Journal of Orthopaedics 15 (2018) 366–371

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Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

Original Article

Unilateral biportal endoscopic decompression by 30° endoscopy in lumbar T

spinal stenosis: Technical note and preliminary report
⁎
Ju-Eun Kima, , Dae-Jung Choib
a
Department of Orthopedic Surgery, An-dong Hospital, 574-2, Susang-dong, Andong-si, Gyeongsangbuk-do, South Korea
b
Barun Hospital, Jin-ju, Kyungsang Province, South Korea

A B S T R A C T

Background context: Open laminectomy has been regarded as the standard surgical method up to date in de-
generative spinal stenosis or herniation of intervertebral disc. The conventional method may lead to instability
and provoke chronic lower back pain by scarifying facet joint, posterior ligamentous complex as well as para-
spinal muscle. For this reason, the new technique using an endoscope, which could protect soft tissue and facet
joint, recently got spotlight.
Purpose: The aim of this study is to introduce a new spinal surgical technique using a 30-degreed endoscopy
through bi- or tri- portals and to report the preliminary result of this technique.
Study design: retrospective study
Methods: One hundred five patients who were suffering from neurologic symptoms by degenerative lumbar
spine disease were included even after preoperative conservative treatment. Two or three portals were used for
each level. One portal was used for viewing, the others, for working of a certain instrument. Unilateral lami-
notomy was followed by bilateral decompression under 30° endoscopy. Clinical outcomes were analyzed in view
of modified-Macnab criteria, Oswestry Disability Index (ODI), Visual analog scale (VAS), and postoperative
complications were analyzed.
Results: The ODI improved from 67.4 ± 11.5 preoperatively to 22.9 ± 12.4 postoperatively. VAS for leg de-
creased from 7.7 ± 1.5 to 2.4 ± 1.3 at final follow up. Eighty-eight percent of the patients were improved over
a level of good based on the Macnab criteria. There were not infection case.
Conclusions: The 30-degreed endoscopy had the advantages of obtaining a wider view. Full endoscopic de-
compression using 30-degreed endoscopy allowed satisfactory result clinically and reduction of surgical infec-
tion. It could be alternative method of microscopic laminectomy.

1. Introduction segment.2 In addition, it could be vulnerable to adjacent segmental

degeneration by wide posterior dissection that injures paraspinal
Spinal stenosis is an encroachment on the neural structure by sur- muscle due to operating posterior lumbar fusion. Multifidus muscle
rounding soft tissue and bone.1 It is the most common reason for spine injury and atrophy are common after posterior lumbar spine surgery
surgery in adults over 60 years.1 The treatment of lumbar spinal ste- and are associated with lower back pain and functional disability.4 The
nosis has been increasing in old age. Posterior spinal fusion is regarded posterior splitting approach is an important cause of multifidus muscle
as the current standard surgical treatment of various lumbar spinal injury and atrophy in posterior lumbar spinal surgery.4 Denervation
stenosis.2 However, these operations lead to several kind of problems. and disuse may be important factors in muscle atrophy in the splitting
The traditional operation of this disease involves wide dissection of approach. Infection and significant blood loss could also be problems in
paraspinal muscle for the enough space for the proper procedure, fol- case of lumbar fusion and wide laminectomy. The prevalence of spinal
lowed by excessive removal of bone structure and ligament structure for surgical site infection was reported 3.5% in validation cohort study. The
decompression.3 Inevitably, most surgeons would operate posterior predisposing factors for surgical site infection were old age, higher BMI
lumbar fusion to prevent due to iatrogenic instability. Although pos- and, presence of certain comorbidities.5 Reduction of infection rate is
terior lumbar fusion with screw fixation leads to a satisfactory outcome. regarded as important due to characteristic of patients who have the
A firm fusion is able to accelerate degeneration of the adjacent unfused spinal stenosis in old age as well as having certain morbidity. According

⁎
Corresponding author.
E-mail address: dspfuture@hanmail.net (J.-E. Kim).

https://doi.org/10.1016/j.jor.2018.01.039
Received 21 August 2017; Accepted 14 January 2018
Available online 31 January 2018
0972-978X/ © 2018 Prof. PK Surendran Memorial Education Foundation. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
J.-E. Kim, D.-J. Choi Journal of Orthopaedics 15 (2018) 366–371

to Huang YH et al., the incidence of significant blood loss (over 500 ml)
during lumbar fusion was reported over 53% and substantial bleeding
in lumbar fusion is associated with a greater incidence of morbidities
and prolonged length of hospital stay.6 In case of open spinal surgery,
since the above problem may occur, various instruments and techniques
were invented in order to prevent these problems. Recently, biportal
endoscopic spinal surgery were reported by several authors7–10,and
have started to get spotlighted. So far, there are few reports that present
clinical outcomes, specifically technical reports about biportal endo-
scopic surgery for spinal stenosis. The purpose of this study evaluates
the unilateral biportal endoscopic spinal surgery for in degenerative
spinal stenosis and presents a technical note.

