Clinical Efficacy of Unilateral Biportal Endoscopic Transforaminal Lumbar Interbody Fusion

Abstract

Unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) is an advanced, minimally invasive spinal surgical technique characterized by the use of 2 discrete portals—one for clear visualization and continuous irrigation and the other for the dexterous manipulation of surgical instruments. This configuration not only affords an expanded view (0° or 30°) but also enhances the freedom of movement for instruments, thereby augmenting the precision and flexibility of the surgery. The superiority of UBE-TLIF lies in its capacity to facilitate rapid postoperative recovery with minimal trauma, reduced intraoperative bleeding, abbreviated hospital stays, and significant amelioration of postoperative lower back pain. Comparatively, UBE-TLIF demonstrates equivalent fusion rates and clinical outcomes to traditional open surgeries while also increasing patient satisfaction.1, 2, 3

In the UBE-TLIF procedure, the potential for nerve root disturbance due to surgical manipulation is a critical consideration. To minimize this, the authors have refined the surgical approach, as demonstrated in Video 1. The insertion of a guidewire is prioritized before the fusion process for 2 key reasons: to ensure accurate segmental alignment under the biportal endoscope and to avoid the risk of spinal canal injury that could arise if the guidewire were to be inserted after spinal decompression. The horizontal orientation of the cage is a pivotal technique, as it not only restores spinal curvature effectively but also circumvents the complications associated with oblique insertion, including the prevention of contralateral foraminal narrowing. This strategic positioning is vital for optimizing spinal alignment and reducing the likelihood of iatrogenic issues.⁴ After cage implantation, the decompression of the dorsal ligamentum flavum is carefully executed, with an emphasis on preserving the ligament to lessen the potential irritation to the nerve roots during the implantation process. This nuanced approach ensures that while achieving spinal fusion, there is also a significant reduction in the risk of nerve root stimulation, striking a harmonious balance between the goals of spinal stabilization and neural element safety.

In this video demonstration, we highlight 2 key advantages of the UBE-TLIF procedure^4,5: (1) Optimal lordosis and stability via cage technique: This study introduces a cage-rotation technique that enhances the accuracy and efficacy of UBE-TLIF. The fusion cage is meticulously inserted at a 45° angle to the lamina, with the process halted once two thirds of the cage is in place. An assistant then delicately taps the final one-third segment, ensuring the cage is perfectly aligned with the posterior vertebral edge. This method differs from the traditional oblique insertion, as it significantly improves the spinal lordosis by augmenting disc height, segmental lordosis, and overall lumbar curvature. Additionally, the traverse cage positioning provides enhanced stability, marked by a greater posterior distance from the vertebral body, thus minimizing the potential for cage subsidence or migration. (2) Prioritizing fusion cage insertion for refined decompression⁶: By prioritizing the fusion cage insertion before the neural decompression, our approach underscores the importance of preserving the ligamentum flavum. This technique reduces neural irritation during the procedure, leading to an improved patient experience postoperatively.

UBE-TLIF offers a safe, efficacious, and swiftly recuperative minimally invasive option for the treatment of lumbar degenerative diseases. It diminishes reliance on costly equipment, thereby facilitating the dissemination and application of this technology in community hospitals.⁷