Biportal endoscopic cervical open-door laminoplasty to treat cervical spondylotic myelopathy.

BACKGROUND: Although cervical laminoplasty is a frequently utilized surgical intervention for cervical spondylotic myelopathy, it is primarily performed using conventional open surgical techniques. We attempted the minimally invasive cervical laminoplasty using biportal endoscopic approach. METHODS: Contralateral lamina access is facilitated by creating space through spinous process drilling, followed by lamina hinge formation. Subsequently, the incised lamina is elevated from ipsilateral aspect, and secure metal plate fixation is performed. CONCLUSION: We successfully performed the cervical open door laminoplasty using biportal endoscopic approach. Biportal endoscopic cervical open-door laminoplasty may be a minimally invasive technique that can prevent complications related with open surgery.

Does obesity and varying body mass index affect the clinical outcomes and safety of biportal endoscopic lumbar decompression? A comparative cohort study.

BACKGROUND: Endoscopic spine surgery has recently grown in popularity due to the potential benefits of reduced pain and faster recovery time as compared to open surgery. Biportal spinal endoscopy has been successfully applied to lumbar disc herniations and lumbar spinal stenosis. Obesity is associated with increased risk of complications in spine surgery. Few prior studies have investigated the impact of obesity and associated medical comorbidities with biportal spinal endoscopy. METHODS: This study was a prospectively collected, retrospectively analyzed comparative cohort design. Patients were divided into cohorts of normal body weight (Bone Mass Index (BMI)18.0-24.9), overweight (BMI 25.0-29.9) and obese (BMI > 30.0) as defined by the World Health Organization (WHO). Patients underwent biportal spinal endoscopy by a single surgeon at a single institution for treatment of lumbar disc herniations and lumbar spinal stenosis. Demographic data, surgical complications, and patient-reported outcomes were analyzed. Statistics were calculated amongst treatment groups using analysis of variance and chi square where appropriate. Statistical significance was determined as p < 0.05. RESULTS: Eighty-four patients were followed. 26 (30.1%) were normal BMI, 35 (41.7%) were overweight and 23 (27.4%) were obese. Patients with increasing BMI had correspondingly greater American Society of Anesthesiologist (ASA) scores. There were no significant differences in VAS Back, VAS Leg, and ODI scores, or postoperative complications among the cohorts. There were no cases of surgical site infections in the cohort. All cohorts demonstrated significant improvement up to 1 year postoperatively. CONCLUSIONS: This study demonstrates that obesity is not a risk factor for increased perioperative complications with biportal spinal endoscopy and has similar clinical outcomes and safety profile as compared to patients with normal BMI. Biportal spinal endoscopy is a promising alternative to traditional techniques to treat common lumbar pathology.

Enhanced recovery after surgery pathway with modified biportal endoscopic transforaminal lumbar interbody fusion using a large cage. Comparative study with minimally invasive microscopic transforaminal lumbar interbody fusion.

PURPOSE: Studies about the clinical efficacy of endoscopic lumbar interbody fusion using an enhanced recovery after surgery (ERAS) pathway are insufficient. Thus, the purpose of this study was to investigate clinical usefulness of biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using an ERAS compared with microscopic TLIF. METHODS: Prospectively collected data were retrospectively analyzed. Patients who received modified biportal endoscopic TLIF with ERAS were grouped into an endoscopic TLIF group. Those who received microscopic TLIF without ERAS were grouped into a microscopic TLIF group. Clinical and radiologic parameters were compared between two groups. Fusion rate was evaluated using sagittal reconstruction images of postoperative computed tomographic (CT) scan. RESULTS: There were 32 patients in the endoscopic TLIF group with ERAS and 41 patients in the microscopic TLIF group without ERAS. Visual analog scale (VAS) scores for back pain preoperatively at day one and day two were significantly (p < 0.05) higher in the non-ERAS microscopic TLIF group than in the ERAS endoscopic TLIF group. Preoperative Oswestry Disability Index were significantly improved at the last follow-up in both groups. The fusion rate at postoperative one year was 87.5% in the endoscopic TLIF group and 85.4% in the microscopic TLIF group. CONCLUSION: Biportal endoscopic TLIF with ERAS pathway may have good aspect to accelerate recovery after surgery. There was no inferiority of fusion rate of endoscopic TLIF comparing to microscopic TLIF. Biportal endoscopic TLIF using a large cage with ERAS pathway may be a good alternative treatment for lumbar degenerative disease.