2. Material and methods

The study was carried out after the approval of the institutional
review board. All patients who received unilateral biportal endoscopic
decompression consented and signed prior to operation. The clinical
outcomes including Oswestry Disability Index, Modified Macnab cri-
teria, VAS, operation time, and complication rate were analyzed from
patients who were treated by unilateral biportal decompression using
30° endoscopy. The number of patients was one hundred five. These
patients were diagnosed with spinal stenosis and treated by our in-
stitution via unilateral biportal endoscopic decompression. Other pa-
tients with other diagnoses such as lumbar disc herniation or re stenosis Fig. 1. A lateral and anteroposterior view of this lumbar spine exhibits the locations of
due to adjustment segmental degeneration were excluded from the the two portals.
patient pool. Unilateral biportal endoscopic decompression was oper-
ated by a single surgeon. Instruments including basic spine instruments
and 30° 4 mm arthroscopy (Linvatec®) which were commonly used in
joint arthroscopy, and Arthrocare (Smith & Nephew®), 4.2 mm arthro-
scopic burr, shaver were used in operation. The procedures were op-
erated under spinal or general anesthesia. The patients were positioned
prone along with the abdomen free, the spine was flexed to widen inter
laminar space.

2.1. Operation technique

Level confirmation was conducted under C-arm prior to operation.

A proximal portal was made just below the pedicle of lamina that had to
be laminotomized, and a distal portal was made in the same manner
just below the pedicle of the lower lamina (Fig. 1). The two portals were
0.5 cm in diameter, enough to insert instruments and endoscope. The
distance of the two portal was different depending on the height of
patient and level. In general, the distal portal was located 2–3 cm
caudal to proximal portal. The scopic trocha was introduced to the
proximal portal and the round-shape, smooth periosteal elevator was
inserted to the distal portal through the paraspinal muscle without any
dissection until it was located at the end of the lamina. (Fig. 2) Sweep
the muscle overlying lamina and inter lamina space with periosteal
elevator to make enough space for vision. In case of failure to acquire
the proper portal, another portal also can be added for smooth pro-
gression. Lower pressure inflow water that is under 30 mmHg should be
initiated through the proximal portal. Outflow should be made through
the distal portal to achieve continuous irrigation to prevent congestion
of soft tissue. If there is no water flow with water congestion in the
operation field, there are some problem that can occur. First, when the
flow of water was congested without a definite water current, the visual
field of operation was not clear, consequentially. Second, water could
infiltrate to the multifidus muscle so that could undergo significant
trouble when working due to limited space by soft tissue swelling of the
muscle. Third, the camera lens can be destroyed due to overheating by
radiofrequency catheter. The water current should be maintained not to
experience these problems. Problem of the water congestion can be
solved by inserting root retractor or 5.5 mm transparent plastic cannula
through the portal (Fig. 3). Identification of the facet joint, a significant Fig. 2. Intraoperative fluoroscopy image of the lumbar spine and a gross photo of both
the working and viewing portals. The two portals meet at the end of the lamina.
landmark in the surgery is very important after obtaining working

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Fig. 3. Endoscopic images of (Right) 5.5 mm transparent plastic cannula and (Left) root retractor which can solve water congestion.

