Comparison of the clinical outcomes of unilateral biportal endoscopy versus minimally invasive transforaminal lumbar interbody fusion for the treatment of lumbar degenerative diseases with single- or two-segments 

Comparison of the clinical outcomes of unilateral biportal endoscopy versus minimally invasive transforaminal lumbar interbody fusion for the treatment of lumbar degenerative diseases with single- or two-segments | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Comparison of the clinical outcomes of unilateral biportal endoscopy versus minimally invasive transforaminal lumbar interbody fusion for the treatment of lumbar degenerative diseases with single- or two-segments Liping Zhao, Yi Zhang, Ze Cao, Jincheng Song, Guozhao Chen, Liming Wang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4524619/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives Unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) is a new minimally invasive technique for intervertebral fusion under full endoscopy. We conducted a comprehensive comparative analysis with another minimally invasive technique (minimally invasive transforaminal lumbar interbody fusion, Mis-TLIF) in terms of surgical trauma, clinical outcomes, laboratory indicators. Methods A retrospective analysis of clinical and imaging data of 77 patients with lumbar degenerative illnesses(37 underwent UBE-TLIF, 40 underwent Mis-TLIF) was performed. Demographic data, clinical outcomes [visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI)], operative data (total operation time, intraoperative blood loss, postoperative drainage, length of hospital stay), and laboratory results [plasma hemoglobin (HB), serum creatine phosphokinase (CPK), and C-reactive protein (CRP) ] were compared between the two groups, The Macnab score, fusion rate and fusion time, and complications were also recorded. Results Both groups experienced significant improvements in VAS for back and leg pain and ODI scores after surgery (P < 0.05). The VAS-Back and ODI scores were significantly better in the UBE-TLIF group than in the Mis-TLIF group at 1 week and 1 month after surgery (P < 0.05). Although the total operation time was significantly longer in the UBE-TLIF group (P < 0.01), the intraoperative blood loss, postoperative drainage and decrease in hemoglobin level were significantly higher in the Mis-TLIF group (P < 0.01). A difference was observed in the fusion time (P 0.05). Serum CRP and CPK levels were considerably lower in the UBE-TLIF group than in the MIS-TLIF group after surgery (P < 0.01). Conclusions Both UBE-TLIF and Mis-TLIF have equivalent and favorable clinical outcomes. UBE-TLIF is better in reducing surgical bleeding and rapidly improving postoperative back pain. Health sciences/Medical research/Study design Health sciences/Medical research/Study design/Randomized controlled trials Figures Figure 1 Figure 2 Introduction Lumbar degenerative illnesses, such as spinal stenosis, spondylolisthesis and instability, are usually treated with lumbar decompression fusion surgery. Compared to conventional open surgery, minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF) causes less muscle tissue destruction and blood loss, does not require extensive laminectomy, and may reduce the risk of postoperative muscle atrophy and chronic low back pain[ 1 ]. Therefore, Mis-TLIF has become a minimally invasive technique widely used for lumbar degenerative conditions[ 2 ]. However, Mis-TLIF requires a high degree of reliance on tubular retractor systems, which is a challenge for achieving sufficient neural decompression and interbody grafting due to the limited surgical field of view and instrument operation[ 3 ]. Some studies reported that Mis-TLIF resulted in a relatively long operative time, increased revision rates, increased hardware-related complications, and a higher incidence of nerve root injury, which may be related to the deep learning curve [ 4 , 5 ]. Recently, unilateral biportal endoscopy (UBE), first reported by De Antoni et al [ 6 ], has gained popularity among spine surgeons. Compared to the uniportal endoscopic technique, UBE has two portals that do not allow interference between intraoperative endoscopy and instrument operation, and improve flexible instrument mobility and surgical efficiency. With the advancement of UBE technology and the improvement of surgical instruments, UBE is becoming an increasingly popular minimally invasive surgical procedure for the treatment of lumbar degenerative diseases such as lumbar spinal stenosis and spondylolisthesis [ 2 , 7 ]. In 2017, Heo et al.[ 8 ] first reported the technique of unilateral biportal endoscopy for transforaminal lumbar interbody fusion (UBE-TLIF), which has the advantages of less trauma, clear visual field during surgery, more thorough removal of intervertebral tissue, and safer surgery. There is a lack of research on indicators related to postoperative outcomes of patients with UBE-TLIF and on objective indicators to assess the trauma associated with UBE-TLIF, such as CPK. UBE-TLIF and Mis-TLIF are both minimally invasive techniques, and there are few studies comparing the two techniques. This study retrospectively analyzed the surgical trauma and postoperative clinical results of UBE-TLIF and Mis-TLIF. Results Data from 77 patients (37 in the UBE-TLIF group and 40 in the Mis-TLIF group) were analyzed in this study. There were no significant differences in age, gender, bone mineral density (BMD), surgery levels, fusion levels, disease types, cage size and follow-up time between the two groups (P>0.05). Demographic data were comparable in both groups and are summarized in Table 1. Typical pre and post-operative imaging data of UBE-TLIF are shown in Figure 1, 2. The total operation time was significantly longer in the UBE-TLIF group than in the Mis-TLIF group (p<0.001). However, intraoperative blood loss and postoperative drainage was significantly higher in the Mis-TLIF group than in the UBE-TLIF (p<0.001). On postoperative day 2, the decrease in hemoglobin levels was significantly different in the UBE-TLIF group than in the Mis-TLIF group (p=0.027, p=0.014). However, there was no difference in the duration of hospitalization between the two groups (Table 2). Serum CPK and CRP levels rose to their highest values on postoperative day 1 and 2, respectively, and recovered to the normal range within 1 week after surgery in both groups. Serum CRP and CKP levels were considerably lower in the ULIF group than in the Mis-TLIF group after surgery (p<0.001; Table 2). The comparison of the clinical results between the two groups is shown in Table 3. All clinical parameters of the VAS-Back, VAS-Leg, and ODI scores improved significantly after surgery in both groups (p<0.05). The VAS-Back and ODI scores improved significantly more in the UBE-TLIF group than in the Mis-TLIF group at 1 week and 1 month after surgery (p0.05). According to the Macnab criteria, the excellent and good rates were not significantly different between the UBE-TLIF group (94.6 %) and the Mis-TLIF group (92.5%) at the last follow-up (P= 0.685; Table 3). Spinal fusion status was assessed according to the Bridwell Grading System, which categorised grades I and II as spinal fusion. There were no significant differences