Unilateral Biportal Endoscopy of the Spine : An Atlas of Surgical Techniques

Minimally invasive surgery (MIS) has emerged as a highly effective and safe option in all surgical areas of medicine, and spine surgery is no exception. The “minimally invasive” concept includes various elements: the in-depth analysis of each case, allowing planning the surgical treatment for each patient. Among the critical information that must be known to plan is the correct identification of the anatomical structure that generates the pathology, which leads to the most important advantage of MIS in spinal surgery, the ability to be highly precise and targeted to the pathology avoiding the procedure-related damage to normal anatomy. Therefore, accuracy is a distinctive quality of MIS, especially in spinal surgery.The way to be more precise in MIS to avoid iatrogenic damage motivates the evolution in surgical techniques. This defines MIS spine surgery as a set of procedures applied to different pathologies that depend on the development of skills by the surgeon and the use of various technologies to resolve the disease with the least possible impact on the patient’s anatomy, with minimal repercussions on the daily life of each person requiring care. This means a quicker and more tolerable return to physical activity.Endoscopic spine surgery is based on a target-addressed concept that determines its ability to be highly accurate. This book will focus on one particular spinal endoscopic technique, the biportal endoscopic spine surgery (BESS) or unilateral biportal endoscopy (UBE). Foreword Foreword Preface Preface Acknowledgments Contents Part I: Generalities Chapter 1: The Unilateral Biportal Endoscopic Spine Surgery Concept: An Overview Introduction An Overview of the UBE Technique Generalities of UBE Conclusion References Chapter 2: Brief History Review of Unilateral Biportal Spinal Endoscopy Introduction Important Milestones for the Development of UBE Discussion Conclusion References Chapter 3: Unilateral Biportal Endoscopic Spinal Surgery Evidence-Based Outcome Introduction Laminectomy for Spinal Stenosis and Disc Herniation Clinical Outcomes Learning Curve Operative Time, Opioid Use, and Hospital Stay Dural Expansion, Facet Preservation, and Secondary Instability Muscle Damage Safety Complications Lumbar Spinal Interbody Fusion Clinical Outcomes Compared with Minimally Invasive TLIF or PLIF Fusion Rate Complications Learning Curve Lumbar Foraminal Stenosis Extraforaminal Decompression at Lumbosacral Lesion Cervical Foraminotomy Cervical Spinal Stenosis Conclusion References Chapter 4: Current Technology Available for Unilateral Biportal Endoscopic Spinal Surgery Introduction Brief Summary of UBE in the Market Technology for UBE Arthroscopic Lenses Arthroscopy Sheath Light Sources Cameras Advanced Imaging Platforms Available for UBE Radiofrequency High-Speed Drill, Shaver, and Burrs Water Pumps Intraoperative Navigation-Assisted UBE Other Technologies Conclusion References Part II: Basic Principles Chapter 5: Basic Principles of Unilateral Biportal Endoscopic Spinal Surgery: Operative Room Setup, Anesthesia, and Patient Positioning Introduction Operative Room Setup Operating Table Lighting Equipment Anesthesiology Machine Intraoperative Fluoroscopy Endoscopy Tower Anesthesia Patient Positioning Surgical Area Preparation Surgical Instruments Discussion Conclusion References Chapter 6: Basic Principles of Unilateral Biportal Endoscopic Spinal Surgery: Technical Considerations Before Starting Introduction Organization of the Working Space in the Surgery Room Patient Positioning Fluid Irrigation Radiological Landmarks for Access Discussion Conclusion References Chapter 7: Basic Principles of Unilateral Biportal Endoscopic Spinal Surgery: Anatomical Considerations of Elementary Approaches Introduction Unilateral Biportal Endoscopic Cervical Approaches Deep Cervical Muscles Bony Elements Ligamentum Flavum The Epidural Space Through Biportal Endoscopy Peridural Membrane Meningovertebral Ligaments Vascular Supply and Drainage of Epidural Space UBE-Paramedian Lumbar Approach Overview Tips for a Left-Sided Paramedian Approach Tips for a Right-Sided Paramedian Approach UBE-Paraspinal Lumbar Approach Overview Conclusion References Chapter 8: Basic Principles of Unilateral Biportal Endoscopic Surgery: Intraoperative Radiation Exposure During UBE Procedures Introduction