Bi-portal Arthroscopic Spinal Surgery (BASS) with 30° arthroscopy for far lateral approach of L5-S1 – Technical note

doi:10.1016/j.jor.2018.01.034

Journal of Orthopaedics

Volume 15, Issue 2, June 2018, Pages 354-358

https://doi.org/10.1016/j.jor.2018.01.034 Get rights and content

Abstract

Background context

Lumbar foraminal stenosis or extraforaminal stenosis is a common cause of spinal cord radiculopathy. Recently, several authors have introduced an endoscopy-based spinal surgery technique.

Purpose

The study aimed to introduce far lateral approach of biportal arthroscopic technique using 30° arthroscopy for foraminal decompression of L5-S1.

Study design

Technical note.

Patient sample

12 consecutive patients.

Outcome measures

The leg VAS with modified Macnab criteria was measured.

Result

The leg VAS improved from VAS 7.5 to 1.8.

Conclusion

Far lateral approach of BASS with 30° arthroscopy is an alternative method that can decompress foraminal stenosis minimally invasively.

Introduction

Degenerative lumbar spinal stenosis is one of the most common diseases of the spine. Lumbar foraminal stenosis, or extraforaminal stenosis, is a common cause of spinal cord radiculopathy with a frequency of about 8–11%. It is caused by ligamentous and osseous structure hypertrophy, therefore, causing the canal space of the exiting nerve root to become narrower.1, 2, 3, 4 In addition, a decrease in intervertebral disc height also causes a decrease in the dimension of the canal space. Several techniques including partial pediculectomy, fusion, foraminotomy, and facetectomy have been introduced to solve this problem. There are currently two major surgical treatment options for this disease: one is decompression with fusion and the other is simple decompression.5, 6, 7 The micro decompression technique to protect facet joints without fusion was first introduced by Wiltse and Spencer, several authors have modified it, and has since been modified by several authors. This operation improved the conditions of about 80% of patients and is considered to be a good surgical treatment for lumbar foraminal stenosis or far lateral stenosis. Alternatively, interbody fusion surgery can definitively expand the intervertebral space to resolve foraminal stenosis without foraminotomy.⁷ However, fusion surgery may cause complications such as adjacent segment disease and pseudoarthrosis.8, 9, 10 Thus, several authors introduced the decompression of foraminal stenosis using uniportal endoscopy of the docking type,2, 3 At the L5-S1 level, the disadvantage is that proper decompression is not possible due to the difficulty of access created by the prominence of iliac crest. Recently, biportal arthroscopic spinal surgery has been reported by several authors,11, 12, 13 and has started to get spotlighted. The literature on the far lateral approach of biportal endoscopy is still lacking. In this report, we would like to introduce far lateral approach of biportal arthroscopic spinal surgery using 30° arthroscopy as an alternative to open surgery for L5-S1 foraminal stenosis without instability and central stenosis.

Section snippets

Material and methods

12 consecutive patients were involved in this study. Preoperative lumbar plain x-ray including flexion extension view, CT, and MRI were checked in all patients. These patients were diagnosed with foraminal stenosis at L5-S1. Patients who did not respond to conservative treatment including medication and physiotherapy despite 6 weeks of conservative treatment were involved. The clinical outcomes including Modified Macnab criteria, VAS, operation time, and complication rate were analyzed from

Result

The mean operation time was 55 min (range: 45–70). There were no infections, dura tears, or neurologic complications. Of the 12 cases, 8 cases were on the left side and 4 were on the right side. The mean leg VAS of patients improved from 7.5 to 1.8 after surgery. At the final follow-up, all twelve cases were recorded with excellent on the Modified Macnab criteria.

Discussion

Open decompression surgery using the Wilte approach is a conventional treatment for extraforaminal or foraminal stenosis.¹⁴ Open microforamotomy reports a success rate of 58%–80% and is reported to have poor outcomes compared to other spinal surgeries.¹⁵ However, excessive dissection of the paraspinal muscle may cause back pain or muscle atrophy. Minimal invasive technique using endoscopy has been attempted by several authors in extraforaminal or foraminal decompression. Recent advances in

Conclusion

The biportal arthroscopic decompression of the foraminal stenosis of L5-S1 using 30° arthroscopy was first described in this article. Far lateral approach of biportal arthroscopic spinal surgery with 30° arthroscopy is an alternative minimally invasive method that can decompress foraminal stenosis.

Conflict of interest

None.