in fusion rates between the UBE-TLIF group (91.89%) and the Mis-TLIF group (90%, p=0.892; Table 4). However, the median intervertebral fusion time was shorter in the UBE-TLIF group (7.16±2.25) than in the Mis-TLIF group (10.73±1.86, p<0.05; Table 4). Surgery on all patients was completed without major complications, such as surgery-related death, thromboembolic events, damagehematoma formation, vascular and nerve injury, and surgical-site infection. One, and two cases of incomplete neural decompression, and dural tear, respectively, occurred in the UBE-TLIF group, while two, and three cases of the same complications in the Mis-TLIF group. All patient with incomplete neural decompression recovered after medication treatment and without a secondary surgery, and patients with dural tears did not suture the dura mater during surgery. There were no between-group differences regarding the complications (P>0.05; Table 4). Discussion With the continuous development of the concept and technology of minimally invasive surgery, minimally invasive lumbar posterior interbody fusion technology has gradually become a clinical hotspot in the field of spinal surgery. Compared to traditional open surgery, Mis-TLIF exposes the surgical site via a dorsal muscle-sparing approach through a tubular retractor system within a small incision, preserving the paravertebral muscles and bony structures as much as possible. However, the tubular retractor system also restricts the surgical field of view and instrument operation to a certain extent, and prolonged muscle traction can cause muscle damage and ischemia. There are still certain difficulties in achieving sufficient decompression and thorough removal of the intervertebral tissue [ 3 ]. UBE-TLIF is a fully endoscopic fusion surgery that has been used in recent years for various lumbar degenerative diseases [ 11 ], especially in patients with severe spinal stenosis associated with lumbar spondylolisthesis or requiring bilateral decompression. The UBE-TLIF has the following advantages: firstly, it has two independent channels that prevent interference between endoscopy and instrument and provide more mobility and a larger working space, which greatly improves surgical efficiency. Secondly, the bone and ligament structures behind the lumbar can be fully preserved, minimising the impact on the paraspinal muscle tissue and postoperative spinal stability. Thirdly, less bleeding, clear endoscopic field of view and safe decompression during the procedure. Fourthly, wide decompression range, allowing simultaneous bilateral decompression. Fifth, endoscopic removal of intervertebral tissue is more thorough, effectively protects the endplate, and prepares a reliable bone graft bed that provides a solid foundation for subsequent intervertebral fusion [ 12 ]. This study also confirmed that UBE-TLIF has a shorter intervertebral fusion time compared with Mis-TLIF. The reason for this could be, firstly, the more thorough endoscopic cleaning of intervertebral discs and cartilage endplates and the more reliable preparation of the bone graft beds. Secondly, it could be related to the better preservation of the bone and ligament structure behind the lumbar, and the better stabilisation of the surgical segment after surgery. Ultimately, however, the two groups achieved the same fusion rates, which is consistent with the fusion rates reported by Song et al [ 13 ]. The results of this study show that both the UBE-TLIF and the Mis-TLIF were able to achieve sufficient nerve decompression and that the patients’ postoperative lower limb neurological symptoms improved significantly. The VAS-back and ODI scores in the UBE-TLIF group were significantly better than those in the Mis-TLIF group at 1 week and 1 month after surgery, but the clinical efficacy of the two groups tended to be the same at the last follow-up, suggesting that UBE-TLIF can improve back pain faster after surgery. Intraoperative paraspinal muscle injury, postoperative muscle denervation and atrophy may lead to postoperative low back pain and poor recovery of paraspinal muscle function. Therefore, reducing paraspinal muscle injury during surgery is crucial for postoperative functional recovery and relief of low back pain [ 2 ]. The MIS-TLIF requires a tubular distractor system, which can easily lead to local muscle injury or ischemia if the paraspinal muscles are stretched excessively and for prolonged periods during the procedure, and postoperative low back pain [ 12 , 14 ]. The UBE-TLIF has two independent channels that do not require prolonged traction of soft tissue during the procedure and cause minimal damage to the paraspinal muscles [ 15 , 16 ]. In addition, the magnification of the field of view under endoscopy allows the articular processes and lamina to be clearly differentiated, avoiding excessive damage to these structures [ 17 , 18 ], which may be the reason for the low back pain and rapid recovery after UBE-TLIF. This also suggests that UBE-TLIF can effectively reduce damage to the paraspinal muscles and bone tissue, alleviate postoperative back pain early and accelerate postoperative recovery[ 19 , 20 ]. Adequate decompression is closely related to the improvement of postoperative lower limb pain. The UBE has independent biportals that can be operated flexibly without interfering with each other. In addition, the endoscope can be brought close to the diseased tissue, even into the lateral recess or intervertebral foramen [ 21 ], which has unique advantages and achieves good decompression effects [ 22 ]. The shorter the distance between the endoscope and the lesion, the higher the safety of surgical decompression, the less laminectomy is required, and the better the small joint can be preserved. Kang et al [ 23 ] reported that the preservation of a large amount of bone tissue under endoscopy can reduce bleeding in the trabecular bone, and the bleeding is further reduced by hydrostatic irrigation. The results of this study showed that there was a significant improvement in VAS-leg and ODI scores in both groups after surgery. There was no significant difference between the two groups in terms of excellent and good rates and complications. However, the UBE-TLIF group showed a decrease in intraoperative bleeding, postoperative drainage, and hemoglobin loss compared to the MIS-TLIF group. This indicates that UBE-TLIF has a good decompression effect and less bleeding, which helps to prevent postoperative anemia and related adverse reactions. In addition, our study showed that UBE-TLIF had a longer operation time than MIS-TLIF, which might be related to the steep learning curve of UBE-TLIF [ 24 , 25 ]. Kim et al [ 23 ] reported the learning curve of UBE-TLIF in the treatment of lumbar degenerative diseases and found that at least 34 independent surgical experiences are required to achieve proficient technical skills, while Chen et al [ 26 ] reported that for surgeons with rich experience in endoscopic and open surgery, about 24 surgical cases are required to overcome the learning curve, achieve stable surgical level, and significantly shorten the operation time. On the other hand, the exposure time of the vertebral plate and articular processes during the procedure is longer than that of MIS-TLIF because it requires