Strategies for Intraoperative Radiation Protection During UBE Procedures Use Wearable Radiation Protective Equipment Use Non-wearable Shields Maximize the Distance Use the “Hands-Off” Technique Setup with the X-Ray Tube on the Bottom Stand on the Side of the Transmitted Beam Reduce Fluoroscopic Dose Wear Dosimeters Tricks to Avoid Unintended Radiation Exposure Make a Reasonable Preoperative Planning Obtain “Standard” AP and Lateral of Radiographic Views of the Target Segment Make a Careful Body Surface Marking Make a Good Exposure of the Interlaminar Window Future Directions for Intraoperative Radiation Reduction in UBE Procedures Add Skin Markers to Preoperative Imaging Studies 3D Computed Tomography Navigation or Robotic Guidance Surgical Instruments Ultrasound Guidance Conclusion References Part III: The Learning Process Chapter 9: The Learning Process of the Unilateral Biportal Endoscopic Spine Surgery: What Does the Surgeon Need to Perform the Technique? Introduction Anatomical Knowledge of the Spine Radiological Spinal Anatomy Understanding Palpation of the Surgical Target Endoscopic Visualization of the Target Emphasizes the Paramedian Approach Discussion Conclusion References Chapter 10: How to Go Further with My Clinical Practice on Unilateral Biportal Endoscopy Introduction Do We Need to Upgrade to Endoscopic Spine? What Is the EBM That Supported UBE and Its Clinical Applications? How to Overcome the Obstacles? Our 12 Steps to Start UBE Conclusion References Chapter 11: From Conventional to Biportal Endoscopic Surgery: The Transition Observed by an Expert Surgeon Introduction Considerations of Endoscopic Technique Technical Characteristic of Open Techniques Technical Characteristic of Endoscopic Techniques Broadening of the Indications of Endoscopic Techniques Lumbar Spinal Stenosis Lumbar Interbody Fusion Discussion Future Perspective Conclusion References Chapter 12: Put It into Practice: The Unilateral Biportal Endoscopic Surgery Introduction Innovation of Lumbar Endoscopic Access Transition to Biportal Endoscopic Access Preoperative Preparation Surgical Indications and Endpoints Surgical Preoperative Planning Operating Room Setup Surgical Instruments Surgical Technique Fluoroscopic Landmarks Creating the Working Space Gaining Access to the Spinal Canal Discectomy/Sequestrectomy Postoperative Management Evaluating Symptom Resolution Discussion Why Do UBE Lumbar Surgery Instead of Open Lumbar Surgery? Comparison of UBE and Full Endoscopy of the Spine Conclusion References Part IV: Lumbar Chapter 13: Unilateral Biportal Endoscopy for Non-migrated Lumbar Disc Herniation Introduction Indications Limitations Equipment Surgical Procedure Paramedian Approach Illustrated Cases Paraspinal Approach Illustrated Case Advantages Complications and Avoidance Conclusion References Chapter 14: Unilateral Biportal Endoscopy for Complex Lumbar Disc Herniations Introduction Preoperative Planning Sagittal Migration Axial Location Size and Consistency Level Surgical Technique Anesthesia and Position Surgical Steps Skin Marking Making Working Space and Triangulation Discectomy Close and End the Procedure Illustrated Cases Discussion How to Avoid Complications Dural Tear Bleeding and Epidural Hematoma Residual Fragment Conclusions References Chapter 15: Unilateral Biportal Endoscopy for Rostrally and Caudally Migrated Lumbar Disc Herniations Introduction Generalities Unilateral Biportal Endoscopic Approaches for Migrated Lumbar Disc Herniations Indications Illustrated Cases Discussion Conclusion References Chapter 16: Unilateral Laminotomy for Bilateral Decompression (ULBD) Through Biportal Endoscopy for Lumbar Spinal Stenosis Introduction Rationale Surgical Procedure Incision Planning and Portal Building Ipsilateral Decompression Contralateral Decompression Surgical Anatomy of Ligamentum Flavum Applied to Biportal Endoscopy Illustrated Cases Discussion Conclusions References Chapter 17: The Unilateral Biportal Endoscopic Paraspinal Approach for Lumbar Foraminal Pathology Introduction Relevant Anatomy Indications and Contraindications Surgical Procedure Step 1: Patient Positioning and Anesthesia Step 2: Entry Point Planning Step 3: Triangular Paraspinal Approach Step 4: Identifying the Bone Landmarks Step 5: Bone Decompression Step 6: Release of the Exiting Nerve Illustrated Cases Discussion Conclusion References Chapter 18: Challenging Cases Treated