Minimally invasive endoscopy in spine surgery: where are we now?

INTRODUCTION: Endoscopic spine surgery (ESS) is a minimally invasive surgical technique that offers comparable efficacy and safety with less collateral damage compared to conventional surgery. To achieve clinical success, it is imperative to stay abreast of technological advancements, modern surgical instruments and technique, and updated evidence. PURPOSES: To provide a comprehensive review and updates of ESS including the nomenclature, technical evolution, bibliometric analysis of evidence, recent changes in the spine communities, the prevailing of biportal endoscopy, and the future of endoscopic spine surgery. METHODS: We conducted a comprehensive review of the literature on ESS for the mentioned topics from January 1989 to November 2022. Three major electronic databases were searched, including MEDLINE, Scopus, and Embase. Covidence Systematic Review was used to organize the eligible records. Two independent reviewers screened the articles for relevance. RESULTS: In total, 312 articles were finally included for review. We found various use of nomenclatures in the field of ESS publication. To address this issue, we proposed the use of distinct terms to describe the biportal and uniportal techniques, as well as their specific approaches. In the realm of technical advancement, ESS has rapidly evolved from addressing disc herniation and spinal stenosis to encompassing endoscopic fusion, along with technological innovations such as navigation, robotics, and augmented reality. According to bibliometric analysis, China, South Korea, and the USA have accounted for almost three-quarters of total publications. The studies of the biportal endoscopy are becoming increasingly popular in South Korea where the top ten most-cited articles have been published. The biportal endoscopy technique is relatively simple to adopt, as it relies on a more familiar approach, requires less expensive instruments, has a shorter learning curve, and is also well-suited for interbody fusion. The uniportal approach provided the smallest area of soft tissue dissection. While robotics and augmented reality in ESS are not widely embraced, the use of navigation in ESS is expected to become more streamlined, particularly with the emergence of recent electromagnetic-based navigation technologies. CONCLUSIONS: In this paper, we provide a comprehensive overview of the evolution of ESS, as well as an updated summary of current trends in the field, including the biportal and uniportal approaches. Additionally, we summarize the nomenclature used in ESS, present a bibliometric analysis of the field, and discuss future directions for the advancement of the field.

Temperature change of epidural space by radiofrequency use in biportal endoscopic lumbar surgery: safety evaluation of radiofrequency.

PURPOSE: Articles evaluating radiofrequency (RF) safety are insufficient. Thus, the purpose of this study was to investigate RF safety during biportal endoscopic lumbar decompressive laminotomy by measuring epidural temperature after RF use. METHODS: Both in vitro cadaveric study and in vivo study were performed. The epidural temperature was measured at epidural space after RF use in three cadavers. The epidural temperature was measured and analysed according to RF mode, RF power, RF usage time, and saline irrigation patency. In the in vivo study, the epidural temperature was measured after biportal endoscopic surgery. Epidural temperatures were measured around ipsilateral and contralateral traversing nerve roots after 1-s use of RF. RESULTS: In the in vivo study, epidural space temperature was increased by 0.31 ± 0.16 °C ipsilaterally and 0.29 ± 0.09° contralaterally after RF use in coagulation mode 1. The epidural temperature of epidural space was increased by 0.21 ± 0.13 °C ipsilaterally and 0.15 ± 0.21 °C contralaterally after RF use in high mode 2. In the in vitro study, epidural temperature was significantly increased with a long duration of RF use and a poor patency of irrigation fluid. CONCLUSION: The use of RF in biportal endoscopic spine surgery might be safe. In order to reduce indirect thermal injuries caused by RF use, it might be necessary to reduce RF use time and maintain continuous saline irrigation patency well.

Clinical outcomes and complications after biportal endoscopic spine surgery: a comprehensive systematic review and meta-analysis of 3673 cases.

