Unilateral Biportal Endoscopy for Lumbar Spinal Stenosis and Lumbar Disc Herniation.

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JBJS Essential Surgical Techniques


BACKGROUND: Unilateral biportal endoscopy (UBE) is a novel minimally invasive technique for the treatment of lumbar spinal stenosis and lumbar disc herniations. Uniportal endoscopy was utilized prior to the advent of UBE and has been considered the workhorse of endoscopic spine surgery (ESS) for lumbar discectomy and decompressive laminectomy. However, there are theoretical advantages to UBE compared with traditional uniportal endoscopy, including that the procedure utilizes typical spinal equipment that should be readily available, requires less capital cost and optical instrumentation, and provides greater operative flexibility as a result of utilizing both a working and a viewing portal

DESCRIPTION: A 0-degree arthroscope is typically utilized for discectomy and lumbar laminectomies. The use of a radiofrequency ablator is critical to help coagulate osseous and muscle bleeders. For irrigation, gravity or a low-pressure pump, typicallyHg, can be utilized

ALTERNATIVES: Nonoperative treatments include oral anti-inflammatory drugs, physical therapy, and epidural injections; if these fail, alternative surgical treatments include open lumbar laminectomy and/or discectomy, tubular lumbar laminectomy and/or discectomy, and other minimally invasive techniques, such as microendoscopy, uniportal endoscopy, and microscopy-assisted decompression.

RATIONALE: UBE is a minimally invasive surgical procedure that better preserves osseous and muscular structure compared with open and tubular techniques. Conventional lumbar laminectomy involves dissection and retraction of the multifidus muscle from the spinous process to the facet joint. This exposure can damage the delicate posterior dorsal rami. Long retraction time can also lead to pressure-induced muscle atrophy and potentially increased chronic low back pain. Alternatively, smaller incisions and shorter hospital stays are possible with UBE.Similar to UBE, tubular surgery can minimize soft-tissue damage compared with open techniques; however, in a randomized trial assessing techniques for spinal stenosis surgery, Kang et al. found that UBE and tubular surgery had similarly favorable clinical outcomes at 6 months postoperatively but UBE resulted in decreased operative time, drain output, opiate use, and length of hospital stay

EXPECTED OUTCOMES: Long-term outcomes do not differ substantially between discectomies performed with use of the presently described technique and procedures done with more traditional minimally invasive (i.e., tubular) techniques; however, visual analogue scale scores for back pain may be better in the short term, and there is evidence of a shorter hospital stay with UBE

IMPORTANT TIPS: The optimal hydrostatic pressure is 30 to 50 mm Hg. Pressure is determined by the distance between the fluid source and the working space. Because the working space does not change, the height of the bag decides pressure. A simple formula for pressure is calculated by dividing the distance from the working field to the irrigation source by 1.36. A rule of thumb is that if the bag is 50 to 70 cm above the patient's back, the pressure should be adequate. The advantages of using gravity rather than a pressure pump are that excessive fluid solution pressure in the epidural space can cause neurological issues such as nuchal pain, headache, and seizure

ACRONYMS AND ABBREVIATIONS: MRI = magnetic resonance imagingRF = radiofrequencyAP = anteroposterior.





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