with UBE: The Far-Out Syndrome Introduction Diagnosis Biportal Endoscopic Decompression of Far-Out Syndrome Rationale Indications and Contraindications Relevant Surgical Anatomy Surgical Technique Step 1: Anesthesia and Patient Position Step 2: Skin Incision Planning Step 3: Biportal (Triangular) Approach Step 4: Completing the Working Space to Identify the Bone Landmarks Step 5: Bone Removal and Nerve Root Decompression Step 6: Other Maneuvers Step 7: Final Suggestions and Wound Closure Illustrated Cases Discussion Conclusions References Untitled Chapter 19: The Biportal Endoscopic Contralateral Approach for Juxtafacet Cystic Lesions of the Lumbar Spine Introduction Indications and Contraindications of the Biportal Endoscopic Contralateral Approach Surgical Technique Step 1: Patient Position and Anesthesia Step 2: Organization of Surgical Staff Step 3: Location of Entry Points Step 4: Contralateral Biportal Approach—Triangulation Step 5: Contralateral Biportal Endoscopic Approach Through a Sublaminar Route Step 6: Creating the Working Space Step 7: Bone Removal Step 8: Cyst Removal and Flavectomy Step 9: Direct Decompression of the Traversing Nerve Root Step 10: Hemostasis and Closure Illustrated Cases Discussion Conclusion References Chapter 20: The Contralateral Sublaminar Approach to Decompress the Lateral Recess and Foramen of the Lumbar Spine at the Same Stage Introduction Indications and Contraindications Indications Contraindications Surgical Technique Incision Planning Triangular Approach Creating the Working Space Contralateral Sublaminar Decompression of the Lateral Recess and Foramen Surgical Tips Possible Complications Illustrated Cases Discussion Conclusion References Chapter 21: Incidental Dural Tears in Unilateral Biportal Endoscopy Introduction Dural Tear in UBE Possible Further Events Regarding Dural Tears in UBE How to Resolve Dural Tears in UBE? Illustrated Cases Conclusion References Chapter 22: Challenging Cases Treated with UBE: Lumbar Revision Surgery Introduction Indications Illustrated Cases Discussion Conclusion References Chapter 23: Unilateral Biportal Endoscopic Transforaminal Lumbar Interbody Fusion: Technique, Variants, and Navigation Introduction Historical Vignettes in Spinal Fusion UBE-TLIF Indications and Contraindications Basic Concepts Surgical Instruments UBE-TLIF Surgical Technique Step 1: Patient Positioning and Anesthesia Step 2: Incision Planning Step 3: Biportal Paraspinal Approach Step 4: Neural Decompression Step 5: Biportal Endoscopic Discectomy and Endplate Preparation Step 6: Graft and Cage Insertion Step 7: Transpedicular Screw Fixation Step 8: Wound Closure Modified Far-Lateral UBE-TLIF UBE-TLIF Under Intraoperative Navigation Illustrated Cases Discussion Conclusion References Chapter 24: Combination of Uniportal and Biportal Endoscopic Approaches for Tandem Spinal Stenosis Introduction Indications Surgical Technique Step 1: Anesthesia and Positioning Step 2: Operating Room Organization Step 3: Uniportal Endoscopic Cervical ULBD Step 4: Unilateral Biportal Endoscopic Lumbar ULBD Illustrated Cases Discussion Limitations How to Avoid Complications Conclusion References Part V: Cervical Chapter 25: Unilateral Biportal Endoscopic Posterior Cervical Foraminotomy and Discectomy Introduction Indications Surgical Instruments Surgical Technique Step 1: Patient Positioning and Anesthesia Step 2: Location of Entry Points Step 3: Triangular Approach Step 4: Foraminotomy Step 5: Discectomy Illustrated Cases Discussion Conclusion References Chapter 26: Unilateral Biportal Endoscopic Posterior Inclinatory Cervical Foraminotomy Introduction Indications Surgical Instruments Surgical Technique Step 1: Patient Positioning and Anesthesia Step 2: Location of Entry Points Step 3: Triangular Approach Step 4: UBE-Posterior Cervical Inclinatory Foraminotomy Illustrated Cases Discussion Conclusion References Chapter 27: Biportal Endoscopic Posterior Decompression for Degenerative Cervical Myelopathy Introduction Indications and Contraindications Surgical Technique Step 1: Patient Positioning and Anesthesia Step 2: Planning for Entry Points Step 3: Posterior Cervical Biportal Approach Step 4: Creating the Working Space Step 5: Over-the-Top Circumferential Bone Removal Step 6: Flavectomy and Neural Decompression Illustrated Case Discussion Conclusion References Part VI: Special Considerations Chapter 28: Biportal