Biportal Endoscopic Technique for Transforaminal Lumbar Interbody Fusion: Review of Current Research

Min-Seok Kang; Dong Hwa Heo; Hyoung-Bok Kim; Heung-Tae Chung

doi:10.14444/8167

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Figure 1
Overview of the biportal endoscopic approach for lumbar interbody fusion.
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Figure 2
Location of the surgical portals for biportal endoscopic transforaminal lumbar interbody fusion using (A) the modified posterolateral approach, (B) the posterolateral approach, and (C) the extraforaminal approach. P(L): The cranial endoscopic portal located above the pedicle in the posterolateral approach. P(R): The caudal working portal located above the pedicle in the posterolateral approach. C: Additional portal for large interbody cage insertion in the modified far-lateral transforaminal approach. D(L): The cranial endoscopic portal located above the intervertebral disc in the modified posterolateral approach. S: Window for pedicle screw insertion in the modified far-lateral transforaminal approach. P+2(L): The cranial endoscopic portal located 2 cm from the outer lateral interpedicular line in the extraforaminal approach. P+2(R): The caudal working portal located 2 cm from the outer lateral interpedicular line in the extraforaminal approach. Q: Assistance portal located at the cross-section of the medial interpedicular line and the intervertebral disc line.
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Figure 3
Two surgical corridors for biportal endoscopic transforaminal lumbar interbody fusion: (A) the posterolateral approach and (B) the trans-Kambin approach.
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Figure 4
Optimization of the surgical field of view in biportal endoscopic lumbar interbody fusion surgery. Based on this, (A) sufficient contralateral sublaminar decompression, (B) ipsilateral total facetectomy, and (C) endplate preparation are possible.
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Figure 5
Biportal endoscopic transforaminal lumbar interbody fusion through a posterolateral approach (Video 1). A 62-year-old female patient complained of bilateral radicular leg pain with back pain. Preoperative x-ray (A) and magnetic resonance imaging (B, C) depicted grade 2 degenerative spondylolisthesis with central stenosis of L4-5. We performed biportal endoscopic transforaminal lumbar interbody fusion at the L4-5 area. Postoperatively, the patient’s radicular pain was significantly improved. Postoperative magnetic resonance imaging and x-ray (D, E, F, G) revealed good reduction of spondylolisthesis and complete decompression of the central canal at L4-5.
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Figure 6
Case of modified far-lateral biportal endoscopic transforaminal lumbar interbody fusion. A 64-year-old male patient presented with bilateral leg pain and claudication. Preoperative x-ray showed isthmic spondylolisthesis of L4-5 (A). We performed modified far-lateral biportal endoscopic transforaminal lumbar interbody fusion at the L4-5 area. Two skin incisions over the pedicles were used for the endoscopic portal and the working portal (B, black lines). An additional lateral skin incision was used for cage insertion (B, white line). A large cage was inserted at L4-5 (C, D). After surgery, spondylolisthesis (E) was well resolved on the postoperative magnetic resonance imaging (F). A large cage was inserted at the L4-5 level (E, G). The intraoperative endoscopic image showed the transverse position of a large cage (H).

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Table

Summary of publications on biportal endoscopic transforaminal lumbar interbody fusion.

Authors	Study Design	No. of Cases (M/F)	Follow-Up (Months)	Clinical Outcomes	Complication Rate	Fusion Rate
Heo et al²⁰	Case series	69 (24/45)	12	Improved VAS and ODI	5 cases (7.2%)	No information
Kim et al²²	Case series	14 (6/8)	2	Improved VAS	2 cases (14.3%)	No information
Heo et al²¹	Case- control	BE-TLIF: 23 (7/16)	12	Improved VAS and ODI	BE-TLIF:1 case (4.3%)	BE-TLIF: 78.3% (x-ray)
Heo et al²¹	Case- control	MIS-TLIF: 45 (19/27)	12	Improved VAS and ODI	MIS-TLIF: 6 cases (13.0%)	MIS-TLIF: 73.9% (x-ray)
Park et al²³	Case- control	BE-TLIF: 71 (26/45)	12	Improved VAS and ODI	BE- TLIF: 5 cases (7.0%)	BE- TLIF: 95.1% (x-ray)
Park et al²³	Case- control	Open PLIF: 70 (20/50)	12	Improved VAS and ODI	MIS-TLIF: 6 cases (8.6%)	MIS-TLIF: 90.0% (x-ray)
Quillo-Olvera et al²⁴	Case series	7 (3/4)	9	Improved VAS and ODI	0 cases (0%)	No information
Kim et al¹⁷	Case- control	BE-TLIF: 32 (17/15)	12	Improved VAS and ODI	Endoscopic TLIF: 2 cases (6.3%)	BE-TLIF: 93.7% (x-ray)
Kim et al¹⁷	Case- control	MIS-TLIF: 55 (25/30)	12	Improved VAS and ODI	MIS-TLIF: 3 cases (5.5%)	MIS-TLIF: 92.7% (x-ray)
Kang et al²⁵	Case-control	BE-TLIF: 47 (17/30)	12	Improved VAS, ODI, and SF-36	BE-TLIF: 6 cases (12.8%)	BE-TLIF: 81.8% (x-ray and CT)
Kang et al²⁵	Case-control	MIS-TLIF: 32 (17/15)	12	Improved VAS, ODI, and SF-36	MIS-TLIF: 5 cases (15.6%)	MIS-TLIF: 88.4% (x-ray and CT)

BE-TLIF, biportal endoscopic transforaminal lumbar interbody fusion; CT, computed tomography; F, female; M, male; MIS-TLIF: minimally invasive transforaminal lumbar interbody fusion; ODI, Oswestry Disability Index; SF-36, 36-Item Short Form Health Survey; VAS, visual analog scale.