PURPOSE: Current literature suggests that biportal spinal endoscopy is safe and effective in treating lumbar spine pathology such as lumbar disc herniation, lumbar stenosis, and degenerative spondylolisthesis. No prior study has investigated the postoperative outcomes or complication profile of the technique as a whole. This study serves as the first comprehensive systematic review and meta-analysis of biportal spinal endoscopy in the lumbar spine. METHODS: A PubMed literature search provided over 100 studies. 42 papers were reviewed and 3673 cases were identified with average follow-up time of 12.5 months. Preoperative diagnoses consisted of acute disc herniation (1098), lumbar stenosis (2432), and degenerative spondylolisthesis (229). Demographics, operative details, complications, and perioperative outcome and satisfaction scores were analyzed. RESULTS: Average age was 61.32 years, 48% male. 2402 decompressions, 1056 discectomies, and 261 transforaminal lumbar Interbody fusions (TLIFs) were performed. Surgery was performed on 4376 lumbar levels, with L4-5 being most common(61.3%). 290 total complications occurred, 2.23% durotomies, 1.29% inadequate decompressions, 3.79% epidural hematomas, and < 1% transient nerve root injuries, infections, and iatrogenic instability. Significant improvement in VAS-Back, VAS-Leg, ODI, and Macnab Scores were seen across the cohort. CONCLUSION: Biportal spinal endoscopy is a novel method to address pathology in the lumbar spine with direct visualization through an endoscopic approach. Complications are comparable to previously published rates. Clinical outcomes demonstrate effectiveness. Prospective studies are required to assess the efficacy of the technique as compared to traditional techniques. This study demonstrates that the technique can be successful in the lumbar spine.

Evaluation of the efficacy and safety of conventional and biportal endoscopic decompressive laminectomy in patients with lumbar spinal stenosis (ENDO-B trial): a protocol for a prospective, randomized, assessor-blind, multicenter trial.

BACKGROUND: Recent studies on biportal endoscopic spine surgery in patients with lumbar spinal stenosis have reported good clinical results. However, these studies have been limited by the small sample sizes and use of a retrospective study design. Therefore, we aim to compare the efficacy and safety of biportal endoscopic decompressive laminectomy with those of conventional decompressive laminectomy in a multicenter, prospective, randomized controlled trial. METHODS: This study will include 120 patients (60 per group, aged 20-80 years) with 1- or 2-level lumbar spinal stenosis, who will be recruited from six hospitals. The study will be conducted from July 2021 to December 2024. The primary outcome (Oswestry Disability Index at 12 months after surgery) will be evaluated through a modified intention-to-treat method. The secondary outcomes will include the following: visual analog scale score for low back and lower extremity radiating pain, EuroQol 5-dimensions score, surgery satisfaction, walking time, postoperative return to daily life period, postoperative surgical scars, and some surgery-related variables. Radiographic outcomes will be analyzed using magnetic resonance imaging or computed tomography. All outcomes will be evaluated before the surgery and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. This protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines for reporting of clinical trial protocols. DISCUSSION: It is hypothesized that the efficacy and safety of biportal endoscopic and conventional decompressive laminectomy will be comparable in patients with lumbar spinal stenosis. The results of this trial will provide a high level of evidence for the efficacy and safety of the biportal endoscopic technique in patients with lumbar spinal stenosis and facilitate the development of clinical practice guidelines. Furthermore, the results of this study may indicate the feasibility of the biportal endoscopic technique for other types of spinal surgery. TRIAL REGISTRATION: The ENDO-B trial is registered at Clinical Research Information Service (CRIS, cris.nih.go.kr ) (KCT0006057; April 52,021).

Contralateral sublaminar approach for decompression of the combined lateral recess, foraminal, and extraforaminal lesions using biportal endoscopy: a technical report.

BACKGROUND: The development of specialized instruments and surgical techniques has enabled the biportal endoscopic system to access the foraminal and extraforaminal area using the contralateral sublaminar approach at the lumbar level. METHODS: Biportal endoscopic contralateral sublaminar approach was used to resolve the contralateral foraminal, and extraforaminal stenosis at the lumbar level. Prominent syndesmophytes and herniated disc compression of the exiting nerve root were successfully removed, and the distorted nerve root was restored to a smooth downward angulation in the far-out area. CONCLUSION: We successfully utilized biportal endoscopy to decompress the combined lumbar lateral recess, foraminal, and extraforaminal lesions using a contralateral sublaminar approach.