Endoscopic Posterior Decompression of Thoracic Spinal Stenosis Due to Ossification of Ligamentum Flavum Introduction Relevant Anatomy and Pathological Findings Indications for Biportal Endoscopic Decompression of Thoracic Spinal Stenosis Surgical Technique Postoperative Measures Surgical Procedure Essentials Illustrated Case Discussion Conclusion References Chapter 29: Biportal Endoscopic Lumbar Facet Joint Denervation for Symptomatic Facet Joint Syndrome Introduction Facetogenic Pain Indications Surgical Technique Perioperative Care Discussion Conclusion References Chapter 30: The Role of Unilateral Biportal Endoscopy in Thoracolumbar Burst Fractures Introduction Indications Surgical Instruments Surgical Technique Illustrated Cases Discussion Conclusion References Chapter 31: Complications Associated with Unilateral Biportal Endoscopic Spine Surgery Introduction Surgical Techniques Complications Incidental Dural Tear (IDT) Postoperative Headache, Postoperative Hematoma, Transient Paresthesia Epidural Hematoma Recurrence of Intervertebral Disc Herniation Incomplete Decompression Iatrogenic Instability (Pars Interarticularis Fracture) CSF Leakage, Ascites, and Edema Infection Learning Curve Discussion Conclusion References Chapter 32: Perioperative Care in Unilateral Biportal Endoscopic Spine Surgery Introduction Preoperative Care Clinical Presentation and Assessment Clinical and Radiological Factors Predictive of Conservative Failure Obesity Revision Surgery Education and Counseling Cessation of Smoking and Alcohol Pre-rehabilitation Pre-anesthetic Medication Nutritional Supplementation Intraoperative Care Antimicrobial Prophylaxis and Skin Preparation Positioning and Intraoperative Setup Urinary Catheterization Thromboprophylaxis Intraoperative Anesthesia Intraoperative Hypothermia Intravenous Tranexamic Acid Postoperative Care Postoperative Nausea and Vomiting (PONV) Wound Care Rehabilitation Opioid-Sparing Multimodal Analgesia Use of Drains Follow-Up Conclusion References Chapter 33: How to Establish the Unilateral Biportal Endoscopic Surgery in the Surgeons’ Daily Practice Introduction The Paradigm Shift from Open Spine Surgery to Minimally Invasive Spine Surgery Lumbar Disc Herniation Lumbar Spinal Stenosis Lumbar Degenerative Spondylolisthesis Thoracic Disc Herniation Cervical Disc Herniation Minimally Invasive Spine Surgery in High-Risk Patients Zone of Benefit of Minimally Invasive Spine Surgery (MISS) Merits of Unilateral Biportal Endoscope (UBE) Versatile Indications Favourable Learning Curve Start-Up of UBE Practice Monitoring of Own Learning Curve Stay Away from Troubles Avoiding Complications Incidental Durotomy Post-operative Spinal Epidural Haematoma Conclusion References Chapter 34: Beyond the Horizon: The Future of Unilateral Biportal Endoscopic Spine Surgery Introduction State of the Art and the Coming Era Establishing Nomenclature in UBE Surgery Enhanced Recovery After Surgery (ERAS) and Day Surgery Novel Anesthesia Techniques Advancements in Optics and Portals Novel Technological Advancements Intraoperative Monitoring Expanding Disease Spectrum Indications Target-Based Surgery The Unstable Spine Spinal Infection Cauda Equina Syndrome Due to Disc Herniation Managing Intradural Pathologies Managing the Complications Conclusion References Index Endoscopic spinal surgery has become popular due its procedure-related benefits. The biportal endoscopic surgery is a recent technique, which has gained popularity in Asia, Europe, and Latin America since it can be applied to treat many diseases of the whole spine as cervical, thoracic, lumbar and sacral. Divided into thirty-four chapters, this first-ever book on unilateral biportal endoscopic spine surgery presents the technique history review and its current applications; the currently available technology and basic principles of this surgery: anesthesia, position, and operative room setup; endoscopic instruments, hydrostatic pressure, and intraoperative radiology; as well as anatomical considerations of basic approaches. It also details the techniques to resolve lumbar, cervical and thoracic spine diseases. Written by the world's most influential groups that perform the method, Unilateral Biportal Endoscopy of the Spine: An Atlas of Surgical Techniques will certainly be widely accepted by all surgeons interested to improve their daily practice in minimally invasive spine surgery.