flavum should be preserved because it can play a role as a protective

barrier until the completion of the bony work at the contralateral la-
mina. If 30° endoscopy is at a 12 O’clock angle, it can visualize the base
of the contralateral lamina and the spinous process. In the case of a 6
O’clock angle, it can visualize inferior articular process and inferior
lamina. When partial laminotomy of superior part at inferior lamina is
necessary, switching the portals for convenient working could be
helpful during operation. Ipsilateral decompression should be per-
formed with arthroscopic burr and Kerrison rongeur until the superior
part of the ligamentum flavum is exposed, (Fig. 5A), followed by the
undercut of contralateral lamina and the base of spinous process in
order to make enough space for handling in contralateral space. The
inferior portion of ligamentum flavum should be ablased in order to
expose the superior end of inferior lamina using RF catheter. After
switching the two portals again, the superior portion of the inferior
lamina was thinning with burr. A blunt dissector such as a curret or
dura elevator verifies the plane between the ligament flavum and the
dura. After confirming no adhesion between the ligamentum flavum
and dura, a flavectomy could be performed using the Kerrison punch
and pituitary forcep for ipsilateral decompression of the neural struc-
ture. For contralateral decompression, both the scope and working in-
strument should exceed the top of the lamina in order to approach the
contralateral ligamentum flavum. Blind usage of the Kerrison punch at
contralateral ligamentum flavum could lead to a high possibility of dura
tear due to the tight ligamentum flavum and folding of dura in severe
spinal stenosis. The Over the top technique is very useful that con-
tralateral side should be decompressed. For Over the top technique,
arrow of scope should be rotated to 11 O’clock to obtain an adequate
view of the contralateral side in case of left decompression case.
(Fig. 5B).When the scope is rotated to 1 O’clock, the operator can obtain
a better view in right side case. The smooth curret could be used to
detach the ligamentum flavum from the contralateral lamina wall and
then make space between the dura and ligamentum flavum for more
safety while working (Fig. 5C). The ligamentum flavum should be re-
moved using a Kerrison punch and pituitary forcep on the condition
that it is detached from both the dura and lamina wall. When tight
Fig. 4. (A)Endoscopic views at the facet joint and (B) laminotomy with burr. The round adhesion is present between ligamentum flavum and dura it is re-
figure indicates the location of the endoscopic view. (White arrow) lamina, (Black arrow) commended to use several tips
facet. First, the magnification of arthroscopy can help surgeons do more
sophisticated work and prevent accidental dura tear due to kerrison
punch. Second, in cases of severe adhesions such as epidural fat loss,
space. The facet joint looks bright by the joint capsule on endoscope.
gentle adheolysis using continuous irrigation and blunt dura elevator
The lamina should be identified along the facet joint. A shaver function
can provide space between dura and ligamentum flavum. Unlike open
or RF catheter can be used to clean soft tissue and debris over the la-
surgery, adheolysis is easier because of the penetration of water into
mina. The arthroscopic 4.2 mm burr or osteotome was used to make
tissues.
thin ipsilateral lamina and a part of the spinous process followed by the
Additional annuloplasty is performed with a RF catheter in the case
Kerrison roungeur to achieve a laminotomy (Fig. 4). The ligamentum

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Fig. 5. (A) An endoscopic view of ipsilateral laminectomy. spinous process (white arrow), ligamentum flavum (black arrow). (B) Contralateral decompression with Over the top
technique. ligamentum flavum (black arrow), dura (white arrow). (C)The schematic view of ‘Over the top technique'., TP transverse process, SP, spinous process, LF, ligamentum flavum.

of disc protrusion which provokes a canal compromise. The operation is follow up. The postoperative mean ODI significantly improved from
finished after confirmation of bilateral decompression use of blunt 67.4 ± 11.5 to 22.9 ± 12.4 (P < 0.01). 88% of patients improved
probe (Fig. 6). After the instruments and endoscope were removed, the over a good base on the Macnab criteria. The recorded outcomes, ac-
skin incision were closed. After drain removal, postoperative MRI was cording to the modified Macnab criteria, were excellent in 81 patients
checked. (Fig. 7). (77%), good in 12 (11%), fair in 10 patient (10%), and poor in 2 patient
(2%) (Table 2). Complications with unilateral biportal endoscopic de-
2.2. Statistatical analysis compression by 30° endoscopy were limited to 3 cases. Although dura
tear occurred in 2 cases, symptoms improved after conservative treat-
All stastistical analyses were performed using Statistical Package for ment. One patient who had neurologic symptoms got revision surgery
Social Sciences (version 18; SPSS, Chicago, Illinois). Values are pre- due to postoperative epidural hematoma. The patient was treated again
sented as means ± standard deviation. Patient data was analyzed by unilateral biportal decompression by 30° endoscopy through the
using the paired t-test. P < 0.05 was regarded as statistically sig- same portals which were used previously.
nificant.
4. Discussion
2.3. Surgical indication
Open decompressive laminectomy is known as the conventional
Radiating leg pain or neurogenic claudication dominant spinal ste- treatment of spinal stenosis. However, back pain and muscle atrophy
nosis, multilevel spinal stenosis Grade I spondylolithesis, can occur due to excessive dissection of the paraspinal muscle, espe-
cially postoperative multifidus.4 The number of posterior lumbar fu-
3. Result sions also increases due to inevitable iatrogenic instability, caused by
wide decompression including facetectomy.11 Adjacent segmental de-
The one hundred five patients were treated in our institution. There generation can occur after posterior lumbar fusion. On this account,
were forty six male patients and fifty nine female patients. The ages of spinal stenosis can recur and develop lower back pain over time.12
the patients ranged from 52 to 86 years old, with a mean age of Minimal invasive spinal surgical techniques were developed and spot-
71.2 ± 8.9. The operation was performed by unilateral biportal en- lighted to reduce surgical trauma and decrease the rate of iatrogenic
doscopic decompression. A record of blood loss was not acquired due to lumbar fusion surgery due to these problem. Problems also include
the character of the operation which uses continuous watery irrigation inevitable muscle dissection and difficulty of decompression at the
(Table 1). The mean follow up period was 14 months. The mean op- contralateral side in the case of ULBD (unilateral laminotomy with bi-
erative time for 1 level was 53 ± 13.5 min. The postoperative mean lateral decompression), which is most similar to the unilateral biportal
VAS for leg decreased from 7.7 ± 1.5 to 2.4 ± 1.3 (P < 0.01) at final endoscopic decompression technique. When tubular spinal surgery is

