Digital three-dimensional assisted unilateral biportal endoscopy in treatment of highly isolated lumbar disc herniation with translaminar approach_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

SU Weiliang ¹ , LU Suni ² , LIU Dong ¹ , XING Jianqiang ¹ , HU Peng ¹ , DOU Yongfeng ¹ , GENG Xiaopeng ¹ ,  WANG Dawei ¹

1. Department of Spinal Surgery, Binzhou Medical University Hospital, Binzhou Shangdong, 256603, P. R. China;
2. Neonatal Intensive Care Unit, Binzhou People’s Hospital, Binzhou Shandong, 256603, P. R. China;

Corresponding author：

WANG Dawei, Email: wdw1129@163.com

Keywords：

Translaminar approach; highly isolated; lumbar disc herniation; unilateral biportal endoscopy; digital three-dimensional technique

DOI：

10.7507/1002-1892.202412012

Video：

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Objective To investigate the effectiveness of digital three-dimensional (3D) assisted unilateral biportal endoscopy (UBE) in the treatment of highly isolated lumbar disc herniation (LDH) with translaminar approach. Methods The clinical data of 59 patients who met the selection criteria and underwent UBE treatment due to highly isolated LDH between January 2022 and December 2023 were retrospectively analyzed. Among them, 25 cases were treated with digital 3D assisted translaminar approach (observation group) and 34 cases were treated with interlaminar approach (control group). There was no significant difference in gender, age, disease duration, surgical segment, and preoperative visual analogue scale (VAS) score and Oswestry disability index (ODI) between the two groups (P>0.05). The operation time, intraoperative blood loss, and lateral articular surface preservation rate were recorded and compared between the two groups. VAS score and ODI were used to evaluate the improvement of pain and function before operation and at 3 and 6 months after operation. The modified MacNab criteria was used to evaluate the effectiveness at last follow-up. Results One patient in the control group had dural tear, and the other patients had no nerve injury, infection, dural tear, or other related complications. There was no significant difference in operation time and intraoperative blood loss between the two groups (P>0.05). Patients in both groups were followed up 6-13 months, with an average of 8.3 months. The lateral articular surface preservation rate in the observation group was significantly higher than that in the control group (P<0.05). Three patients in the observation group and 2 patients in the control group had calf muscle venous thrombosis, which was cured after anticoagulant treatment with rivaroxaban and delayed exercise time. There was no recurrence or second operation during the follow-up period. The VAS score and ODI of the two groups at 3 and 6 months after operation significantly improved when compared with those before operation (P<0.05). There was no significant difference between the two groups at each time point after operation (P>0.05). At last follow-up, the effectiveness was evaluated according to the modified MacNab criteria, and there was no significant difference in the evaluation grade and excellent and good rate between the two groups (P>0.05). Conclution UBE via translaminar approach is safe and effective for the treatment of highly isolated LDH, which is beneficial to protect the facet joint, maintain spinal stability, and reduce soft tissue injury. With the assistance of digital 3D technique, preoperative planning can be performed accurately.

