Abstract
Background
The biportal endoscope-assisted unilateral foraminal approach is an option for various foraminal pathologies. Lumbar interbody fusion is the standard treatment for foraminal stenosis because both direct and indirect neural decompressions can be obtained.
Method
We used the biportal endoscopic technique for extraforaminal lumbar interbody fusion (BE-EFLIF) and have described the steps, with discussion regarding the indications, advantages, possible complications, and ways to overcome complications.
Conclusion
BE-EFLIF achieves direct neural decompression of lateral spinal canal under endoscopic visualization. It achieves indirect neural decompression using a large footprint lordotic interbody cage, while preserving the lumbar posterior arch as much as possible.
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Acknowledgments
We would like to thank Editage (www.editage.co.kr) for English language editing.
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Authors and Affiliations
Contributions
MSK and HJP contributed to the conception of the study. MSK, HJJ, and HJP wrote the manuscript. HJC and HJP reviewed the manuscript. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
This study protocol was approved by the Hallym University Institutional Review Board (IRB file no. IRB FILE No. 2020-03-014-001) and adhered to the guidelines of the Declaration of Helsinki.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Additional information
Key Points
BE-EFLIF is a minimally invasive alternative to conventional lumbar instrumented fusion for obtaining both direct and indirect neural decompression sufficiently while preserving facet joints as much as possible.
BE-EFLIF is performed on the same surgical anatomy as the biportal endoscopic technique for paraspinal approach in the prone position.
Unlike microscope-assisted EFLIF, it does not require the paravertebral muscle traction and operation table tilt.
In partial lateral facetectomy, it is relatively easy to remove the internally overgrown SAP and it helps to achieve sufficient neural decompression of the lateral recess.
Using a total of three surgical ports up to the Q port provides various angles of surgical visualization and enables the more dynamic handling of surgical instruments.
Using a nerve protector through additional ports can prevent excessive traction or crushing injury, especially during the interbody cage implantation process.
Moreover, the flexible use of the three surgical ports has great advantages in performing the process of implantation of the interbody cage and aligning it to the appropriate position.
An interbody cage with long (≥ 32 mm of length), lordotic, and large footprints may be used, and the interbody cage may be placed on one side of the dense apophyseal ring of the endplate.
Inserting a surgical drain into the Q portal allows for essentially avoiding the interference of the surgical drain when performing pedicle screw fixation.
It is expected to be a more useful indication in the vertical foraminal stenosis with severe disc height loss and peridural fibrosis after previous decompressive laminectomy.
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Kang, MS., Chung, HJ., Jung, HJ. et al. How I do it? Extraforaminal lumbar interbody fusion assisted with biportal endoscopic technique. Acta Neurochir 163, 295–299 (2021). https://doi.org/10.1007/s00701-020-04435-1
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DOI: https://doi.org/10.1007/s00701-020-04435-1