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Fig. 7. (A) Central spinal stenosis of L4-5 is shown in this preoperative MRI. (B)
Postoperative MRI showing that the spinal canal was decompressed completely by uni-
lateral biportal decompression with 30°endoscopy.

Table 1
Record of blood loss.

Preoperative Postoperative (Final f/u)

VAS for Leg 7.7 ± 1.5 2.4 ± 1.3

ODI. 67.4 ± 11.5 22.9 ± 12.4
Macnab criteria Above good – 88%

Table 2
Recorded outcomes.
Fig. 6. (A) An endoscopic view of the contralateral side after decompression. annulus (red
arrow), contralateral facet joint (black arrow), traversing root (white arrow). (B) The Characteristic Value
complete decompression of the spinal canal. annulus (red arrow), ipsilateral facet (black
arrow), ipsilateral traversing root (white arrow). (For interpretation of the references to Age 52 to 86 (71.2 ± 8.9)
colour in this figure legend, the reader is referred to the web version of this article.) Male/Female 46/59
Mean operation time for 1 level. 53 ± 13.5
Complication (dura tear) 2
operated, the diameter of tube is not wide enough to work properly in a (epidural hematoma) 1
16 mm tube. In addition, it has not been verified with regard to spinal (infection) 0
instability due to the damage of the supraspinous ligament by tubular
spinal surgery up to date.13 Although, microscopic decompression
technique is anatomically familiar to spine surgeons, more muscle not the tube. In addition, the triangulation technique is used as a basic
dissection is required compared to the unilateral biportal endoscopic concept for arthroscopy and biporal endoscopic surgery has a sub-
technique. It is relatively not easy to obtain good contralateral view stantial advantage over the other technique as it provides un-
depending on the patient. In contrast, the advantage of the unilateral constrained working space through two independent portals. Therefore,
biportal endoscopic technique is that it provides a good view of the while decompression of only the central stenosis is possible by the
contralateral, sublaminar foraminal area without additional incision. In single portal technique, the biportal technique can decompress both
addition, there is less muscle dissection. The risk of infection is low and central stenosis and lateral stenosis.
clear visualization and less intraoperative bleeding can be obtained due Unilateral biportal endoscopic decompression technique allows the
to continuous saline irrigation. However, the surgeon should under- decompression of the contralateral side and the identification of the
stand the concept of triangulation and overcome a steep learning curve contralateral facet as well as the traversing root without excessive re-
in order to perform this operation. Meningeal irritation can be caused sectioning of the bony structure. The portals made in the intermuscular
by excessive saline irrigation after surgery. plane of the multifidus provide space between the multifidus and the
Although Komp et al. recently reported a retrospective study related lamina in order to prevent failed back syndrome, which is caused by
to decompression surgery using single portal endoscopy in spinal ste- muscle atrophy and denervation of the posterior ligament complex and
nosis. There are disadvantages to viewing and working in a single portal the paraspinal muscle. Also, tissue debris did not congest due to con-
compared to two portals.14 The single portal technique is narrow in tinuous water flow through an in and out point. Although the pre-
vision because viewing and working are done by one portal. The single valence of spinal surgical site infection was reported 3.5% in validation
portal has also a limited working space. In the biportal technique, cohort study.5 There are not any infection cases up to date because of
working is done freely in the space between the muscle and the lamina, the continuous irrigation. It can be considered that the improvement of

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the inflammatory environment was achieved by continuous irrigation. Conflict of interest

There were two cases of dura tear. The dura tear of both cases occurred
early in the learning curve, and fortunately it was a small tear within None.
about 5 mm. The symptoms of patients improved after conservative
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