1.	Choi G, Lee SH, Lokhande P, et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976), 2008, 33(15): E508-E515.
2.	Shepard N, Cho W. Recurrent lumbar disc herniation: A review. Global Spine J, 2019, 9(2): 202-209.
3.	Benzakour T, Igoumenou V, Mavrogenis AF, et al. Current concepts for lumbar disc herniation. Int Orthop, 2019, 43(4): 841-851.
4.	Divi SN, Makanji HS, Kepler CK, et al. Does the size or location of lumbar disc herniation predict the need for operative treatment? Global Spine J, 2022, 12(2): 237-243.
5.	Xie X, Zhang G, Liu N. Clinical effect of unilateral biportal endoscopy in the treatment of lumbar diseases: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne, 2022, 17(1): 61-68.
6.	Zhang Y, Song J, Lin W, et al. Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis. BMC Surg, 2024, 24(1): 113. doi: 10.1186/s12893-024-02379-2.
7.	Choi KC, Lee JH, Kim JS, et al. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10, 228 cases. Neurosurgery, 2015, 76(4): 372-380.
8.	Cai H, Liu C, Lin H, et al. Full-endoscopic foraminoplasty for highly down-migrated lumbar disc herniation. BMC Musculoskelet Disord, 2022, 23(1): 303. doi: 10.1186/s12891-022-05254-4.
9.	Chen WC, Wang WT, Pao JL. Unilateral biportal endoscopic discectomy via translaminar approach for highly upward-migrated lumbar disc herniation: a technical note and preliminary treatment outcomes. BMC Musculoskelet Disord, 2024, 25(1): 722. doi: 10.1186/s12891-024-07819-x.
10.	Yin J, Gao G, Chen S, et al. Comparative study between unilateral biportal endoscopic discectomy and percutaneous interlaminar endoscopic discectomy for the treatment of L₅/S₁ disc herniation. World Neurosurg, 2024, 194: 123526. doi: 10.1016/j.wneu.2024.11.109.
11.	Liu Y, Li X, Tan H, et al. Learning curve of uniportal compared with biportal endoscopic techniques for the treatment of lumbar disc herniation. Orthop Surg, 2025, 17(2): 513-524.
12.	Peng J, Lin R, Fang D, et al. Learning curve insights in Unilateral Biportal Endoscopic (UBE) spinal procedures: proficiency cutoffs and the impact on efficiency and complications. Eur Spine J, 2025. doi: 10.1007/s00586-024-08632-9.
13.	邵佳申, 孟海, 苏楠, 等. 单侧双通道脊柱内镜下单侧椎板切除双侧减压技术治疗腰椎管狭窄症的并发症特征及影响因素. 国际外科学杂志, 2024, 51(10): 710-716.
14.	Cossandi C, Fanti A, Gerosa A, et al. Translaminar approach for treatment of hidden zone foraminal lumbar disc herniations: Surgical technique and preoperative selection of patients with long-term follow-up. World Neurosurg, 2018, 16: 182-187.
15.	Di Lorenzo N, Porta F, Onnis G, et al. Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach. Neurosurgery, 1998, 42(1): 87-89.
16.	Ahn Y, Kim JE, Yoo BR, et al. A new grading system for migrated lumbar disc herniation on sagittal magnetic resonance imaging: An agreement study. J Clin Med, 2022, 11(7): 1750. doi: 10.3390/jcm11071750.
17.	Balain B, Bhachu DS, Gadkari A, et al. 2nd and 3rd generation full endoscopic lumbar spine surgery: clinical safety and learning curve. Eur Spine J, 2023, 32(8): 2796-2804.