Biportal endoscopic unilateral laminotomy with bilateral decompression for the treatment of cervical spondylotic myelopathy.

BACKGROUND: The advantages of biportal endoscopic approaches over conventional open surgery include the preservation of the normal structures, less intraoperative bleeding, fast postoperative recovery, and preservation of the motion segments. METHOD: We attempted the posterior biportal endoscopic approach for cervical stenosis at the C5-C6-C7 levels. Biportal endoscopic right ipsilateral hemilaminectomy with bilateral decompression at the C5-C6-C7 levels and right foraminotomy at the C6-C7 level were performed under general anesthesia. CONCLUSIONS: We successfully performed neural decompression at the C5-C6-C7 levels using biportal endoscopic surgery. The biportal endoscopic posterior cervical approach may be an alternative surgical method for treating cervical myelopathy.

Modified far lateral endoscopic transforaminal lumbar interbody fusion using a biportal endoscopic approach: technical report and preliminary results.

BACKGROUND: Endoscopic transforaminal lumbar interbody fusion (TLIF) has the disadvantage of the small cage size and by consequence risk for cage subsidence. We succeeded to insert a large oblique lumbar interbody fusion (OLIF) cage during biportal endoscopic TLIF. METHODS: Unilateral total facetectomy was performed to expose the exiting and traversing nerve roots. The distance between the exiting and traversing nerve roots was measured before OLIF cage insertion. We inserted an OLIF cage instead of a TLIF cage. CONCLUSION: We successfully performed modified far lateral biportal endoscopic TLIF using large OLIF cages. Modified far lateral biportal endoscopic TLIF is usually suitable for the L4-5 and L5-S1 levels.

Clinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery.

OBJECTIVEThe aims of enhanced recovery after surgery (ERAS) are to improve surgical outcomes, shorten hospital stays, and reduce complications. The objective of this study was to introduce ERAS with biportal endoscopic transforaminal lumbar interbody fusion (TLIF) and to investigate the clinical results.METHODSPatients were divided into two groups based on the fusion procedures. Patients who received microscopic TLIF without ERAS were classified as the non-ERAS group, whereas those who received percutaneous biportal endoscopic TLIF with ERAS were classified as the ERAS group. The mean Oswestry Disability Index (ODI) and visual analog scale (VAS) scores were compared between the two groups. In addition, demographic characteristics, diagnosis, mean operative time, estimated blood loss (EBL), fusion rate, readmissions, and complications were investigated and compared.RESULTSForty-six patients were grouped into the non-ERAS group (microscopic TLIF without ERAS) and 23 patients into the ERAS group (biportal endoscopic TLIF with ERAS). The VAS score for preoperative back pain on days 1 and 2 was significantly higher in the non-ERAS group than in the ERAS group (p < 0.05). The mean operative duration was significantly higher in the ERAS group than in the non-ERAS group, while the mean EBL was significantly lower in the ERAS group than in the non-ERAS group (p < 0.05). There was no significant difference in fusion rate between the two groups (p > 0.05). Readmission was required in 2 patients who were from the non-ERAS group. Postoperative complications occurred in 6 cases in the non-ERAS group and in 2 cases in the ERAS group.CONCLUSIONSPercutaneous biportal endoscopic TLIF with an ERAS pathway may have good aspects in reducing bleeding and postoperative pain. Endoscopic fusion surgery along with the ERAS concept may help to accelerate recovery after surgery.

Comparative analysis of three types of minimally invasive decompressive surgery for lumbar central stenosis: biportal endoscopy, uniportal endoscopy, and microsurgery.

