Unilateral Biportal Endoscopy for the Treatment of Lumbar Disc Herniation

Summary

Presented here is a step-by-step surgical protocol of unilateral biportal endoscopy (UBE), a minimally invasive approach for treating lumbar disc herniation. By using two ports, surgical accuracy and flexibility are enhanced. This article provides a comprehensive description of UBE and highlights the practical application of this approach in clinical practice.

Abstract

Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery technique increasingly employed in treating degenerative lumbar diseases, such as lumbar disc herniation, lumbar spinal stenosis, and spondylolisthesis. In UBE, two independent yet interconnected surgical channels are established-one for the endoscope and the other for surgical instruments-providing a broad and clear surgical field of view. UBE offers several advantages over traditional open surgery, including reduced tissue damage, shorter hospital stays, and faster recovery times. Additionally, it combines the benefits of microscopic surgery and interlaminar endoscopy, enhancing flexibility, accuracy, and reliability during the procedure. The learning curve for UBE is shorter than that for transforaminal endoscopy, as the surgical processes closely resemble those of conventional open surgery. Despite its favorable clinical outcomes, such as reduced blood loss and shorter hospitalization, UBE carries potential complications, including epidural hematoma, dural injury, and compression of the outlet nerve root. To mitigate these risks, it is crucial to ensure appropriate patient selection, apply the correct surgical technique, and engage in careful postoperative monitoring. This article provides a detailed summary of the step-by-step surgical techniques used in UBE for treating lumbar disc herniation. It serves as a comprehensive guide to enhance practitioners’ understanding of UBE. The presentation also underscores the importance of rigorous training and expertise to ensure optimal patient outcomes.

Introduction

Degenerative disc disease (DDD), also known as lumbar spinal stenosis or herniation, is a prevalent condition affecting the spinal column and stands as the primary reason for spinal surgery, particularly among elderly patients^1,2,3. Standard surgical approaches for addressing lumbar disc herniation and stenosis have historically involved wide laminectomy and decompression surgery^4,5. However, both procedures entail significant trauma, pain, and prolonged recovery times.

In recent years, minimally invasive spinal surgery has gained preference over open spinal surgery due to its associated benefits, including reduced trauma, diminished pain, and faster recovery⁶. Percutaneous endoscopic surgery is a frequently utilized minimally invasive technique, employing an endoscope to operate through small incisions in the skin. While this method offers numerous advantages over traditional surgery, technical challenges may arise, especially in cases of severe stenosis or when bilateral decompression is necessary⁷.

Unilateral double-door endoscopic surgery, initially developed by Campin and Sampson in 1986, has garnered increasing attention^8,9. A crucial innovation in the technique was proposed and documented by D'Antoni in 1996¹⁰, with substantial enhancements resulting from recent advances in double-channel technology^11,12,13. Unilateral biportal endoscopic decompression (UBE) represents a percutaneous endoscopic procedure that allows surgeons to operate without constraints on the size of the working tube or channel. In UBE, two small incisions made on either side of the spinous process facilitate the completion of the operation. The use of a high-definition endoscope, coupled with continuous irrigation using normal saline, ensures a clear view of the surgical field and precise decompression^6,14.

Overall, UBE stands as a significant advancement in the realm of minimally invasive spinal surgery. Its numerous advantages over traditional surgery, such as enhanced precision, reduced tissue trauma, and expedited recovery times, position it as a promising technique for addressing DDD and other spinal conditions. Indeed, studies have reported satisfactory results using UBE for treating DDD¹⁵. As double-channel technology progresses, UBE is poised to become the preferred method among spinal surgeons, aiming to provide their patients with the highest standard of care.

Protocol

This study received approval from the Ethical Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU). Full compliance with ethical standards was consistently observed throughout the study duration. Informed written consent was obtained from all participating patients. The inclusion criteria for patients encompassed lumbar disc herniation and lateral recess stenosis, with the primary clinical presentation being unilateral lower limb neurological symptoms. Conversely, the exclusion cr…

Representative Results

From December 2020 to February 2022, a study assessed the efficacy and safety of unilateral biportal endoscopy (UBE) decompression therapy in treating patients with lumbar disc herniation and lateral recess stenosis. 104 patients (40 males and 64 females) with a mean age of 41.49 ± 16.01 years were enrolled. Of these patients, 81 cases (77.88%) had lumbar disc herniation, while 23 cases (22.12%) had lateral recess stenosis. The study group had an average follow-up period of 15.91 ± 5.69 months, and the mean sur…

Discussion

The conventional standard treatment for lumbar disc herniation is lumbar microscopic discectomy, with a conventional laminectomy, to remove the affected disc⁴. This method poses a risk of postoperative spinal instability and persistent back pain. Percutaneous transforaminal endoscopic discectomy is a minimally invasive technique that limits soft tissue damage and protects the posterior ligamentous complex and other biomechanical systems. Several studies have demonstrated its effectiveness in treat…

Materials

4-0 or 5-0 Polydioxanone	Shandong Weigao Group Medical Polymer Co. , Ltd.	9270504	Their PDS sutures are typically used for soft tissue approximation and ligation.
Electric grinder	Guizhou Zirui Technology Co. , Ltd.	04-14-08	Grinding removes lamina bone and exposes ligamentum flavum tissue
Kerrison Rongeur Forceps	Xi'an Surgical Medical Science and Technology Co. , Ltd.	04-03-03	Used for biting dead bones or repairing bone stumps.
Minimally invasive spinal surgery channel expansion tube	Xi'an Surgical Medical Science and Technology Co. , Ltd.	04-17-13	Used to expand the surgical field of view.
Nerve stripping ion	Xi'an Surgical Medical Science and Technology Co. , Ltd.	04-18-01	Used for stripping or separating nerve root tissue
Periosteal stripping ion	Xi'an Surgical Medical Science and Technology Co. , Ltd.	04-18-01	Used to peel off or separate the periosteum and soft tissue attached to the bone surface.
Plasma Surgical Blade (RF electrode/ablation electrode)	Xi'an Surgical Medical Science and Technology Co. , Ltd.	6825-01-03	Used to ablate soft tissue such as muscle and fascia, or to clot the surface of muscle and nerve tissue
Spinal surgery using nerve hooks	Xi'an Surgical Medical Science and Technology Co. , Ltd.	04-04-01	Used in orthopedic surgery to expose the surgical field of view, or to peel, stretch, or occlude nerve roots during orthopedic surgery.