Technique of Biportal Endoscopic Transforaminal Lumbar Interbody Fusion

Abstract

Biportal endoscopic transforaminal lumbar interbody fusion (TLIF) may have advantages of minimally invasive fusion surgery as well as those of endoscopic surgery. The purpose of this study was to present the biportal endoscopic TLIF technique along with video presentations and a review of the literature on this technique. Basically, the biportal endoscopic TLIF technique is similar to minimally invasive TLIF with a tubular retractor. There were 2 options in the biportal endoscopic TLIF procedures. The first was the insertion of one long TLIF cage and the other was the insertion of 2 short posterior lumbar interbody fusion (PLIF) cages. After the interbody fusion procedures, percutaneous pedicles screw fixation was performed. Biportal endoscopic TLIF achieved complete neural decompression through laminectomy and facetectomy like conventional TLIF. Endplate preparation was performed completely under a clear and magnified endoscopic view. It was also feasible to insert a large TLIF cage or 2 cages for PLIF without exiting nerve root injury. Biportal endoscopic TLIF might have the advantages of endoscopic surgery as well as minimally invasive fusion surgery. Direct neural decompression, endplate preparation under endoscopic guidance, and the insertion of a large TLIF cage or 2 PLIF cages may be the merits of biportal endoscopic lumbar fusion procedures.

Biportal Endoscopic Lumbar Interbody Fusion: Review of Current Evidence and the Literature

“…There are minor variations in the biportal ELIF technique amongst practitioners,and the surgical technique has been previously described [4][5][6]10,11,16) . Briefly, patients are prepared in a prone position under general or epidural anesthesia.…”

“…Two articles described the technique and reported preliminary clinical results 6,10) . One article was a technical note and review article 4) . This article focused on the technical aspect of biportal ELIF.…”

“…. As a consequence, complete direct decompression of the central canal, lateral recess, and foraminal area with less motion and vision limitation is possible (Figure 2) [4][5][6]10,11,16) . Specifically, decompression of the contralateral exiting nerve root is relatively easy through the contralateral sublaminar approach (Figure 2D).…”

“…While conventional posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) techniques have shown good clinical and radiological outcomes for lumbar degenerative disease, they have also been associated with paraspinal muscle injury from subperiosteal dissections and retraction, which can lead to increased postoperative back pain and muscle atrophy 2,9,18,19) . Threfore, recent techniques for endoscopic lumbar interbody fusion (ELIF) have been developed, which are associated with minimal muscle injury to posterior musculo-ligamentous structures, good clinical outcomes, and satisfactory fusion rates 1,[4][5][6]8,[10][11][12]16,17,[21][22][23] . There are several studies on uniportal ELIF 8,12,17,[21][22][23] , and biportal ELIF has been published by several investigators [4][5][6]10,11,16) .…”

“…Unlike uniportal ELIF, independent movement of the endoscope and surgical instruments is possible, and the working portal is used only for surgical instruments not though the working cannula. As a result, biportal ELIF can achieve direct ipsilateral and contralateral decompression similar to MIS TLIF with fewer limitations of motion and vision [4][5][6]10,11,16) . Moreover, biportal ELIF has advantages in terms of minimal invasiveness 5,11,16) .…”