar interbody fusion surgical techniques are then described. There are 3 biportal endoscopic TLIF techniques. In the available literature, the postoperative 1-year outcomes of biportal endoscopic TLIF were comparable to those of posterior lumbar interbody fusion (PLIF) and minimally invasive (MIS)-TLIF. Clinical parameters were significantly improved after biportal endoscopic TLIF. Compared to PLIF or MIS-TLIF, biportal endoscopic-TLIF may have the advantage of a faster recovery. Biportal endoscopic TLIF showed no inferiority in fusion rates compared to PLIF or MIS-TLIF. The postoperative complications were usually minor. The postoperative 1-year clinical and radiological outcomes of biportal endoscopic TLIF were favorable compared to those of PLIF and MIS-TLIF. However, long-term outcomes should be investigated through prospective, randomized controlled trials in the future. This review article outlines the most current evidence-based medicine with regard to spinal surgery with an aim to introduce a new technique.

Indications, Contraindications, and Complications of Biportal Endoscopic Decompressive Surgery for the Treatment of Lumbar Stenosis: A Systematic Review

Articles evaluating radiofrequency (RF) safety are insufficient. Thus, the purpose of this study was to investigate RF safety during biportal endoscopic lumbar decompressive laminotomy by measuring epidural temperature after RF use. Both in vitro cadaveric study and in vivo study were performed. The epidural temperature was measured at epidural space after RF use in three cadavers. The epidural temperature was measured and analysed according to RF mode, RF power, RF usage time, and saline irrigation patency. In the in vivo study, the epidural temperature was measured after biportal endoscopic surgery. Epidural temperatures were measured around ipsilateral and contralateral traversing nerve roots after 1-s use of RF. In the in vivo study, epidural space temperature was increased by 0.31 ± 0.16°C ipsilaterally and 0.29 ± 0.09° contralaterally after RF use in coagulation mode 1. The epidural temperature of epidural space was increased by 0.21 ± 0.13°C ipsilaterally and 0.15 ± 0.21°C contralaterally after RF use in high mode 2. In the in vitro study, epidural temperature was significantly increased with a long duration of RF use and a poor patency of irrigation fluid. The use of RF in biportal endoscopic spine surgery might be safe. In order to reduce indirect thermal injuries caused by RF use, it might be necessary to reduce RF use time and maintain continuous saline irrigation patency well.

Systematic review and proportional meta-analysis. To assess total and specific complication rates associated with lumbar biportal endoscopic spine surgery (BESS). In recent years, BESS has emerged as an effective minimally invasive technique for treating lumbar spine conditions, offering benefits such as reduced tissue damage and improved outcomes. However, the safety of BESS across lumbar pathologies is underexplored, with complication rates reported up to 50%. We registered on PROSPERO (CRD42024570377) and systematically searched PubMed, Medline, Embase, and Cochrane Library (Jan 2013-Mar 2024) per PRISMA guidelines. Studies were included if they focused on lumbar BESS in cohorts of at least 10 adult patients and provided extractable complication data. We excluded conference abstracts, reviews, meta-analyses, non-English studies, and those using microendoscopic, lateral, or oblique approaches. A random-effects model was used to pool complication rates, and study quality was assessed using the Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale. Analyses were performed in R Studio. Seventy-five studies with 4404 patients (sample sizes 10-797) were included. Most studies were retrospective and geographically concentrated in China and Korea. Patients ranged from 27.6 to 80 years old, with 51.8% being male, and follow-up durations spanned from 3 to 27.5 months. The overall pooled complication rate for lumbar BESS was 7.75% (95% CI: 5.97%, 10.01%). Specific complication rates included dural tears (2.64%), nerve palsies (1.33%), postoperative hematomas (1.80%), surgical site infections (0.20%), and surgical revisions (1.68%). Total complication rates showed significant heterogeneity (I²=82.0%, P <0.01), while specific complications exhibited low to moderate heterogeneity. Lumbar BESS has a low overall complication rate of 7.75%, with dural tears and nerve palsies being the most common. Results should be interpreted with caution due to significant heterogeneity. Future research should explore risk factors of specific complication types and compare long-term outcomes with traditional methods.