OBJECTIVERecently, minimally invasive unilateral laminotomy with bilateral decompression (ULBD) has been performed for lumbar stenosis using endoscopic approaches. The object of this retrospective study was to compare the clinical and radiological outcomes of three types of minimally invasive decompressive surgery: microsurgery, percutaneous uniportal endoscopic surgery, and percutaneous biportal endoscopic surgery.METHODSIn the period from March 2016 to December 2017, minimally invasive ULBD was performed using microscopy, a uniportal endoscopic approach, or a biportal endoscopic approach to treat lumbar canal stenosis. Patients were classified into three groups based on the surgery they had undergone. The angle of medial facetectomy area and postoperative dural expansion were measured using MR images. The visual analog scale (VAS) score for leg and back pain, Oswestry Disability Index (ODI), operation time, and complications were assessed. Clinical and radiological parameters were compared among the three groups.RESULTSThere were 33 patients in the microscopy group, 37 in the biportal endoscopy group, and 27 in the uniportal endoscopy group. Preoperatively stenotic dural areas were significantly expanded in each of the three groups after surgery (p < 0.05). Mean dural expansion in the uniportal endoscopy group was significantly lower than that in the microscopy or biportal endoscopy group (p < 0.05). The mean angle of the facetectomy in the biportal endoscopic group was significantly lower than that in the microscopic group or uniportal endoscopic group (p < 0.05). On the 1st day after surgery, the VAS score for back pain was significantly higher in the microscopic group than in the uniportal or biportal endoscopic group (p < 0.05). However, there were no significant differences in the VAS score for back pain, VAS score for leg pain, or ODI at the final follow-up among the three groups (p > 0.05).CONCLUSIONSAlthough radiological results were different among the three groups of patients, postoperative clinical outcomes were significantly improved after each type of surgery. The percutaneous biportal or uniportal endoscopic approach offers the advantage of reduced immediate postoperative pain. A percutaneous uniportal or biportal endoscopic lumbar approach may be effective for the treatment of lumbar central stenosis and an alternative to conventional microsurgical decompression.

Clinical and radiological outcomes of spinal endoscopic discectomy-assisted oblique lumbar interbody fusion: preliminary results.

OBJECTIVE Direct neural decompression cannot be achieved by performing lateral lumbar interbody fusion (LLIF). To overcome the indirect decompressive effect of LLIF, additional endoscopic discectomy with oblique lumbar interbody fusion (OLIF) has been attempted. The purpose of this study was to assess the clinical and radiological outcomes of patients who underwent OLIF with additional endoscopic discectomy. METHODS Spinal endoscopic discectomy-assisted OLIF was attempted to remove herniated disc material. Only patients with a follow-up time that exceeded 12 months were enrolled. Clinical parameters examined were the Oswestry Disability Index and visual analog scale scores of back and leg pain. Postoperative MRI was also performed. RESULTS Fourteen patients were enrolled. Central and foraminal disc herniations were evident in 8 and 6 patients, respectively. Concomitant central or foraminal herniated discs were removed completely after additional endoscopic discectomy, and disc removal was confirmed by postoperative MRI. Mean preoperative visual analog scale scores and Oswestry Disability Index scores improved postoperatively. CONCLUSIONS OLIF with additional endoscopic discectomy results in successful direct neural decompression without posterior decompressive procedures. Endoscopic assistance might overcome the limitations of LLIF.

Bone loss of vertebral bodies at the operative segment after cervical arthroplasty: a potential complication?

OBJECTIVE Bony overgrowth and spontaneous fusion are complications of cervical arthroplasty. In contrast, bone loss or bone remodeling of vertebral bodies at the operation segment after cervical arthroplasty has also been observed. The purpose of this study is to investigate a potential complication-bone loss of the anterior portion of the vertebral bodies at the surgically treated segment after cervical total disc replacement (TDR)-and discuss the clinical significance. METHODS All enrolled patients underwent follow-up for more than 24 months after cervical arthroplasty using the Baguera C disc. Clinical evaluations included recording demographic data and measuring the visual analog scale and Neck Disability Index scores. Radiographic evaluations included measurements of the functional spinal unit's range of motion and changes such as bone loss and bone remodeling. The grading of the bone loss of the operative segment was classified as follows: Grade 1, disappearance of the anterior osteophyte or small minor bone loss; Grade 2, bone loss of the anterior portion of the vertebral bodies at the operation segment without exposure of the artificial disc; or Grade 3, significant bone loss with exposure of the anterior portion of the artificial disc. RESULTS Forty-eight patients were enrolled in this study. Among them, bone loss developed in 29 patients (Grade 1 in 15 patients, Grade 2 in 6 patients, and Grade 3 in 8 patients). Grade 3 bone loss was significantly associated with postoperative neck pain (p < 0.05). Bone loss was related to the motion preservation effect of the operative segment after cervical arthroplasty in contrast to heterotopic ossification. CONCLUSIONS Bone loss may be a potential complication of cervical TDR and affect early postoperative neck pain. However, it did not affect mid- to long-term clinical outcomes or prosthetic failure at the last follow-up. Also, this phenomenon may result in the motion preservation effect in the operative segment after cervical TDR.