controlling soft tissue bleeding and maintaining a clear surgical field of view. The CRP and CKP concentration in serum is an ideal objective index for evaluating muscle injuries after operation. In the absence of infection, postoperative CRP and CKP levels typically peak 2 to 3 days and 1 to 2 days after surgery, respectively, and return to normal 1 to 2 weeks later [ 19 , 27 ]. In this study, serum CPK and CRP levels rose to their highest levels on postoperative day 1 and 2, respectively, and recovered to the normal range within 1 week after surgery in both groups. However, serum CRP and CKP levels were considerably lower in the UBE-TLIF group than in the Mis-TLIF group after surgery. These findings revealed that UBE-TLIF induces less unavoidable systemic inflammatory response and less iatrogenic muscle injury, which is associated with less postoperative pain and higher quality of life in the early postoperative period. Therefore, UBE-TLIF is a unique and useful technique for lumbar degenerative diseases as it is less invasive and can improve functional recovery. In summary, UBE-TLIF offers the advantages of minimal trauma, early relief of low back pain after surgery, safe decompression, and less bleeding. It can effectively treat lumbar degenerative diseases in short segments, and can be used as a viable alternative to traditional minimally invasive surgery. Materials and Methods Ethical approval This retrospective study was approved by the Ethics Committee of the Affiliated Zhangjiagang Hospital of Soochow University, China. The work described was conducted in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for human experimentation. Approval number: 2022KY0771002. Study design and patients This retrospective study of the collected data was conducted on 77 patients with lumbar degenerative diseases. The patients were divided into two groups: UBE-TLIF group (37 cases) and Mis-TLIF group (40 cases) between February 2020 and April 2023. Written informed consent was obtained from all patients. All surgeries were performed by an experienced surgeon. Each patient was monitored for at least 1 year. The inclusion criteria were as follows: (1) Clinical symptoms: Patients aged between 50 and 80 years with radiating pain or numbness in the lower limbs (visual analog scale [VAS] score ≥4) and/or neurogenic intermittent claudication, with or without low back pain; (2) Imaging findings: Definite lumbar disc herniation with endplate inflammation, lumbar spinal stenosis with low-grade degenerative and isthmic spondylolisthesis( Meyerding grade ≤ 2 degrees), and segmental instability (anterior translation [≥ 3 mm] and/or change intervertebral space angle [≥ 15˚] after increasing segmental sagittal motion on lumbar magnetic resonance imaging (MRI) and extension-flexion radiographs[9]; (3) Continuous conservative treatment has been ineffective for more than 3 months; (4) Lesions in single or double segments. The exclusion criteria were high-grade degenerative and isthmic spondylolisthesis (Meyerding grade >2 degrees), advanced adult spinal deformity (coronal Cobb angle > 25˚), other spinal diseases (e.g. Spinal infection, ankylosing spondylitis, spinal tumor, spinal trauma, or neurological disorders), cognitive and psychological disorders (e.g. Alzheimer’s dementia, mental retardation) and other conditions such as cardiac and pulmonary dysfunction that the surgeon deems unsuitable for participation in the study. Surgical procedure All patients received general anaesthesia and were placed in the prone position for the UBE-TLIF and Mis-TLIF procedures. UBE-TLIF group: The surgical slit and bilateral pedicle were localised using C-arm fluoroscopy, ensuring that the surgical slit was perpendicular to the floor, and marked on the skin. Guidewires was inserted into each pedicle (Figure 2 ⑦) , and the guidewire incision was extended longitudinally by approximately 1.5cm on the side with severe symptoms. Through each surgical port, the muscle tissue was carefully peeled off from the lamina, spinous process and facet joint. A 30˚ endoscope and the surgical instruments were inserted through the viewing portal and working portal, respectively. A radiofrequency device was used to further expose the spinous process, lamina and articular process regions.The ipsilateral inferior articular process, part of the lamina and the root of the spinous process were removed with the osteotome, the contralateral lamina was undercut (Figure 2 ①) and the medial part of the articular process and the ligamentum flavum were removed with Kerrison, exposing the disc, the dura mater and the ipsilateral nerve roots (Figure 2 ②). The disc tissue was removed and the cartilage endplate was thoroughly scraped (Figures ③ and ④). The autologous bone particles were implanted through a funnel into the anterior disc space (Figure 2 ⑤), then the fusion cage was implanted into the vertebral space under endoscopic monitoring(Figure 2 ⑥). During this phase, the dura and the traversing root must be protected by inserting a dural retractor into the working portal. Under C-arm fluoroscopy, bilateral percutaneous minimally invasive pedicle screws were inserted via guidewires, and the connecting rods and tails were installed and tightened on both sides (Figure 2 ⑧). The slippage of the vertebral body was completely reduced. Finally, the surgeon had to ensured that the dural sac and bilateral nerve roots were sufficiently decompressed and that the pedicle screws and cage were in good position. A drainage tube was inserted and the incision was cleaned and sutured. Mis-TLIF group: The paramedian longitudinal incision of the surgical segment of about 3 cm was made on the side with the severe symptoms. The skin, subcutaneous tissue and deep fascia were incised in layers, and the dissection was performed with the fingers through the intermuscular plane between the multifidus and longissimus muscles until the articular process was touched. The guidewire was inserted into both pedicles and a quadrant tubular retractor system was placed stepwise on the decompression side. A radiofrequency tool was used to further expose the lamina and the articular process. The upper and lower facet joints and part of the lamina were completely resected with the osteotome. The dura mater and the nerve root were completely exposed after removal of part of the ligamentum flavum, the facet joint and the lamina. Decompression of the spinal canal, cleaning of the intervertebral space and implantation of the cage and pedicle screw rod system were the same as for the UBE-TLIF procedure. Outcomes and measurements Patient demographics were recorded, including age, gender, bone mineral density (BMD), surgeryl levels, fusion levels, disease types, cage size, and follow-up time. Clinical outcomes included VAS-back, VAS-leg, and ODI at 1 week, 1 month, 6 months, and the final follow-up after surgery. At the last follow-up, the excellent and good rate according to the Macnab score [10] was also recorded. At 12 months after surgery, anteroposterior, extension-flexion radiographs and three-dimensional computed tomography (3D-CT) scans of the lumbar were performed and the fusion rate was graded according to the Bridwell Interbody Fusion Grading System. Two blinded independent observers