Form June to January , the data of the consecutive hospitalized patients with LDH undergoing UBE or PELD in Huzhou Central Hospital were retrospectively collected. According to the following inclusion and exclusion criteria. 54 patients were suitable for our study.
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The inclusion criteria included the following: (1) clinical symptoms of back or radiating pain; (2) magnetic resonance images with single level herniation associated with symptoms; (3) conservative treatment failed over three months; (4) follow-up of at least 6 months.
The exclusion criteria included the following: (1) segmental instability; (2) recurrent LDHs; (3) severe central or lateral-recess stenosis; (4) Cauda equina syndrome. (5) spinal tumors; (6) ankylosing spondylitis; (7) lumbar vertebral fracture.
All surgical procedures were performed by one experienced surgeon.
All surgical operations were performed under general anesthesia. Patients were placed in a prone position on a radiolucent table. The surgeon confirmed the target intervertebral site in a frontal view and stood on the left side of the patient. Two skin insertion points were made at 1&#;1.5 cm lateral to the midline, and the surface of the inferior margin of the upper lamina was the incision for endoscope insertion, while the surface of superior margin of the lower lamina was the incision for surgical instruments insertion. The soft tissue was endoscopically cauterized with radiofrequency ablation, to create working space. Next, the spinolaminar junction at the target intervertebral site were identified, a partial laminotomy was performed, part of the inferior lamina of the upper lumbar spine and superior lamina of the lower lumbar spine were removed using an electric drill. The interlaminar ligament was dissected and removed using Kerrison punch and a radiofrequency probe, followed by dissection and exposure of the annulus of the protruding intervertebral disc. Prior to discectomy, overgrown epidural vessels were coagulated carefully to minimize bleeding. The ruptured fragments were then removed using Kerrison punches and pituitary forceps. Finally, decompression of the nerve root and pulsation of the dura mater was confirmed, a drain inserted, and the surgical incision closed (Fig. 1).
Fig. 1A, B Preoperative sagittal and axial magnetic resonance images in a 34-year-old male patient complaining of left radicular leg pain, showing L4&#;L5 disc herniation on the left side. C Image of the patient who underwent unilateral biportal endoscopic discectomy. D Endoscopic image showing the relaxation of L5 nerve root after decompression. E, F Postoperative sagittal and axial magnetic resonance images made one day after surgery. High signal intensity (red arrow) indicating blood extravasates. G, H Postoperative computed tomography made two days after surgery showing defect of lamina after partial laminotomy
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All surgical operations were performed under local anesthesia. Patients were lying lateral with the affected side facing upwards. Under X-ray guidance, the puncture site was confirmed and marked by the surgeon, an 18-gauge spinal needle was then inserted into the target intervertebral disc level. In the lateral view, the needle tip was located at the posterior vertebral bodyline. In the anterio-posterior view, the same needle tip layed at the medial pedicular line. A guidewire was inserted through the spinal needle, and then the needle was removed. Next, an incision was made in order to insert a tapered cannulated obturator along the guidewire, followed by insertion of the obturator into the disc with hammering. Thereafter, a bevel-ended, oval-shaped working cannula was inserted. Finally, an endoscope was inserted through the working cannula, and the herniated disc removed with endoscopic forceps and radiofrequency probe, and the surgical incision closed (Fig. 2).
Fig. 2A, B Preoperative sagittal and axial magnetic resonance images in a 29-year-old male patient complaining of right radicular leg pain, showing L5-S1 disc herniation on the right side. C Image of the patient who underwent percutaneous endoscopic lumbar discectomy. D Endoscopic image showing the relaxation of S1 nerve root after decompression. E, F Postoperative sagittal and axial magnetic resonance images made one day after surgery
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General information included age, gender, height and weight for body-mass index (BMI) calculation, follow-up duration, disc location and disc level. Perioperative data included hematocrit (Hct), Hemoglobin (Hb), total blood loss (TBL), intraoperative blood loss (IBL), hidden blood loss (HBL), operation time, incision length, hospital stay, complications and total hospitalization costs were collected and evaluated.