Fully endoscopic lumbar interbody fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results.

OBJECTIVE Minimally invasive spine surgery can minimize damage to normal anatomical structures. Recently, fully endoscopic spine surgeries have been attempted for lumbar fusion surgery. In this study, the authors performed a percutaneous unilateral biportal endoscopic (UBE) technique as a minimally invasive surgery for lumbar fusion. The purpose of this study is to present the UBE technique of fully endoscopic lumbar interbody fusion (LIF) and to analyze the clinical results. METHODS Patients who were to undergo single-level fusion surgery from L3-4 to L5-S1 were enrolled. Two channels (endoscopic portal and working portal) were used for endoscopic lumbar fusion surgery. All patients underwent follow-up for more than 12 months. Demographic characteristics, diagnosis, operative time, and estimated blood loss were evaluated. MRI was performed on postoperative Day 2. Clinical evaluations (visual analog scale [VAS] for the leg and Oswestry Disability Index [ODI] scores) were performed preoperatively and during the follow-up period. RESULTS A total of 69 patients (24 men and 45 women) were enrolled in this study. The mean follow-up period was 13.5 months. Postoperative MRI revealed optimal direct neural decompression after fully endoscopic fusion surgery. VAS and ODI scores significantly improved after the surgery. There was no postoperative neurological deterioration. CONCLUSIONS Fully endoscopic LIF using the UBE technique may represent an alternative minimally invasive LIF surgery for the treatment of degenerative lumbar disease. Long-term follow-up and larger clinical studies are needed to validate the clinical and radiological results of this surgery.

Whole cerebrospinal axis infection after lumbar epidural injection: a case report.

PURPOSE: Lumbar epidural injection is a popular treatment for degenerative lumbar disease. Although post-procedural epidural infection is rare, meningitis and epidural abscess are life-threatening conditions, and need additional medical and surgical intervention. The purpose of this article is to report a patient with fatal whole cerebrospinal axis infection after lumbar epidural injections. METHODS: A 64-year-old female patient presented with septic shock and quadriparesis. In the past, this patient had received lumbar epidural injections several times for degenerative spondylolisthesis at L4-5 in another hospital. The magnetic resonance imaging showed epidural abscess, a compressed dura and spinal cord from C1 to S2, and cerebral meningitis. We performed laminectomies and removal of the abscesses. Her mental status was diminished to a deep, drowsy state after three postoperative weeks. Brain computed tomography scans revealed hydrocephalus. Therefore, ventriculoperitoneal shunting was performed. RESULTS: Methicillin resistant Staphylococcus epidermidis was cultured from blood samples. The patient's infection was completely controlled and her mental status improved to alert; however, her quadriparesis remained. CONCLUSIONS: Although lumbar epidural injection is an effective procedure to treat lumbar radicular pain, this procedure can induce fatal complications such as sepsis and epidural abscess. LEVEL OF EVIDENCE: 5.

Biportal endoscopic transforaminal lumbar interbody fusion using a large cage for degenerative spondylolisthesis with stenosis.

Recently, biportal endoscopic transforaminal lumbar interbody fusion (TLIF) has been used to treat lumbar degenerative diseases, such as lumbar instability and spondylolisthesis. Biportal endoscopic TLIF may have the advantages of endoscopic spine approaches and minimally invasive lumbar fusion surgeries. In this biportal endoscopic TLIF, large cages similar to oblique lumbar interbody fusion (OLIF) cages have been used. Biportal endoscopic TLIF using a large cage can be successfully performed in the lower lumbar area. The author presents the surgical technique of biportal endoscopic TLIF using a large cage. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23231.

