Unilateral biportal endoscopic lumbar interbody fusion enhanced the recovery of patients with the lumbar degenerative disease compared with the conventional posterior procedures: A systematic review and meta-analysis

Abstract

BackgroundMinimally invasive endoscopic technique is an important component of Enhanced Recovery After Surgery (ERAS) protocol for neurosurgery. In recent years, unilateral biportal endoscopic lumbar interbody fusion (ULIF) has been used in the treatment of lumbar degenerative diseases (LDD). This study aims to investigate whether ULIF could enhance the recovery of patients with LDD compared with the conventional minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) or posterior lumbar interbody fusion (PLIF).MethodsA comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, Cochrane Library database, China National Knowledge Internet, and Wanfang database. Surgical data, clinical outcomes, radiographic outcomes, and surgical complications were compared between patients with LDD who underwent ULIF and those who underwent conventional MI-TLIF or PLIF.ResultsNotably, 12 studies, comprising 981 patients with LDD, were included. Of these patients, 449 underwent ULIF and 532 patients (355 MI-TLIF and 177 PLIF) were treated with conventional procedures. There was no significant difference in the fusion rate, cage subsidence rate, and surgical complications between the ULIF group and the MI-TLIF or PLIF group. Compared with MI-TLIF, the ULIF group presented a significantly reduced estimated blood loss (EBL) (WMD, −106.00; 95% CI −140.99 to −71.10, P < 0.001) and shorter length of hospital stay (LOS) (WMD, −1.27; 95% CI −1.88 to −0.66, P < 0.001); better short-term improvement in ODI (WMD, −2.12; 95% CI −3.53 to −0.72, P = 0.003) and VAS score for back pain (VAS-BP) (WMD, −0.86; 95% CI −1.15 to −0.58, P < 0.001) at 1 month post-operatively. Compared with PLIF, the ULIF group presented a significantly reduced EBL (WMD, −149.22; 95% CI −284.98 to −13.47, P = 0.031) and shorter LOS (WMD, −4.40; 95% CI −8.04 to −0.75, P = 0.018); better short-term improvement in VAS-BP (WMD, −1.07; 95% CI −1.77 to −0.38, P = 0.002) and VAS score for leg pain (VAS-LP) (WMD, −0.40; 95% CI −0.72 to −0.08, P = 0.014) at 1–2 week post-operatively; enhanced short- and long-term improvement in ODI at 1 month post-operatively (WMD, −3.12; 95% CI −5.72 to −0.53, P = 0.018) and the final follow-up (WMD, −1.97; 95% CI −3.32 to −0.62, P = 0.004), respectively.ConclusionCompared with conventional MI-TLIF and PLIF, ULIF was associated with reduced EBL, shorter LOS, and comparable fusion rate as well as complication management. Compared with MI-TLIF, a better short-term improvement in VAS-BP and ODI was achieved by ULIF; compared with open PLIF, additional enhanced short-term improvement in VAS-LP and long-term improvement in ODI were observed in ULIF. ULIF could enhance the recovery of patients with LDD compared with conventional posterior procedures.Systematic trial registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=230695, CRD42021230695.

Endoscopic Transforaminal Lumbar Interbody Fusion

“…With advancements in endoscopic instruments and surgical techniques, the incidence of complications in endoscopic TLIF has decreased dramatically in recent years. A recent meta-analysis showed that the incidence of complications in PE-TLIF was 10.1%, which is close to that of MIS-TLIF (12.7%); the incidence of complications in UBE-TLIF (7.8%) was also similar to that of MIS-TLIF (7.1%) [8,10]. The most common complications are dura tear, nerve injury, endplate injury, and screw misplacement.…”

“…A large amount of research has confirmed that PE-TLIF, UBE-TLIF, and MIS-TLIF all have the capacity to achieve satisfactory clinical effects, with no significant differences in mid-to long-term outcomes. Several meta-analyses have reported that both PE-TLIF and UBE-TLIF are superior to MIS-TLIF in early relief of low back pain, especially within three months after surgery; however, there is no significant difference between the alleviation of leg discomfort and the enhancement of the Oswestry Disability Index [7,8]. These results suggest that endoscopic TLIF could achieve adequate nerve decompression, with less ischemic damage to paraspinal muscles, ligaments, and posterior soft tissue.…”

“…Most literature reports a longer operating time in endoscopic TLIF procedures than that in MIS-TLIF [8]. The most time-consuming aspect of endoscopic lumbar fusion surgery is the handling of intervertebral space and endplate preparation.…”

Clinical efficacy of percutaneous endoscopic posterior lumbar interbody fusion and modified posterior lumbar interbody fusion in the treatment of lumbar degenerative disease

“…First, bleeding can be prevented in advance by using radiofrequency ablation under the endoscopic field of vision, which can provide a clear surgical field of vision and reduce intraoperative bleeding [ 4 ]. Second, continuous fluid irrigation plays a vital role in controlling epidural and bone surface bleeding, which can reduce intraoperative blood loss [ 18 ]. Third, the adjacent pedicles will not be injured because a visible trephine is used for facetectomy [ 19 ], resulting in a small scope of bone resection and less bone bleeding, which is conducive to reducing intraoperative blood loss.…”

Evaluation of the learning curve and complications in unilateral biportal endoscopic transforaminal lumbar interbody fusion: cumulative sum analysis and risk-adjusted cumulative sum analysis

“…The development of the spinal endoscopic techniques and innovations in instrumentation have enabled spine surgeons to achieve decompression of the spinal canal and even interbody fusion through indirect visualization with the assistance of spinal endoscopy [ 1 ]. Unilateral biportal endoscopy (UBE) is an emerging minimally invasive spinal endoscopy technique that has attracted the attention of spine surgeons for its advantages of less blood loss, less trauma, and faster postoperative recovery [ 2 , 3 ]. Since Heo applied the UBE technique to transforaminal lumbar interbody fusion (TLIF) for the first time and got satisfactory outcomes in 2017 [ 4 ], the indications for UBE have gradually expanded to various degenerative spinal diseases.…”