The TBL was calculated according to the formula proposed by Gross [10].
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$$\mathrm{TBL }(\mathrm{mL})=\mathrm{EBV}(\mathrm{L})\times \frac{{\mathrm{Hct}}_{\mathrm{pre}}-{\mathrm{Hct}}_{\mathrm{post}}}{{\mathrm{Hct}}_{\mathrm{ave}}}\times $$
where EBV&#;=&#;patient&#;s estimated blood volume; \({\mathrm{Hct}}_{\mathrm{pre}}\)= patient&#;s pre-operative hematocrit; \({\mathrm{Hct}}_{\mathrm{post}}\) = patient&#;s post-operative hematocrit;\({\mathrm{Hct}}_{\mathrm{ave}}\)= (\({\mathrm{Hct}}_{\mathrm{pre}}-{\mathrm{Hct}}_{\mathrm{post}}\))/2; and EBV was calculated on the basis of the Nadler formula [11].
$${\text{EBV }}\left( {{\text{ml}}} \right) = {\text{k1}} \times {\text{height}}\left( {\text{m}} \right) \times {3} + {\text{k2}} \times {\text{weight }}\left( {{\text{kg}}} \right) + {\text{k3}},$$
For men, k1&#;=&#;0., k2&#;=&#;0., and k3&#;=&#;0., for women k1&#;=&#;0., k2&#;=&#;0., and k3&#;=&#;0..
The IBL was calculated as the suction fluid minus the liquid used to irrigation during the surgery, and the weight difference between gauzes and surgical towels before and after surgery.
The HBL was calculated as follows: HBL&#;=&#;TBL&#;IBL&#;postoperative drainage. In UBE group, the postoperative drainage was recorded as the amount of blood in the drainage bag until it was removed when the drainage flow was&#;<&#;50 ml/day. In PELD group, no drains were placed, and the postoperative drainage was calculated as zero.
The clinical outcomes were evaluated by collecting questionnaire answers [visual analogue scale (VAS) for measuring back and leg pain intensity and Oswestry disability index (ODI) for disability] preoperatively and 1 day, 1 month and 6 months postoperatively. The patient satisfaction rate of clinical outcomes was assessed by modified MacNab criteria, which include four grades: excellent, good, fair, and poor, excellent and good were recognized as clinically satisfactory.
All statistical analyses were performed using SPSS software. (Version 26.0, Chicago, IL, USA). Intergroup comparisons were employed using independent samples t-test, Chi-Square tests and Mann&#;Whitney U tests; Intragroup comparisons were conducted using paired t test. Comparisons with values of P&#;<&#;0.05 were considered statistically significant.
Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery technique increasingly employed in treating degenerative lumbar diseases, such as lumbar disc herniation, lumbar spinal stenosis, and spondylolisthesis. In UBE, two independent yet interconnected surgical channels are established-one for the endoscope and the other for surgical instruments-providing a broad and clear surgical field of view. UBE offers several advantages over traditional open surgery, including reduced tissue damage, shorter hospital stays, and faster recovery times. Additionally, it combines the benefits of microscopic surgery and interlaminar endoscopy, enhancing flexibility, accuracy, and reliability during the procedure. The learning curve for UBE is shorter than that for transforaminal endoscopy, as the surgical processes closely resemble those of conventional open surgery. Despite its favorable clinical outcomes, such as reduced blood loss and shorter hospitalization, UBE carries potential complications, including epidural hematoma, dural injury, and compression of the outlet nerve root. To mitigate these risks, it is crucial to ensure appropriate patient selection, apply the correct surgical technique, and engage in careful postoperative monitoring. This article provides a detailed summary of the step-by-step surgical techniques used in UBE for treating lumbar disc herniation. It serves as a comprehensive guide to enhance practitioners' understanding of UBE. The presentation also underscores the importance of rigorous training and expertise to ensure optimal patient outcomes.
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