Biportal endoscopic posterior cervical foraminotomy with discectomy for unilateral radicular arm pain due to cervical herniated disc.

Recently, biportal endoscopic cervical approaches have been used to treat cervical degenerative disease. Biportal endoscopic posterior cervical foraminotomy with or without discectomy has the advantage of reducing damage to the normal tissues during surgery and enhancing fast recovery after surgery. The biportal endoscopic cervical approach was performed using two portals. The first portal was an endoscopic viewing portal for the spinal endoscope, and the other portal was a working portal for using surgical instruments. The author illustrates the surgical technique of biportal endoscopic posterior cervical foraminotomy with discectomy. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23225.

Does the use of tranexamic acid intraoperatively reduce postoperative blood loss and complications following biportal endoscopic lumbosacral decompression?

Background: Biportal endoscopic spine surgery is an effective minimally invasive technique for treating common lumbar pathologies. We aim to evaluate the impact of intraoperative tranexamic acid (TXA) use on postoperative blood loss in biportal endoscopic decompression surgery. Methods: Patients undergoing biportal endoscopic lumbar discectomies and decompressions either by same day surgery or overnight stay at a single institution beginning in October 2021 were prospectively enrolled. This study was non-randomized, non-blinded with the first cohort of consecutive patients receiving 1 g of intravenous TXA intra-operatively before closure and the second cohort of consecutive patients receiving no TXA. Exclusion criteria included any revision surgery, any surgery for the diagnosis of spinal instability, infection, tumor, or trauma, any contraindication for TXA. Results: Eighty-four patients were included in the study, with 45 (54%) receiving TXA and 39 (46%) not receiving TXA. Median follow-up was 168 days [interquartile range (IQR), 85-368 days]. There were no differences in patient or surgical characteristics between cohorts. Estimated blood loss (EBL) was similar (P=0.20), while post-operative drain output was significantly lower in the TXA cohort (P=0.0028). Single level discectomies had significantly less drain output as compared to 2 level unilateral laminotomy, bilateral decompression (ULBD) cases (P<0.005). Post-operative complications were similar, with low rates of wound complication (1.2%) and transient postoperative weakness (2.4%, P>0.99 for both). Oswestry disability index (ODI), visual analog scale (VAS) back and VAS leg scores decreased significantly; the absolute decrease in scores did not differ between groups (P=0.71, 0.22, 0.86, respectively). Conclusions: Systemic intraoperative TXA administration is associated with a significant decrease in post-operative blood loss in biportal spinal endoscopy, with no impact on the improvement in patient-reported outcomes (PROs) or rate of post-operative complications. Single level biportal discectomies had significantly less postoperative drainage with TXA and may not need drains postoperatively. Larger, randomized studies are necessary to evaluate the cost-effectiveness of TXA use in biportal spinal endoscopy.

The Use of Dual Direction Expandable Titanium Cage With Biportal Endoscopic Transforaminal Lumbar Interbody Fusion: A Technical Consideration With Preliminary Results.

OBJECTIVE: Expandable cage technology has emerged for lumbar interbody fusion to restore intervertebral disc space height and alignment through a narrow surgical corridor. The purpose of this study is to present the technique of biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using dual direction expandable cage and provide early clinical results. METHODS: We performed the biportal endoscopic TLIF using a dual direction expandable titanium cage for height restoration and a larger footprint in 10 patients. Clinical parameters including Oswestry Disability Index (ODI), visual analogue scale (VAS), and complications were retrospectively analyzed. Also, we investigated radiologic parameters using preoperative and postoperative x-ray images. RESULTS: We successfully inserted dual direction expandable cages during biportal endoscopic TLIF. There was no significant subsidence or collapse of the expandable cages during the 6-month follow-up period. Lumbar lordosis and disc height were significantly increased after surgery. ODI and VAS scores were significantly improved at 6 months after surgery. CONCLUSION: In this report, we describe the first use of a dual direction expandable interbody TLIF cage that expands in both width and height in biportal endoscopic TLIF surgery. Early clinical and radiographic outcomes of this TLIF technique may be favorable in early 6-month follow-up.