Unilateral biportal endoscopy, also known as tubular dilation endoscopy, is a minimally invasive spinal surgical technique that uses two small incisions and a tubular retractor to access the spine. This allows surgeons to perform interbody fusions, decompressions, discectomies, and other spine procedures through a less invasive approach compared to traditional open spinal surgery.
History and Development of the Technique
The concept of using Unilateral Biportal Endoscopy techniques for spinal procedures originated in the early 1990s as surgeons looked for alternatives to open spinal surgery. Initial techniques used single portal access but had limitations in visualization and instrumentation. In the late 1990s and early 2000s, surgeons began experimenting with multi-portal endoscopic techniques using more than one working channel.
The modern unilateral biportal technique was first described by Choi et al. in a 2010 publication. They reported on 20 patients who underwent lumbar discectomies, decompressions, and fusions through two skin incisions and a tubular retractor system. This allowed for bi-directional visualization and the use of irrigation to improve optics during the procedures. Over the next decade, surgeons refined the technique and began applying it to a wider variety of spinal pathologies.
Surgical Steps in Unilateral Biportal Endoscopy
Unilateral biportal endoscopy typically begins with the patient in the prone position on a radiolucent table under fluoroscopic guidance. Two small incisions are made on one side of the spine, usually 6-8cm apart. A series of tubular dilators are then used to dilate the soft tissues down to the lamina or disc space.
A tubular retractor is placed over the dilators connecting the two incisions. The distal port is used for the endoscope and irrigation while the proximal port accommodates surgical instruments. The endoscope provides real-time high definition magnified 3D visualization of the surgical field. Instruments such as shavers, rongeurs, and pituitary rongs can then be introduced through the working channel under endoscopic guidance.
For decompression procedures like discectomies or laminectomies, the endoscope is used to visually confirm adequate nerve root decompression. For fusion cases, the endoscope allows for preparation of the endplates and placement of bone graft and cages or rods and screws. Closure involves removing the tubes and closure of the small incisions. The entire procedure is done through the tubular sleeves without any muscle dissection required.
Advantages over Open and Traditional MIS Surgery
Compared to open spinal surgery, unilateral biportal endoscopy provides several key benefits to surgeons and patients:
- Minimally Invasive Approach: The technique uses only two tiny incisions rather than a long posterior midline incision. This results in less soft tissue and muscle dissection, less blood loss, and minimal tissue trauma.
- Reduced Post-Operative Pain: Studies have consistently shown less post-operative pain, lower opioid usage, and faster recovery with MIS approaches like unilateral biportal endoscopy versus open surgery.
- Improved Visualization: The endoscope provides high-definition 3D magnified views inside the spinal canal and disc spaces. This allows for more meticulous decompression and visualization of critical neurovascular structures compared to traditional MIS techniques.
- Less Disruption of Paraspinal Muscles: Since the entire procedure is done through narrow tubular sleeves rather than through open channels, there is minimal trauma to the important back muscles and supporting ligaments. This leads to less post-operative weakness and pain.
- Shorter Hospital Stays: With less post-operative discomfort and faster recoveries, patients are often discharged from the hospital much sooner after unilateral biportal endoscopy versus open spinal procedures.
- Earlier Return to Normal Activity: Multiple studies have shown patients return to work and normal daily activities an average of 1-2 weeks sooner with endoscopic techniques versus open surgeries.
- Success Comparable to Open Surgery: Early studies have shown unilateral biportal endoscopy can achieve comparable fusion, decompression, and clinical success rates as open surgery with all the advantages of a minimally invasive approach.
Specific Spinal Applications
While initial experience with unilateral biportal endoscopy focused on discectomies, surgeons are now using the technique for a variety of other spinal pathologies:
- Lumbar Discectomies: Removal of herniated disc material compressing spinal nerves remains the most common application due to the precision and visualization benefits of the endoscope.
- Cervical and Lumbar Decompressions: In select patients with lateral recess, foraminal, or central canal stenosis, unilateral biportal endoscopy allows for meticulous decompression of nerves equal to open procedures.
- Interbody Fusions: Preparation of the endplates and insertion of bone graft and/or cages can be effectively performed through bilateral portals to achieve arthrodesis.
- Transforaminal Lumbar Interbody Fusions (TLIF): Increased angle and quality of endplate preparation enables TLIF procedures to be performed unilaterally versus open bilateral approaches.
- Corpectomies: Vertebral body resections for traumatic, infectious, or tumorous lesions can be carried out endoscopically with biportal visualization and instrumentation.
- Kyphosis Corrections: In select patients, the endoscope enables direct visual guided insertion of pedicle screws, rods, and kyphosis reduction procedures.
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