measured the degree of spinal fusion, and recorded the fusion time. Operative data including total operative time (from skin incision to skin closure), intraoperative blood loss (estimated suction, irrigation, and lavage volumes), postoperative drainage and hospital stay (length of hospital stay after surgery) were recorded. In addition, CPK and CRP were measured at 1, 2, and 7 days after surgery. Perioperative complications were defined as intraoperative or postoperative complications within 1 month after surgery. Late complications were defined as complications between 1 month and the final follow-up. Recurrent pain was defined as recurrent axial back and/or leg pain with a VAS score of ≥4 during the follow-up period. Statistical analysis All data were statistically analysed using SPSS 22.0 software. The measured data are expressed as mean values±standard deviation and subjected to a normality test. The independent sample t-test and the paired t-test are used for comparison between groups and within groups when they conform to the normal distribution, respectively. VAS and ODI scores at different time points were compared using repeated measures analysis of variance. The Green house Geisser method was used for correction if the data did not meet the requirements of the sphericity test. The Bonferroni method was used to compare different time points within the same group, and multi-factor analysis of variance was performed to compare two groups at the same time point. Comparison of count data between groups using χ2 inspection. A statistically significant difference is indicated by P<0.05. Declarations Acknowledgements We would like to thank all authors that contributed substantially to the manuscript and the support from the Zhangjiagang Science and Technology Bureau Project (no. 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Assessing changes in cervical epidural pressure during biportal endoscopic lumbar discectomy. J Neurosurg Spine. 34, 196–202, DOI: 10.3171/2020.6.SPINE20586 (2020). Kim JE, Yoo HS, Choi DJ, Hwang JH, Park EJ, Chung S. Learning curve and clinical outcome of biportal endoscopic-assisted lumbar interbody fusion. Biomed Res Int. 2020, 8815432, DOI: 10.1155/2020/8815432 (2020). Park SM, Kim HJ, Kim GU, et al. Learning curve for lumbar decompressive laminectomy in biportal endoscopic spinal surgery using the cumulative summation test for learning curve. World Neurosurg. 122, e1007-e1013, DOI: 10.1016/j.wneu.2018.10.197(2019 ). Chen L, Zhu B, Zhong HZ, et al. The learning curve of unilateral biportal endoscopic (UBE) spinal surgery by CUSUM analysis. Front Surg. 9, 873691, DOI: 10.3389/fsurg.2022.873691 (2022). Kim HS, Choi SH, Shim DM, et al. Advantages of the new endoscopic unilateral laminectomy for bilateral decompression (ULBD) over conventional microscopic ULBD. Clin Orthop Surg. 12, 330–336, DOI: 10.4055/cios19136 (2020). Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4524619","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":316525070,"identity":"69f26e08-e8f7-4a78-9190-da7b4c3c34e7","order_by":0,"name":"Liping Zhao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACPgYGNiBlw8PG3nzgwIcfRGhhg2hJk+PnOZZ4cGYP8VoOG0vOyDE+zMFGjBbp9mcPflQwJ244c+bDYQYeBnl+sQMEtMgcSDfsOcOWuOF474bDBRYMhjNnJxDQIpFwTIK3jQdoy9kNh2fwMCQY3CaoJbFN8m+bROKGGzkPDvOwEaUlmU2at80A5H0GIrXIHGOTljmTAApkA2AgSxD2Cz8wxCTfVPwHReXjDx9+2MjzSxPQwiCBl0uMllEwCkbBKBgFmAAAiBhE3uEaNcQAAAAASUVORK5CYII=","orcid":"","institution":"the Affiliated ZhangjiagangHospital of Soochow University","correspondingAuthor":true,"prefix":"","firstName":"Liping","middleName":"","lastName":"Zhao","suffix":""},{"id":316525071,"identity":"155391c3-f41b-479a-837b-bdf62fa74b39","order_by":1,"name":"Yi Zhang","email":"","orcid":"","institution":"the Affiliated ZhangjiagangHospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Zhang","suffix":""},{"id":316525072,"identity":"f1e3cee0-0e92-46b0-b7ca-169069725128","order_by":2,"name":"Ze Cao","email":"","orcid":"","institution":"the Affiliated ZhangjiagangHospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Ze","middleName":"","lastName":"Cao","suffix":""},{"id":316525075,"identity":"e81a8b83-fe94-498f-a987-362c13e73f9d","order_by":3,"name":"Jincheng Song","email":"","orcid":"","institution":"the Affiliated ZhangjiagangHospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jincheng","middleName":"","lastName":"Song","suffix":""},{"id":316525077,"identity":"ea7e1cde-5ff8-446a-961e-63eab1b6b65a","order_by":4,"name":"Guozhao Chen","email":"","orcid":"","institution":"the Affiliated ZhangjiagangHospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Guozhao","middleName":"","lastName":"Chen","suffix":""},{"id":316525078,"identity":"3ae4e50c-2ad9-4c37-87f9-8bad65cca87a","order_by":5,"name":"Liming Wang","email":"","orcid":"","institution":"the Affiliated ZhangjiagangHospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Liming","middleName":"","lastName":"Wang","suffix":""},{"id":316525079,"identity":"2645d943-971f-47c9-ac2f-273f277aedd5","order_by":6,"name":"Weiping Sha","email":"","orcid":"","institution":"the Affiliated ZhangjiagangHospital of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Weiping","middleName":"","lastName":"Sha","suffix":""}],"badges":[],"createdAt":"2024-06-04 02:24:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4524619/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4524619/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59119274,"identity":"cc23fabb-5e78-40d7-93af-13a310640951","added_by":"auto","created_at":"2024-06-26 14:36:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1522411,"visible":true,"origin":"","legend":"\u003cp\u003eA UBE-TLIF case. A 70-year-old woman presented with recurrent lower back pain radiating to the left lower limb with intermittent claudication for 5 years, which worsened and failed to respond to conservative treatment for 12 months. Diagnosis: L34 spondylolisthesis with spinal canal stenosis and L4/5 lumbar disc herniation with spinal canal stenosis. ①,②：Preoperative anteroposterior and lateral X-rays of the lumbar spine; ③,④: Preoperative axial CT scans; ⑥～⑧: Preoperative sagittal and axial MRI showed L34 spondylolisthesis with spinal canal stenosis and L4/5 lumbar disc herniation with spinal canal stenosis; ⑨,⑩,: Postoperative anteroposterior and lateral X-rays; ⑪～⑬: Axial CT after UBE-TLIF showed sufficient spinal canal decompression and local bone defect; ⑭: Sagittal MRI showed good vertebral body sequence and spinal canal volume at 4 months after surgery; ⑮: Sagittal CT showed intervertebral bone fusion at 8 months after surgery.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4524619/v1/7cbf8f2fd9153fad52d2b1d1.png"},{"id":59119273,"identity":"502e22e6-6600-47c1-ad72-9245c60b849a","added_by":"auto","created_at":"2024-06-26 14:36:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2406586,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical procedure for UBE-TLIF. ①,②The bilateral lower articular process, medial facet of the bilateral upper articular process and part of the lamina were removed to ensure adequate decompression of the transverse nerve roots; ③,④Intervertebral disc tissue was removed, and cartilage endplate was scraped; ⑤Bone particles were implanted into the intervertebral space; ⑥An appropriate size interbody fusion cage was placed under endoscopy; ⑦,⑧After inserting pedicle screws under the guidance of guide wires, install connecting rods and screw tails.