18.	Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg, 2002, 97(1 Suppl): 7-12.
19.	李中锋, 刘晏东, 温力鹏, 等. 单孔非同轴脊柱内镜下经跨棘突入路治疗游离型腰椎间盘突出症的早期疗效. 中国修复重建外科杂志, 2025, 39(1): 83-87.
20.	Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine (Phila Pa 1976), 2005, 30(22): 2570-2578.
21.	Kim N, Jung SB. Percutaneous unilateral biportal endoscopic spine surgery using a 30-degree arthroscope in patients with severe lumbar spinal stenosis: A technical note. Clin Spine Surg, 2019, 32(8): 324-329.
22.	Dezawa A, Mikami H, Sairyo K. Percutaneous endoscopic translaminar approach for herniated nucleus pulposus in the hidden zone of the lumbar spine. Asian J Endosc Surg, 2012, 5(4): 200-203.
23.	Lin GX, Park CW, Suen TK, et al. Full endoscopic technique for high-grade up-migrated lumbar disk herniation via a translaminar keyhole approach: Preliminary series and technical note. J Neurol Surg A Cent Eur Neurosurg, 2020, 81(5): 379-386.
24.	张智, 刘元彬, 郑佳状, 等. 经皮脊柱内镜经椎板入路治疗向上重度游离型腰椎间盘突出症的临床研究. 中国骨与关节杂志, 2023, 12(1): 76-79.
25.	王栋, 许锦超, 程伟, 等. 经皮脊柱内镜通过骨性隧道治疗游离型腰椎间盘突出症. 中国骨伤, 2021, 34(11): 994-1001.
26.	余洋, 谢一舟, 石银, 等. 三维有限元法分析腰椎不同尺寸关节突成形后相关节段的生物力学特征. 中国组织工程研究, 2021, 25(33): 5288-5293.
27.	Ito Z, Shibayama M, Nakamura S, et al. Clinical comparison of unilateral biportal endoscopic laminectomy versus microendoscopic laminectomy for single-level laminectomy: A single-center, retrospective analysis. World Neurosurg, 2021, 148: e581-e588.
28.	Musa G, Barrientos REC, Makirov SK, et al. Repeat discectomy for recurrent same level disc herniation: A literature review of the past 5 years. Surg Neurol Int, 2023, 14: 100. doi: 10.25259/SNI_168_2023.
29.	Heo DH, Son SK, Eum JH, et al. Fully endoscopic lumbar interbody fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results. Neurosurg Focus, 2017, 43(2): E8. doi: 10.3171/2017.5.FOCUS17146.
30.	Lee CW, Yoon KJ, Kim SW. Percutaneous endoscopic decompression in lumbar canal and lateral recess stenosis—The surgical learning curve. Neurospine, 2019, 16(1): 63-71.
31.	朱斌, 田大胜, 陈磊, 等. 单边双通道内镜技术在腰椎疾病中的应用研究进展. 中华骨科杂志, 2020, 40(15): 1030-1038.
32.	张玉红, 冯波, 苏炜良, 等. 单侧双通道脊柱内镜技术椎管减压术治疗双节段腰椎管狭窄症的早期临床疗效. 中国修复重建外科杂志, 2023, 37(6): 706-712.
33.	Ding H, Hai Y, Zhou L, et al. Clinical application of personalized digital surgical planning and precise execution for severe and complex adult spinal deformity correction utilizing 3D printing techniques. J Pers Med, 2023, 13(4): 602. doi: 10.3390/jpm13040602.
34.	Tappa K, Bird JE, Arribas EM, et al. Multimodality imaging for 3D printing and surgical rehearsal in complex spine surgery. Radiographics, 2024, 44(3): e230116. doi: 10.1148/rg.230116.
35.	李鹏, 李想, 马琳, 等. 3D打印技术辅助全脊柱内镜精准开窗髓核摘除术治疗高度游离型腰椎间盘突出症的疗效观察. 中国骨与关节损伤杂志, 2023, 38(1): 25-29.
36.	赵加庆, 刘栋, 陆素妮, 等. 数字3D技术辅助单孔分体内镜手术治疗高度游离型腰椎间盘突出症. 中国组织工程研究, 1-7[2025-01-27]. http://kns.cnki.net/kcms/detail/21.1581.R.20241204.1136.006.html.
37.	Pao JL. Biportal endoscopic transforaminal lumbar interbody fusion using double cages: Surgical techniques and treatment outcomes. Neurospine, 2023, 20(1): 80-91.