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Percutaneous endoscopic lumbar foraminotomy: an advanced surgical technique and clinical outcomes
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Laminal fenestration for the treatment of lumbar nerve root foraminal stenosis
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Risk factor for unsatisfactory outcome after lumbar foraminal and far lateral microdecompression
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Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis
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Cited by (28)

Biportal Endoscopic Spine Surgery: Clinical Results for 163 Patients
2023, World Neurosurgery
Biportal endoscopy spine surgery is an endoscopic procedure that uses 2 portals, 1 for the endoscope and 1 for the instruments. It provides an excellent and very versatile field of view, with the advantage of another portal to approach the most common degenerative lumbar pathologies.
We evaluated a retrospective series of patients who underwent biportal endoscopy with ≥1 year of follow-up. Relevant epidemiological and clinical data, such as the Oswestry disability index and visual analog scale for pain, were also considered. Complications and the effects of the learning curve are also discussed.
We included 163 patients treated within a 5-year period with ≥1 year of follow-up available. The main pathologies were disc herniation (53.4%), foraminal stenosis (19%), and central canal stenosis (16.6%). The outcomes regarding disability and pain scores after surgery were very good, with a redistribution of the patient sample to the mild categories of disability. Inferential analysis showed relative and absolute improvements for both disc herniation and canal stenosis in terms of the Oswestry disability index and visual analog scale for pain, especially for disc herniation. The incidence of complications was approximately 7%. The most common approach was interlaminar (89%), and the most common pathology was disc herniation (54.9%). The duration of surgery overall and for the different stages had improved at the end of the learning curve with a reduction of almost 58 minutes.
Biportal endoscopy is a minimally invasive procedure that is safe and effective, with a low rate of complications. It has a reproducible learning curve and provides very good outcomes regarding functionality and pain scores.
Indications, Contraindications, and Complications of Biportal Endoscopic Decompressive Surgery for the Treatment of Lumbar Stenosis: A Systematic Review
2022, World Neurosurgery
Citation Excerpt :
Finally, 41 articles were selected for analysis (Figure 1)1,2,5-43 comprising 25 articles that were related to lumbar central or lateral recess stenosis, 8 related to lumbar foraminal or extraforaminal stenosis, and 8 related to the complications of the biportal endoscopic approach. The biportal endoscopic approach has been successfully used to treat lumbar central or lateral recess stenosis (23 articles), central stenosis with lipomatosis (1 article),19 lumbar foraminal and extraforaminal stenosis (6 articles), and the far-out syndrome (2 articles, extraforaminal entrapment of the L5 nerve root by lumbosacral transitional vertebrae) (Figure 2)6,7,9-11,19-24,28,30,32,35,40,42,44 Therefore, these stenotic lesions were considered the most favorable indications for the biportal endoscopic approach (Table 1). Traumatic lesions, infections, tumors, musculoskeletal disorders, instability, high-grade spondylolisthesis, isthmic spondylolisthesis, and severe scoliosis (deformity) were contraindications to biportal endoscopic decompressive surgery (Table 1).1,2,6,9,14,20,28,30
Biportal endoscopic spine surgery is gaining popularity in managing degenerative lumbar diseases and has optimal indications and contraindications. The perioperative complications related to the biportal endoscopic approach affect the postoperative outcomes. Therefore, this study aimed to review the indications, contraindications, and complications of biportal endoscopic decompression for lumbar stenosis.
For this systematic review, articles on biportal endoscopic decompressive surgery for lumbar stenosis, including central, lateral recess and foraminal stenoses, were searched for and reviewed. Additionally, the complications, indications, and contraindications of biportal endoscopic surgery for lumbar stenosis were reviewed.
Forty-one articles were included in this study. The indications for biportal endoscopic decompression are central lumbar stenosis, central stenosis with lipomatosis, lateral recess stenosis, foraminal stenosis, and the far-out syndrome. The contraindications include trauma, infection, tumor, instability, high-grade spondylolisthesis, isthmic spondylolisthesis, and severe scoliosis. Perioperative complications are typically minor; major complications include durotomy, epidural hematoma, incomplete decompression, infection, facet joint injury, neural injury, increased epidural pressure, and postoperative instability.
Favorable indications for a biportal endoscopic approach are central lumbar, lateral recess, foraminal, extraforaminal stenoses, and the Bertolotti syndrome. Incidental durotomy and postoperative epidural hematomas are common complications of biportal endoscopic decompression.