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4524619/v1/a22a08df2512e3f4333f5cb1.png"},{"id":61610126,"identity":"34ae6a21-ef65-43a3-89c1-ef65eadc0bb5","added_by":"auto","created_at":"2024-08-02 00:46:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4223510,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4524619/v1/923eb9b7-5073-46c9-b9c7-0ac87dbe2be6.pdf"},{"id":59119272,"identity":"82c297cf-7c83-4c5b-b51c-f65807445ebf","added_by":"auto","created_at":"2024-06-26 14:36:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23475,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4524619/v1/18081457f55e6443e77f042b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of the clinical outcomes of unilateral biportal endoscopy versus minimally invasive transforaminal lumbar interbody fusion for the treatment of lumbar degenerative diseases with single- or two-segments ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLumbar degenerative illnesses, such as spinal stenosis, spondylolisthesis and instability, are usually treated with lumbar decompression fusion surgery. Compared to conventional open surgery, minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF) causes less muscle tissue destruction and blood loss, does not require extensive laminectomy, and may reduce the risk of postoperative muscle atrophy and chronic low back pain[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Therefore, Mis-TLIF has become a minimally invasive technique widely used for lumbar degenerative conditions[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, Mis-TLIF requires a high degree of reliance on tubular retractor systems, which is a challenge for achieving sufficient neural decompression and interbody grafting due to the limited surgical field of view and instrument operation[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Some studies reported that Mis-TLIF resulted in a relatively long operative time, increased revision rates, increased hardware-related complications, and a higher incidence of nerve root injury, which may be related to the deep learning curve [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecently, unilateral biportal endoscopy (UBE), first reported by De Antoni et al [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], has gained popularity among spine surgeons. Compared to the uniportal endoscopic technique, UBE has two portals that do not allow interference between intraoperative endoscopy and instrument operation, and improve flexible instrument mobility and surgical efficiency. With the advancement of UBE technology and the improvement of surgical instruments, UBE is becoming an increasingly popular minimally invasive surgical procedure for the treatment of lumbar degenerative diseases such as lumbar spinal stenosis and spondylolisthesis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In 2017, Heo et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] first reported the technique of unilateral biportal endoscopy for transforaminal lumbar interbody fusion (UBE-TLIF), which has the advantages of less trauma, clear visual field during surgery, more thorough removal of intervertebral tissue, and safer surgery.\u003c/p\u003e \u003cp\u003eThere is a lack of research on indicators related to postoperative outcomes of patients with UBE-TLIF and on objective indicators to assess the trauma associated with UBE-TLIF, such as CPK. UBE-TLIF and Mis-TLIF are both minimally invasive techniques, and there are few studies comparing the two techniques. This study retrospectively analyzed the surgical trauma and postoperative clinical results of UBE-TLIF and Mis-TLIF.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eData from 77 patients (37 in the UBE-TLIF group and 40 in the Mis-TLIF group) were analyzed in this study. There were no significant differences in age, gender, bone mineral density (BMD), surgery levels, fusion levels, disease types, cage size and follow-up time between the two groups (P\u0026gt;0.05). Demographic data were comparable in both groups and are summarized in Table 1. Typical pre and post-operative imaging data of UBE-TLIF are shown in Figure 1, 2.\u003c/p\u003e\n\u003cp\u003eThe total operation time was significantly longer in the UBE-TLIF group than in the Mis-TLIF group (p\u0026lt;0.001). However, intraoperative blood loss and postoperative drainage was significantly higher in the Mis-TLIF group than in the UBE-TLIF (p\u0026lt;0.001). On postoperative day 2, the decrease in hemoglobin levels was significantly different in the UBE-TLIF group than in the Mis-TLIF group (p=0.027, p=0.014). However, there was no difference in the duration of hospitalization between the two groups (Table 2). Serum CPK and CRP levels rose to their highest values on postoperative day 1 and 2, respectively, and recovered to the normal range within 1 week after surgery in both groups. Serum CRP and CKP levels were considerably lower in the ULIF group than in the Mis-TLIF group after surgery (p\u0026lt;0.001; Table 2).\u003c/p\u003e\n\u003cp\u003eThe comparison of the clinical results between the two groups is shown in Table 3. All clinical parameters of the VAS-Back, VAS-Leg, and ODI scores improved significantly after surgery in both groups (p\u0026lt;0.05). The VAS-Back and ODI scores improved significantly more in the UBE-TLIF group than in the Mis-TLIF group at 1 week and 1 month after surgery (p\u0026lt;0.05). However, there was no significant difference in VAS-Back and ODI scores at 6 months and the last follow-up, and in VAS-Leg between the two groups after surgery (P\u0026gt;0.05). According to the Macnab criteria, the excellent and good rates were not significantly different between the UBE-TLIF group (94.6 %) and the Mis-TLIF group (92.5%) at the last follow-up (P= 0.685; Table 3).\u003c/p\u003e\n\u003cp\u003eSpinal fusion status was assessed according to the Bridwell Grading System, which categorised grades I and II as spinal fusion. There were no significant differences in fusion rates between the UBE-TLIF group (91.89%) and the Mis-TLIF group (90%, p=0.892; Table 4). However, the median intervertebral fusion time was shorter in the UBE-TLIF group (7.16\u0026plusmn;2.25) than in the Mis-TLIF group (10.73\u0026plusmn;1.86, p\u0026lt;0.05; Table 4).