1. Choi G, Lee SH, Lokhande P, et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976), 2008, 33(15): E508-E515.
2. Shepard N, Cho W. Recurrent lumbar disc herniation: A review. Global Spine J, 2019, 9(2): 202-209.
3. Benzakour T, Igoumenou V, Mavrogenis AF, et al. Current concepts for lumbar disc herniation. Int Orthop, 2019, 43(4): 841-851.
4. Divi SN, Makanji HS, Kepler CK, et al. Does the size or location of lumbar disc herniation predict the need for operative treatment? Global Spine J, 2022, 12(2): 237-243.
5. Xie X, Zhang G, Liu N. Clinical effect of unilateral biportal endoscopy in the treatment of lumbar diseases: a systematic review and meta-analysis. Wideochir Inne Tech Maloinwazyjne, 2022, 17(1): 61-68.
6. Zhang Y, Song J, Lin W, et al. Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis. BMC Surg, 2024, 24(1): 113. doi: 10.1186/s12893-024-02379-2.
7. Choi KC, Lee JH, Kim JS, et al. Unsuccessful percutaneous endoscopic lumbar discectomy: a single-center experience of 10, 228 cases. Neurosurgery, 2015, 76(4): 372-380.
8. Cai H, Liu C, Lin H, et al. Full-endoscopic foraminoplasty for highly down-migrated lumbar disc herniation. BMC Musculoskelet Disord, 2022, 23(1): 303. doi: 10.1186/s12891-022-05254-4.
9. Chen WC, Wang WT, Pao JL. Unilateral biportal endoscopic discectomy via translaminar approach for highly upward-migrated lumbar disc herniation: a technical note and preliminary treatment outcomes. BMC Musculoskelet Disord, 2024, 25(1): 722. doi: 10.1186/s12891-024-07819-x.
10. Yin J, Gao G, Chen S, et al. Comparative study between unilateral biportal endoscopic discectomy and percutaneous interlaminar endoscopic discectomy for the treatment of L₅/S₁ disc herniation. World Neurosurg, 2024, 194: 123526. doi: 10.1016/j.wneu.2024.11.109.
11. Liu Y, Li X, Tan H, et al. Learning curve of uniportal compared with biportal endoscopic techniques for the treatment of lumbar disc herniation. Orthop Surg, 2025, 17(2): 513-524.
12. Peng J, Lin R, Fang D, et al. Learning curve insights in Unilateral Biportal Endoscopic (UBE) spinal procedures: proficiency cutoffs and the impact on efficiency and complications. Eur Spine J, 2025. doi: 10.1007/s00586-024-08632-9.
13. 邵佳申, 孟海, 苏楠, 等. 单侧双通道脊柱内镜下单侧椎板切除双侧减压技术治疗腰椎管狭窄症的并发症特征及影响因素. 国际外科学杂志, 2024, 51(10): 710-716.
14. Cossandi C, Fanti A, Gerosa A, et al. Translaminar approach for treatment of hidden zone foraminal lumbar disc herniations: Surgical technique and preoperative selection of patients with long-term follow-up. World Neurosurg, 2018, 16: 182-187.
15. Di Lorenzo N, Porta F, Onnis G, et al. Pars interarticularis fenestration in the treatment of foraminal lumbar disc herniation: a further surgical approach. Neurosurgery, 1998, 42(1): 87-89.
16. Ahn Y, Kim JE, Yoo BR, et al. A new grading system for migrated lumbar disc herniation on sagittal magnetic resonance imaging: An agreement study. J Clin Med, 2022, 11(7): 1750. doi: 10.3390/jcm11071750.
17. Balain B, Bhachu DS, Gadkari A, et al. 2nd and 3rd generation full endoscopic lumbar spine surgery: clinical safety and learning curve. Eur Spine J, 2023, 32(8): 2796-2804.
18. Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg, 2002, 97(1 Suppl): 7-12.
