Decompression After Posterior Lumbar Interbody Fusion without Moving Implant via Unilateral Biportal Endoscopic Technique

Summary

In this study, we introduce a protocol for decompression 3 years after posterior lumbar interbody fusion (PLIF) using a unilateral biportal endoscopic (UBE) technique without removing the implant. This protocol highlights how the UBE technique can enhance intraoperative visualization, improve efficiency, reduce operating time, and achieve adequate nerve root decompression.

Abstract

The complexity and diversity of reasons for revising posterior lumbar interbody fusion (PLIF) are well-documented. Common triggers include weak initial surgical indications, delayed intervention, diagnostic oversights or misjudgments, insufficient decompression, internal fixation complications, postoperative disease progression or recurrence, and adjacent segment degeneration. Pathological drivers such as intervertebral disc degeneration, facet joint degeneration, spinal instability, and spondylolisthesis in operated segments frequently cause nerve compression, spinal cord injury, or vertebral fractures. These conditions manifest as low back pain, radiating nerve pain, and intermittent claudication.

Critical determinants for revision include patient age, surgical technique, number of operated PPPP segments, age at initial surgery, and prior laminectomy status. Traditional revision involves open surgery to remove fixation rods, followed by decompression and re-instrumentation. However, surgical site adhesions increase procedural complexity, risking dural tears and nerve root injuries during direct visualization. Minimally invasive unilateral biportal endoscopic (UBE) decompression has emerged to address unilateral nerve root canal stenosis post fusion without hardware removal. While UBE has demonstrated safety and efficacy, its adoption remains limited by high technical demands, restricting patient access.

This paper explores the role of UBE in revision surgery, emphasizing its ability to achieve neural decompression while preserving instrumentation. The technique's steep learning curve necessitates specialized training, contributing to geographic disparities in availability. To broaden access, the authors advocate clarifying rationale and defining dissemination strategies of UBE, including standardized training, explicit surgical indications, and outcome assessment frameworks. Addressing these challenges could improve patient outcomes and advance minimally invasive spinal care, particularly in revision contexts where traditional approaches pose higher morbidity risks. Democratizing the benefits of UBE requires structured efforts to mitigate technical barriers and foster interdisciplinary collaboration, ensuring equitable integration of this innovation.

Introduction

As the application of internal fixation technology expands, there has been a consistent annual increase in the volume and quality of posterior lumbar interbody fusion (PLIF) and fusion surgeries¹. Despite these advancements, the necessity for revision surgeries arises in some cases due to the recurrence of symptoms post operation, driven by factors such as the inappropriate selection of surgical strategies, intraoperative errors, and complications inherent to internal fixation procedures².The primary objective of revision surgeries for PLIF is to alleviate nerve compression and restore the stability of the lumbar spine

Protocol

The surgical protocol was meticulously reviewed and granted approval by the Ethics Review Committee of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine. Prior to the surgery, the patient, along with her immediate family, provided signed, informed consent, demonstrating their understanding and agreement to the proposed surgical intervention, ensuring that the medical plan is in strict adherence to the Core System of Medical Quality and Safety. A detailed list of the surgical instruments and equipment utilized for this procedure is outlined in the Table of Materials.

1. Preoperative preparat....

Results

The surgery was performed on June 3, 2024, and lasted for 1.5 h. The patient returned to the ward safely with stable vital signs and a visual analog scale (VAS) score of 3. On postoperative day 1, the pain and numbness in the left lower limb had significantly improved and the VAS score was reduced to 2. We recommended that the patient rest in bed more and perform ankle pump exercises to prevent thrombosis. On postoperative day 2, the patient walked 200 m with a brace and a stable gait; there was a slight pain in the surg.......

Discussion

Lumbar interbody fusion (LIF) is a widely performed orthopedic procedure, demonstrating efficacy in addressing lumbar degenerative diseases, scoliosis, spinal deformities, and traumas¹¹. However, degenerative discs, small spinal joints, and insufficient initial decompression could lead to reoperation in some patients¹². Open surgery could damage soft tissue and bone because the implants should be removed using a large approach.Although traditional revision surgery offers su.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
0°endoscopic	bonss		High-definition, wide-angle
Displayer	bonss		Anti-glare screen, show realistic images
Endoscopic camera	bonss		IP8X waterproof rating, facilitating sterilization
Endoscopic lens sheath	bonss		Single-valve design, the inlet valve can rotate 360°
Endoscopic video system	bonss		4K ultra-clear imaging
Estabishment of approach and neuroprotective devices	bonss		Highly targeted and easy to operate
Grinding bit and handle	bonss		Efficient, running smoothly, with high strength.
handle of the bone rongeurs	bonss		Good grip, easy to replace
LED luminescence	bonss		Ultra-high brightness, with 20 levels of brightness adjustment available
Neural hook and Bone-cutting tools	bonss		A wide variety of models, easy to operate
Nucleus pulposus forceps and head of bone rongeur	bonss		The models are diverse and can be adapted for operation in multiple parts
Pedal	bonss		Waterproof, pressure-resistant and convenient
Plasma	bonss		Integrated design, powerful in performance, high surgical efficiency
Radio frequency plasma surgical system	bonss		Endoscopic cutting ablation function
Surgical dynamic system	bonss		Large-sized touch screen, rich display and convenient operation.