\u003c/p\u003e\n\u003cp\u003eSurgery on all patients was completed without major complications, such as surgery-related death, thromboembolic events, damagehematoma formation, vascular and nerve injury, and surgical-site infection. One, and two cases of incomplete neural decompression, and dural tear, respectively, occurred in the UBE-TLIF group, while two, and three cases of the same complications in the Mis-TLIF group. All patient with incomplete neural decompression recovered after medication treatment and without a secondary surgery, and patients with dural tears did not suture the dura mater during surgery. There were no between-group differences regarding the complications (P\u0026gt;0.05; Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWith the continuous development of the concept and technology of minimally invasive surgery, minimally invasive lumbar posterior interbody fusion technology has gradually become a clinical hotspot in the field of spinal surgery. Compared to traditional open surgery, Mis-TLIF exposes the surgical site via a dorsal muscle-sparing approach through a tubular retractor system within a small incision, preserving the paravertebral muscles and bony structures as much as possible. However, the tubular retractor system also restricts the surgical field of view and instrument operation to a certain extent, and prolonged muscle traction can cause muscle damage and ischemia. There are still certain difficulties in achieving sufficient decompression and thorough removal of the intervertebral tissue [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUBE-TLIF is a fully endoscopic fusion surgery that has been used in recent years for various lumbar degenerative diseases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], especially in patients with severe spinal stenosis associated with lumbar spondylolisthesis or requiring bilateral decompression. The UBE-TLIF has the following advantages: firstly, it has two independent channels that prevent interference between endoscopy and instrument and provide more mobility and a larger working space, which greatly improves surgical efficiency. Secondly, the bone and ligament structures behind the lumbar can be fully preserved, minimising the impact on the paraspinal muscle tissue and postoperative spinal stability. Thirdly, less bleeding, clear endoscopic field of view and safe decompression during the procedure. Fourthly, wide decompression range, allowing simultaneous bilateral decompression. Fifth, endoscopic removal of intervertebral tissue is more thorough, effectively protects the endplate, and prepares a reliable bone graft bed that provides a solid foundation for subsequent intervertebral fusion [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This study also confirmed that UBE-TLIF has a shorter intervertebral fusion time compared with Mis-TLIF. The reason for this could be, firstly, the more thorough endoscopic cleaning of intervertebral discs and cartilage endplates and the more reliable preparation of the bone graft beds. Secondly, it could be related to the better preservation of the bone and ligament structure behind the lumbar, and the better stabilisation of the surgical segment after surgery. Ultimately, however, the two groups achieved the same fusion rates, which is consistent with the fusion rates reported by Song et al [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results of this study show that both the UBE-TLIF and the Mis-TLIF were able to achieve sufficient nerve decompression and that the patients\u0026rsquo; postoperative lower limb neurological symptoms improved significantly. The VAS-back and ODI scores in the UBE-TLIF group were significantly better than those in the Mis-TLIF group at 1 week and 1 month after surgery, but the clinical efficacy of the two groups tended to be the same at the last follow-up, suggesting that UBE-TLIF can improve back pain faster after surgery. Intraoperative paraspinal muscle injury, postoperative muscle denervation and atrophy may lead to postoperative low back pain and poor recovery of paraspinal muscle function. Therefore, reducing paraspinal muscle injury during surgery is crucial for postoperative functional recovery and relief of low back pain [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The MIS-TLIF requires a tubular distractor system, which can easily lead to local muscle injury or ischemia if the paraspinal muscles are stretched excessively and for prolonged periods during the procedure, and postoperative low back pain [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The UBE-TLIF has two independent channels that do not require prolonged traction of soft tissue during the procedure and cause minimal damage to the paraspinal muscles [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, the magnification of the field of view under endoscopy allows the articular processes and lamina to be clearly differentiated, avoiding excessive damage to these structures [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], which may be the reason for the low back pain and rapid recovery after UBE-TLIF. This also suggests that UBE-TLIF can effectively reduce damage to the paraspinal muscles and bone tissue, alleviate postoperative back pain early and accelerate postoperative recovery[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdequate decompression is closely related to the improvement of postoperative lower limb pain. The UBE has independent biportals that can be operated flexibly without interfering with each other. In addition, the endoscope can be brought close to the diseased tissue, even into the lateral recess or intervertebral foramen [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], which has unique advantages and achieves good decompression effects [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The shorter the distance between the endoscope and the lesion, the higher the safety of surgical decompression, the less laminectomy is required, and the better the small joint can be preserved. Kang et al [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] reported that the preservation of a large amount of bone tissue under endoscopy can reduce bleeding in the trabecular bone, and the bleeding is further reduced by hydrostatic irrigation. The results of this study showed that there was a significant improvement in VAS-leg and ODI scores in both groups after surgery. There was no significant difference between the two groups in terms of excellent and good rates and complications. However, the UBE-TLIF group showed a decrease in intraoperative bleeding, postoperative drainage, and hemoglobin loss compared to the MIS-TLIF group. This indicates that UBE-TLIF has a good decompression effect and less bleeding, which helps to prevent postoperative anemia and related adverse reactions.\u003c/p\u003e \u003cp\u003eIn addition, our study showed that UBE-TLIF had a longer operation time than MIS-TLIF, which might be related to the steep learning curve of UBE-TLIF [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Kim et al [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] reported the learning curve of UBE-TLIF in the treatment of lumbar degenerative diseases and found that at least 34 independent surgical experiences are required to achieve proficient technical skills, while Chen et al [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] reported that for surgeons with rich experience in endoscopic and open surgery, about 24 surgical cases are required to overcome the learning curve, achieve stable surgical level, and significantly shorten the operation time. On the other hand, the exposure time of the vertebral plate and articular processes during the procedure is longer than that of MIS-TLIF because it requires controlling soft tissue bleeding and maintaining a clear surgical field of view.