The lack of stereoscopic vision in endoscopic spine surgery may lead to a risk of neural or vascular injury during endoscopic surgery. Three-dimensional (3D) endoscopy has not yet been attempted in the field of spinal endoscopic surgery. To present the technique, clinical efficacy, and safety of the 3D biportal endoscopic approach for the treatment of lumbar degenerative disease. We attempted 3D biportal endoscopic surgery for lumbar degenerative disease in a series of patients. Clinical outcomes and complications were evaluated postoperatively using a short questionnaire about 3D biportal endoscopic spine surgery that solicited respondents' opinions on the advantages and disadvantages of 3D biportal endoscopic surgery compared to the conventional 2D biportal endoscopic approach. We performed 3D biportal endoscopic spine surgery in 38 patients with lumbar degenerative disease. Optimal neural decompression was revealed by postoperative magnetic resonance imaging in all enrolled patients. The 3D endoscopic vision clearly demonstrated the surgical anatomy starting with the exposure of ligamentum flavum, dura, and nerve root, and 3D endoscopy precisely depicted pathologic lesions such as bony osteophytes and ruptured disc herniation. There were no major complications including neural injury or durotomy. The 3D endoscope may be able to distinguish between normal structures and lesions. The stereognosis and depth sensation of 3D biportal endoscopic spinal surgery might have a favorable impact on the safety of patients during endoscopic spine surgery.

BackgroundUnilateral biportal endoscopic (UBE) spine surgery is a minimally invasive procedure for treating lumbar disorders. Hidden blood loss (HBL) is easily ignored by surgeons because blood loss is less visible. However, there are limited studies on HBL in UBE spine surgery. This study aimed to evaluate HBL and its possible risk factors in patients undergoing UBE spine surgery.MethodsPatients with lumbar disc herniation or lumbar spinal stenosis who underwent unilateral biportal endoscopic surgery between December 2020 and February 2022 at our hospital were retrospectively analyzed. Patient demographics, blood loss-related parameters, and surgical and radiological information were also collected. Pearson or Spearman correlation analysis was conducted to determine the association between clinical characteristics and HBL. Multivariate linear regression analysis was used to determine the independent risk factors for HBL.ResultsFifty-two patients (17 males and 35 females) were retrospectively enrolled in this study. The mean total blood loss (TBL) volume was 434 ± 212 ml, and the mean HBL volume was 361 ± 217 ml, accounting for 77.9% of the TBL in patients who underwent UBE surgery. Multivariate linear regression analysis revealed that HBL was positively associated with operation time (P = 0.040) and paraspinal muscle thickness at the target level (P = 0.033).ConclusionsThe amount of HBL in patients undergoing UBE surgery should not be neglected. Operation time and paraspinal muscle thickness at the target level may be independent risk factors for HBL.

History of endoscopic spine surgery: where did it all begin? Development of indications and techniques.

Clinical and radiological outcomes between biportal endoscopic decompression and microscopic decompression in lumbar spinal stenosis

Lumbar disk herniation (LDH) is a common condition affecting millions worldwide. The management of LDH has evolved over the years, with the development of newer surgical techniques that aim to provide better outcomes with minimal invasiveness. One promising emerging technique is biportal endoscopic spinal surgery (BESS), which utilizes specialized endoscopic equipment to treat LDH through two small incisions. This review aims to assess the effectiveness of BESS as a management option for LDH by analyzing the available literature on surgical outcomes and potential complications associated with the technique. Our review shows that BESS is associated with favorable postoperative results as judged by clinical scoring systems, such as visual analog scale, Oswestry disability index, and MacNab criteria. BESS has several advantages over traditional open surgery, including minimized blood loss, a shorter duration of hospitalization, and an expedited healing process. However, the technique has limitations, such as a steep learning curve and practical challenges for surgeons. Our review offers recommendations for the optimal use of BESS in clinical practice, and provides a foundation for future research and development in this field, aiming to improve patient outcomes and quality of life.