19. 李中锋, 刘晏东, 温力鹏, 等. 单孔非同轴脊柱内镜下经跨棘突入路治疗游离型腰椎间盘突出症的早期疗效. 中国修复重建外科杂志, 2025, 39(1): 83-87.
20. Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine (Phila Pa 1976), 2005, 30(22): 2570-2578.
21. Kim N, Jung SB. Percutaneous unilateral biportal endoscopic spine surgery using a 30-degree arthroscope in patients with severe lumbar spinal stenosis: A technical note. Clin Spine Surg, 2019, 32(8): 324-329.
22. Dezawa A, Mikami H, Sairyo K. Percutaneous endoscopic translaminar approach for herniated nucleus pulposus in the hidden zone of the lumbar spine. Asian J Endosc Surg, 2012, 5(4): 200-203.
23. Lin GX, Park CW, Suen TK, et al. Full endoscopic technique for high-grade up-migrated lumbar disk herniation via a translaminar keyhole approach: Preliminary series and technical note. J Neurol Surg A Cent Eur Neurosurg, 2020, 81(5): 379-386.
24. 张智, 刘元彬, 郑佳状, 等. 经皮脊柱内镜经椎板入路治疗向上重度游离型腰椎间盘突出症的临床研究. 中国骨与关节杂志, 2023, 12(1): 76-79.
25. 王栋, 许锦超, 程伟, 等. 经皮脊柱内镜通过骨性隧道治疗游离型腰椎间盘突出症. 中国骨伤, 2021, 34(11): 994-1001.
26. 余洋, 谢一舟, 石银, 等. 三维有限元法分析腰椎不同尺寸关节突成形后相关节段的生物力学特征. 中国组织工程研究, 2021, 25(33): 5288-5293.
27. Ito Z, Shibayama M, Nakamura S, et al. Clinical comparison of unilateral biportal endoscopic laminectomy versus microendoscopic laminectomy for single-level laminectomy: A single-center, retrospective analysis. World Neurosurg, 2021, 148: e581-e588.
28. Musa G, Barrientos REC, Makirov SK, et al. Repeat discectomy for recurrent same level disc herniation: A literature review of the past 5 years. Surg Neurol Int, 2023, 14: 100. doi: 10.25259/SNI_168_2023.
29. Heo DH, Son SK, Eum JH, et al. Fully endoscopic lumbar interbody fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results. Neurosurg Focus, 2017, 43(2): E8. doi: 10.3171/2017.5.FOCUS17146.
30. Lee CW, Yoon KJ, Kim SW. Percutaneous endoscopic decompression in lumbar canal and lateral recess stenosis—The surgical learning curve. Neurospine, 2019, 16(1): 63-71.
31. 朱斌, 田大胜, 陈磊, 等. 单边双通道内镜技术在腰椎疾病中的应用研究进展. 中华骨科杂志, 2020, 40(15): 1030-1038.
32. 张玉红, 冯波, 苏炜良, 等. 单侧双通道脊柱内镜技术椎管减压术治疗双节段腰椎管狭窄症的早期临床疗效. 中国修复重建外科杂志, 2023, 37(6): 706-712.
33. Ding H, Hai Y, Zhou L, et al. Clinical application of personalized digital surgical planning and precise execution for severe and complex adult spinal deformity correction utilizing 3D printing techniques. J Pers Med, 2023, 13(4): 602. doi: 10.3390/jpm13040602.
34. Tappa K, Bird JE, Arribas EM, et al. Multimodality imaging for 3D printing and surgical rehearsal in complex spine surgery. Radiographics, 2024, 44(3): e230116. doi: 10.1148/rg.230116.
35. 李鹏, 李想, 马琳, 等. 3D打印技术辅助全脊柱内镜精准开窗髓核摘除术治疗高度游离型腰椎间盘突出症的疗效观察. 中国骨与关节损伤杂志, 2023, 38(1): 25-29.
36. 赵加庆, 刘栋, 陆素妮, 等. 数字3D技术辅助单孔分体内镜手术治疗高度游离型腰椎间盘突出症. 中国组织工程研究, 1-7[2025-01-27]. http://kns.cnki.net/kcms/detail/21.1581.R.20241204.1136.006.html.
37. Pao JL. Biportal endoscopic transforaminal lumbar interbody fusion using double cages: Surgical techniques and treatment outcomes. Neurospine, 2023, 20(1): 80-91.

Chinese Journal of Reparative and Reconstructive Surgery

Latest ArticlesDigital three-dimensional assisted unilateral biportal endoscopy in treatment of highly isolated lumbar disc herniation with translaminar approach

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