\u003c/p\u003e \u003cp\u003eThe CRP and CKP concentration in serum is an ideal objective index for evaluating muscle injuries after operation. In the absence of infection, postoperative CRP and CKP levels typically peak 2 to 3 days and 1 to 2 days after surgery, respectively, and return to normal 1 to 2 weeks later [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In this study, serum CPK and CRP levels rose to their highest levels on postoperative day 1 and 2, respectively, and recovered to the normal range within 1 week after surgery in both groups. However, serum CRP and CKP levels were considerably lower in the UBE-TLIF group than in the Mis-TLIF group after surgery. These findings revealed that UBE-TLIF induces less unavoidable systemic inflammatory response and less iatrogenic muscle injury, which is associated with less postoperative pain and higher quality of life in the early postoperative period. Therefore, UBE-TLIF is a unique and useful technique for lumbar degenerative diseases as it is less invasive and can improve functional recovery.\u003c/p\u003e \u003cp\u003eIn summary, UBE-TLIF offers the advantages of minimal trauma, early relief of low back pain after surgery, safe decompression, and less bleeding. It can effectively treat lumbar degenerative diseases in short segments, and can be used as a viable alternative to traditional minimally invasive surgery.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was approved by the Ethics Committee of the Affiliated Zhangjiagang Hospital of Soochow University, China. The work described was conducted in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) for human experimentation. Approval number: 2022KY0771002.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design and patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study of the collected data was conducted on 77 patients with lumbar degenerative diseases. The patients were divided into two groups: UBE-TLIF group (37 cases) and Mis-TLIF group (40 cases) between February 2020 and April 2023. Written informed consent was obtained from all patients. All surgeries were performed by an experienced surgeon. Each patient was monitored for at least 1 year.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows: (1) Clinical symptoms: Patients aged between 50 and 80 years with radiating pain or numbness in the lower limbs (visual analog scale [VAS] score \u0026ge;4) and/or neurogenic intermittent claudication, with or without low back pain; (2) Imaging findings: Definite lumbar disc herniation with endplate inflammation, lumbar spinal stenosis with low-grade degenerative and isthmic spondylolisthesis( Meyerding grade \u0026le; 2 degrees), and segmental instability (anterior translation [\u0026ge; 3 mm] and/or change intervertebral space angle [\u0026ge; 15˚] after increasing segmental sagittal motion on lumbar magnetic resonance imaging (MRI) and extension-flexion radiographs[9]; (3) Continuous conservative treatment has been ineffective for more than 3 months; (4) Lesions in single or double segments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria were high-grade degenerative and isthmic spondylolisthesis (Meyerding grade \u0026gt;2 degrees), advanced adult spinal deformity (coronal Cobb angle \u0026gt; 25˚), other spinal diseases (e.g. Spinal infection, ankylosing spondylitis, spinal tumor, spinal trauma, or neurological disorders), cognitive and psychological disorders (e.g. Alzheimer\u0026rsquo;s dementia, mental retardation) and other conditions such as cardiac and pulmonary dysfunction that the surgeon deems unsuitable for participation in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients received general anaesthesia and were placed in the prone position for the UBE-TLIF and Mis-TLIF procedures.\u003c/p\u003e\n\u003cp\u003eUBE-TLIF group: The surgical slit and bilateral pedicle were localised using C-arm fluoroscopy, ensuring that the surgical slit was perpendicular to the floor, and marked on the skin. Guidewires was inserted into each pedicle (Figure 2 ⑦) , and the guidewire incision was extended longitudinally by approximately 1.5cm on the side with severe symptoms. Through each surgical port, the muscle tissue was carefully peeled off from the lamina, spinous process and facet joint. A \u0026nbsp;30˚ endoscope and the surgical instruments were inserted through the viewing portal and working portal, respectively. A radiofrequency device was used to further expose the spinous process, lamina and articular process regions.The ipsilateral inferior articular process, part of the lamina and the root of the spinous process were removed with the osteotome, the contralateral lamina was undercut (Figure 2 ①) and the medial part of the articular process and the ligamentum flavum were removed with Kerrison, exposing the disc, the dura mater and the ipsilateral nerve roots (Figure 2 ②). The disc tissue was removed and the cartilage endplate was thoroughly scraped (Figures ③ and ④). The autologous bone particles were implanted through a funnel into the anterior disc space (Figure 2 ⑤), then the fusion cage was implanted into the vertebral space under endoscopic monitoring(Figure 2 ⑥). During this phase, the dura and the traversing root must be protected by inserting a dural retractor into the working portal. Under C-arm fluoroscopy, bilateral percutaneous minimally invasive pedicle screws were inserted via guidewires, and the connecting rods and tails were installed and tightened on both sides (Figure 2 ⑧). The slippage of the vertebral body was completely reduced. Finally, the surgeon had to ensured that the dural sac and bilateral nerve roots were sufficiently decompressed and that the pedicle screws and cage were in good position. A drainage tube was inserted and the incision was cleaned and sutured.\u003c/p\u003e\n\u003cp\u003eMis-TLIF group: The paramedian longitudinal incision of the surgical segment of about 3 cm was made on the side with the severe symptoms. The skin, subcutaneous tissue and deep fascia were incised in layers, and the dissection was performed with the fingers through the intermuscular plane between the multifidus and longissimus muscles until the articular process was touched. The guidewire was inserted into both pedicles and a quadrant tubular retractor system was placed stepwise on the decompression side. A radiofrequency tool was used to further expose the lamina and the articular process. The upper and lower facet joints and part of the lamina were completely resected with the osteotome. The dura mater and the nerve root were completely exposed after removal of part of the ligamentum flavum, the facet joint and the lamina. Decompression of the spinal canal, cleaning of the intervertebral space and implantation of the cage and pedicle screw rod system were the same as for the UBE-TLIF procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes and measurements \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient demographics were recorded, including age, gender, bone mineral density (BMD), surgeryl levels, fusion levels, disease types, cage size, and follow-up time. Clinical outcomes included VAS-back, VAS-leg, and ODI at 1 week, 1 month, 6 months, and the final follow-up after surgery. At the last follow-up, the excellent and good rate according to the Macnab score [10] was also recorded. At 12 months after surgery, anteroposterior, extension-flexion radiographs and three-dimensional computed tomography (3D-CT) scans of the lumbar were performed and the fusion rate was graded according to the Bridwell Interbody Fusion Grading System. Two blinded independent observers measured the degree of spinal fusion, and recorded the fusion time.