Comparison of Unilateral Biportal Endoscopic Discectomy with Other Surgical Technics: A Systemic Review of Indications and Outcomes of Unilateral Biportal Endoscopic Discectomy from the Current Literature
2022, World Neurosurgery
Citation Excerpt :
The research yielded 35 primary articles from 4 electronic databases. Of these articles, 20 were excluded by the investigators, and 15 passed the title and abstract screening process.19-39 Five articles included both herniated disc and stenosis cases.23,30,32,36,37
Unilateral biportal endoscopic (UBE) spine surgery for spinal diseases has been increasing in popularity because of its favorable outcomes. The goal of this systemic review is to analyze the status of outcomes and complications in lumbar disc herniation during UBE discectomy.
A comprehensive search of the PubMed, Embase, Web of Science, and OVID databases published until June 30, 2021, was performed. The outcomes of interest were indications, operative time, blood loss, hospital stay, complications, visual analog scale score, and Oswestry Disability Index.
Seven studies were included in our research. UBE surgery for lumbar stenosis was excluded. A total of 230 patients with lumbar disc herniation were enrolled in the 7 selected studies. The mean operative time was 74.4 minutes, and the mean length of hospital stay was 4.5 days. Mean incidence of complications reported in the 7 articles was 6.2%. UBE showed shorter hospital stays than did microdiscectomy, no significant differences of Oswestry Disability Index or visual analog scale scores, and good recovery rate among other discectomy techniques (microdiscectomy, full endoscopic transforaminal endoscopic lumbar discectomy, and interlaminar endoscopic lumbar discectomy) at 1 month follow-up.
Even with the small number of studies and reports analyzed, biases were the main limitation of this analysis; overall, the clinical outcomes and complication rates associated with UBE discectomy were relatively good. It is clear that UBE discectomy is a good treatment choice for lumbar disc herniation, but to prevent unique UBE surgery complications, a clear understanding of the surgical procedures and careful efforts to overcome the learning curve are necessary.
A Helpful Third Portal for Unilateral Biportal Endoscopic Decompression in Patients with Cervical Spondylotic Myelopathy: A Technical Note
2022, World Neurosurgery
Unilateral biportal endoscopic (UBE) laminotomy with bilateral decompression is a high-risk operation when performed in the cervical spine. In this study, we aimed to design an auxiliary portal for treatment of cervical spondylotic myelopathy using a percutaneous biportal endoscopic approach.
Six patients with cervical spondylotic myelopathy were consecutively treated using an auxiliary portal (Zhang’s portal) during percutaneous biportal endoscopic surgery between June 2020 and July 2021. Clinical outcomes were assessed by comparing preoperative and postoperative Japanese Orthopaedic Association scores and status based on modified Macnab criteria.
The study enrolled 6 patients (2 men and 4 women; mean age, 51.6 ± 10.8 years). The mean operative time was 78.6 ± 37.4 minutes. There were no cases of infection, cerebrospinal fluid leakage, or neurological complications. The mean Japanese Orthopaedic Association score improved from 7.5 to 12.1. At final follow-up, outcomes were considered excellent for all patients based on modified Macnab criteria.
Zhang’s portal can allow for safe, flexible, and convenient contralateral decompression without the need to remove excessive portions of bone from the spinous process. Our results suggest that applying Zhang’s portal in unilateral biportal endoscopy surgery represents an alternative when aiming to decompress the contralateral canal in patients with cervical spondylotic myelopathy caused by hypertrophy of the ligamentum flavum.
Clinical Comparison of Unilateral Biportal Endoscopic Laminectomy versus Microendoscopic Laminectomy for Single-Level Laminectomy: A Single-Center, Retrospective Analysis
2021, World Neurosurgery
Citation Excerpt :
This study shows that UBEL was superior to MEL in the bone resection area and the facet preservation rate, and that UBEL produced excellent results although no significant difference in complications were indicated. There have been numerous reports on UBE, including those on its application to the decompression of lumbar spinal canal stenosis; removal of lumbar disc herniation; removal of foraminal stenosis; and lumbar interbody fusion—all of which produce results as excellent as conventional methods.10-15 As for image evaluation, Heo et al.9 reported the significantly higher facet preservation rate of UBEL compared with those of uniportal endoscopy and microsurgery.
The purpose of this study was to compare clinical results of microendoscopic laminectomy (MEL) with those of unilateral biportal endoscopic laminectomy (UBEL) in patients with single-level lumbar spinal canal stenosis.
