Clin Orthop Surg.  2018 Sep;10(3):328-336. 10.4055/cios.2018.10.3.328.

Clinical and Radiological Outcomes of Unilateral Biportal Endoscopic Decompression by 30° Arthroscopy in Lumbar Spinal Stenosis: Minimum 2-Year Follow-up

• Kim JE
• Choi DJ

• KMID: 2418753
• DOI: http://doi.org/10.4055/cios.2018.10.3.328

Abstract

BACKGROUND
Open microscopic laminectomy has been the standard surgical method for degenerative spinal stenosis without instability till now. However, it is associated with complications such as paraspinal muscle injury, excessive bleeding, and wound infection. Several surgical techniques, including microendoscopic decompression, have been introduced to solve these problems.
METHODS
Authors analyzed retrospectively 55 patients presenting with neurological symptoms due to degenerative lumbar spinal stenosis refractory to conservative treatment. Patients with foraminal stenosis requiring foraminal decompression were excluded. Two or three portals were used for each level. One portal was used for viewing purpose and the others for instrument passage. Unilateral laminotomy was followed by bilateral decompression under the view of 30° arthroscopy. Clinical outcomes were evaluated using modified Macnab criteria, Oswestry disability index (ODI), and visual analogue scale (VAS). Postoperative complications were checked during the 2-year follow-up. Plain radiographs before and after surgery were compared to analyze the change of disc height decrement and alignment.
RESULTS
ODI scores improved from 67.4 ± 11.5 preoperatively to 19.3 ± 12.1 at 2-year follow-up (p < 0.01). VAS scores of the leg decreased from 7.7 ± 1.5 to 1.7 ± 1.5 at the final follow-up (p < 0.01). Per the modified Macnab criteria, 81% of the patients improved to good/excellent. No cases of infection occurred. The intervertebral angle was significantly reduced from 6.26°± 3.54° to 5.58°± 3.23° at 2 years postoperatively (p = 0.027) and the dynamic intervertebral angle changed from 6.54°± 3.71° to 6.76°± 3.59°, which was not statistically significant (p = 0.562). No significant change in slippage was observed (3.76% ± 5.01% preoperatively vs. 3.81% ± 5.28% at the final follow-up [p = 0.531]). The dynamic percentage slip did not change significantly, from 2.65% ± 3.37% to 2.76% ± 3.71% (p = 0.985). However, intervertebral distance decreased significantly from 10.43 ± 2.23 mm to 10.0 ± 2.24 mm (p = 0.000).
CONCLUSIONS
Full endoscopic decompression using a 30° arthroscopy demonstrated a satisfactory clinical outcome at the 2-year follow-up. This technique reduces wound infection rate and did not bring about postoperative segmental spinal instability. It could be a feasible alternative to conventional open microscopic decompression or fusion surgery for degenerative lumbar spinal stenosis.

Keyword

Spinal stenosis; Endoscopic spine surgery; Minimally invasive spine surgery; Endoscopy; Arthroscopy

MeSH Terms

Arthroscopy*
Constriction, Pathologic
Decompression*
Endoscopy
Follow-Up Studies*
Hemorrhage
Humans
Laminectomy
Leg
Methods
Paraspinal Muscles
Postoperative Complications
Retrospective Studies
Spinal Stenosis*
Wound Infection

Figure

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  Fig. 1 Measurement of radiological data. (A) Intervertebral distance: vertical distance between the vertebrae at 50% (white line) of the anteroposterior diameter of each vertebral body (gray line). (B) Slip percentage: slip% = (B− A / B) × 100. White line: anteroposterior diameter of the vertebral body of the lower vertebra. Gray line: anteroposterior diameter of the vertebral body of the upper vertebra. Dotted line: end of vertebra. (C) Intervertebral angle.

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  Fig. 2 Flowchart of patient inclusion. UBED: unilateral biportal endoscopic decompression.

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  Fig. 3 (A) Setup for unilateral biportal endoscopic decompression surgery. (B) Locations of viewing (upper) and working (lower) portals. (C) Intraoperative photo showing the arthroscope and arthroscopic burr introduced through viewing and working portals.

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  Fig. 4 (A) Intraoperative endoscopic image showing decompression of the central canal and ipsilateral laminotomy. (B) Postoperative photo showing the skin incision point in unilateral biportal endoscopic decompression.

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  Fig. 5 (A) Visual analogue scale (VAS) pain scores assessed preoperatively and at 2 months and 2 years postoperatively. (B) Oswestry disability index (ODI) scores assessed preoperatively and at 2 months and 2 years postoperatively. (C) According to modified Macnab criteria, 81% of patients who underwent unilateral biportal endoscopic decompression experienced excellent or good results.

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  Fig. 6 Preoperative (A, B) and postoperative (C, D) T2-weighted magnetic resonance imaging scans obtained in a patient who underwent L4–5 decompression.

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