\u003c/p\u003e\n\u003cp\u003eOperative data including total operative time (from skin incision to skin closure), intraoperative blood loss (estimated suction, irrigation, and lavage volumes), postoperative drainage and hospital stay (length of hospital stay after surgery) were recorded. In addition, CPK and CRP were measured at 1, 2, and 7 days after surgery. Perioperative complications were defined as intraoperative or postoperative complications within 1 month after surgery. Late complications were defined as complications between 1 month and the final follow-up. Recurrent pain was defined as recurrent axial back and/or leg pain with a VAS score of \u0026ge;4 during the follow-up period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data were statistically analysed using SPSS 22.0 software. The measured data are expressed as mean values\u0026plusmn;standard deviation and subjected to a normality test. The independent sample t-test and the paired t-test are used for comparison between groups and within groups when they conform to the normal distribution, respectively. VAS and ODI scores at different time points were compared using repeated measures analysis of variance. The Green house Geisser method was used for correction if the data did not meet the requirements of the sphericity test. The Bonferroni method was used to compare different time points within the same group, and multi-factor analysis of variance was performed to compare two groups at the same time point. Comparison of count data between groups using \u0026chi;2 inspection. A statistically significant difference is indicated by P\u0026lt;0.05.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWe would like to thank all authors that contributed substantially to the manuscript\u0026nbsp;and\u0026nbsp;the support from\u0026nbsp;the\u0026nbsp;Zhangjiagang Science and Technology Bureau Project\u0026nbsp;(no.\u0026nbsp;ZKYL2241)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u0026nbsp;\u003c/strong\u003e\u003cem\u003eMaterial preparation, data collection and analysis were performed by\u0026nbsp;\u003c/em\u003eL.P.Z, L.M.W and W.P.S\u003cem\u003e. The first draft of the manuscript was written by\u0026nbsp;\u003c/em\u003eY.Z and G.Z.C\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003cem\u003eZ.C\u003c/em\u003e \u003cem\u003eprepared figures 1-2 and J.C.S prepared\u0026nbsp;\u003c/em\u003e\u003cem\u003etable\u003c/em\u003e\u003cem\u003es 1-4.\u0026nbsp;\u003c/em\u003e\u003cem\u003eT\u003c/em\u003e\u003cem\u003ehe manuscript was reviewed and revisde by\u0026nbsp;\u003c/em\u003eLiping Zhao\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003cem\u003eAll authors reviewed the manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cem\u003eAll included patients gave their written informed consent. The study was approved by the Ethics Committee of Zhangjiagang Hospital Affiliated to Soochow University(approval no.\u003c/em\u003e2022KY0771002\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003eThe datasets used and analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHan Q, Meng F, Chen M, Lu X, Zhao D, Wu D, Wang T, Qin R. Comparison between PE-TLIF and MIS-TLIF for the treatment of middle-aged and elderly patients with single-level lumbar disc herniation. 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Clin Orthop Surg. 12, 330\u0026ndash;336, DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4055/cios19136\u003c/span\u003e\u003cspan address=\"10.4055/cios19136\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e(2020).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4524619/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4524619/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eUnilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) is a new minimally invasive technique for intervertebral fusion under full endoscopy. We conducted a comprehensive comparative analysis with another minimally invasive technique (minimally invasive transforaminal lumbar interbody fusion, Mis-TLIF) in terms of surgical trauma, clinical outcomes, laboratory indicators.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis of clinical and imaging data of 77 patients with lumbar degenerative illnesses(37 underwent UBE-TLIF, 40 underwent Mis-TLIF) was performed. Demographic data, clinical outcomes [visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI)], operative data (total operation time, intraoperative blood loss, postoperative drainage, length of hospital stay), and laboratory results [plasma hemoglobin (HB), serum creatine phosphokinase (CPK), and C-reactive protein (CRP) ] were compared between the two groups, The Macnab score, fusion rate and fusion time, and complications were also recorded.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBoth groups experienced significant improvements in VAS for back and leg pain and ODI scores after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The VAS-Back and ODI scores were significantly better in the UBE-TLIF group than in the Mis-TLIF group at 1 week and 1 month after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Although the total operation time was significantly longer in the UBE-TLIF group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), the intraoperative blood loss, postoperative drainage and decrease in hemoglobin level were significantly higher in the Mis-TLIF group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). A difference was observed in the fusion time (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There were no between-group differences for the fusion rate, postoperative complications, excellent and good rates and hospital stay (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Serum CRP and CPK levels were considerably lower in the UBE-TLIF group than in the MIS-TLIF group after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBoth UBE-TLIF and Mis-TLIF have equivalent and favorable clinical outcomes. UBE-TLIF is better in reducing surgical bleeding and rapidly improving postoperative back pain.\u003c/p\u003e","manuscriptTitle":"Comparison of the clinical outcomes of unilateral biportal endoscopy versus minimally invasive transforaminal lumbar interbody fusion for the treatment of lumbar degenerative diseases with single- or two-segments ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-26 14:36:49","doi":"10.21203/rs.3.rs-4524619/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"269337cb-8d34-4a41-96bc-d9b8bb2cf153","owner":[],"postedDate":"June 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":33471752,"name":"Health sciences/Medical research/Study design"},{"id":33471753,"name":"Health sciences/Medical research/Study design/Randomized controlled trials"}],"tags":[],"updatedAt":"2024-08-02T00:38:34+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-26 14:36:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4524619","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4524619","identity":"rs-4524619","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}