The subjects consisted of 181 patients who underwent MEL (139 cases) and UBEL (42 cases) who were followed up for at least 6 months. All patients had lumber canal stenosis for 1 level. Outcomes of the patients were assessed with the duration of surgery, the bone resection area in 3-dimensional computed tomography, the facet preservation rates in computed tomography axial imagery, Visual Analog Scale (VAS) for low back pain, the Oswestry Disability Index, and the EuroQol 5-Dimensions questionnaire.
The bone resection area in 3-dimensional computed tomography was 1.5 for MEL versus 1.0 cm² for UBEL (P < 0.05). The facet preservation rates on the advancing side and the opposite side were 78% versus 86% (advancing side: MEL vs. UBEL) and 85% versus 94% (opposite side) (P < 0.05). The VAS (low back pain) score, VAS (leg pain), Oswestry Disability Index, and EuroQol 5-Dimension questionnaire significantly dropped in both groups at the final period (P < 0.05), however, exhibiting no difference between the 2 groups at each period. MEL resulted in greater numbers of complications, including 5 cases of hematoma paralysis, 8 cases of dura injury, 2 cases of reoperation, as opposed to zero cases of hematoma paralysis and only 2 cases of dura injury resulting from UBEL.
The UBEL method is a more useful technique than the MEL method as it requires a smaller bone resection area and produces fewer complications.
Evaluation of Postoperative Spinal Epidural Hematoma After Biportal Endoscopic Spine Surgery for Single-Level Lumbar Spinal Stenosis: Clinical and Magnetic Resonance Imaging Study
2019, World Neurosurgery
Citation Excerpt :
Minimally invasive spinal surgery is becoming increasingly important, with the advantages of lower morbidity and less tissue trauma. Biportal endoscopic spinal surgery (BESS) has been introduced by several investigators since 2015.19-22 BESS is a technique of performing decompression by using 2 portals, inserting an endoscope on one side and surgical instruments on the other side.
Symptomatic postoperative spinal epidural hematoma is a serious complication that may occur after lumbar spine surgery. We analyzed epidural hematoma using postoperative magnetic resonance imaging (MRI) after biportal endoscopic spinal surgery and its impact on clinical outcome.
The subjects of this study were 158 patients who underwent single-level decompression using the biportal endoscopic spinal surgery technique from 2015 to 2017. MRI was performed in all patients before and after surgery, and postoperative MRI was used to identify epidural hematoma. The preoperative and postoperative visual analog scale (VAS) score for leg and back pain, Oswestry Disability Index (ODI), and modified Macnab criteria were recorded for evaluation of clinical outcome. The group with postoperative spinal epidural hematoma (group A) and without hematoma (group B) were comparatively analyzed, both radiologically and clinically.
The mean age of the patients was 67.9 ± 11.1 years (range, 49–89). The total number with grade 0 (no hematoma) was 119 levels patients (75.3%) on the T2 axial image of postoperative MRI. The total number of patients with hematoma was 39 (24.7%) according to T2-weighted axial postoperative MRI. Two patients underwent revision surgery because of hematoma-related symptoms. The improvement of clinical outcome measures including VAS leg, VAS back, and ODI was significantly different between group A and B (P < 0.05).
The incidence of postoperative spinal epidural hematoma after biportal endoscopic spinal surgery according to postoperative MRI was higher than expected, regardless of the patients' postoperative symptoms. Postoperative hematoma has a decisive influence on postoperative results, and revision surgery might be necessary if canal encroachment is >50% with concomitant symptoms.

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Bi-portal Arthroscopic Spinal Surgery (BASS) with 30° arthroscopy for far lateral approach of L5-S1 – Technical note

Abstract

Background context

Purpose

Study design

Patient sample

Outcome measures

Result

Conclusion

Introduction

Section snippets

Material and methods

Result

Discussion

Conclusion

Conflict of interest

Spine update. Lumbar foraminal stenosis

Spine

Outside-in technique, clinical results, and indications with transforaminal lumbar endoscopic surgery: a retrospective study on 220 patients on applied radiographic classification of foraminal spinal stenosis

Int J Spine Surg

Percutaneous endoscopic lumbar foraminotomy: an advanced surgical technique and clinical outcomes

Neurosurgery

Laminal fenestration for the treatment of lumbar nerve root foraminal stenosis

Br J Neurosurg

Risk factor for unsatisfactory outcome after lumbar foraminal and far lateral microdecompression

Spine

Foraminal stenosis and single-level degenerative disc disease: a randomized controlled trial comparing decompression with decompression and instrumented fusion

Spine

Comparative observational study of surgical outcomes of lumbar foraminal stenosis using minimally invasive microsurgical extraforaminal decompression alone versus posterior lumbar interbody fusion: a prospective cohort study

Eur Spine J

Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis

Spine