Comparative Analysis of Clinical Efficacyof Unilateral Biportal Endoscopic and Open Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Degenerative

Comparative Analysis of Clinical Efficacyof Unilateral Biportal Endoscopic and Open Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Degenerative | 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 Research Article Comparative Analysis of Clinical Efficacyof Unilateral Biportal Endoscopic and Open Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Degenerative Yongcun Geng, Dengming Yan, Ming Jiang, Tao Ma, Junyang Li, Xiaoshuang Tu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4762881/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Objective: To study the clinical efficacy of unilateral biportal endoscopic lumbar interbody fusion (ULIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of lumbar degenerative diseases, and to compare perioperative indicators, radiological outcomes, and paraspinal muscle atrophy resulting from these two different surgical methods. Background: Transforaminal lumbar interbody fusion (TLIF) is widely recognized as an effective surgical method to alleviate low back pain. In recent years, unilateral biportal endoscopic lumbar interbody fusion (ULIF) has been increasingly applied. Methods: We recorded the basic information of patients who underwent single-segment ULIF or TLIF for the first time in our hospital from May 2021 to November 2022, including age, gender, BMI, diagnosis, and surgical segment. Perioperative indicators such as estimated blood loss, operation time, postoperative hospital stay, and complications were observed in both groups. Clinical efficacy was assessed preoperatively and at 1 month, 3 months, and 12 months postoperatively using the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI). Patient satisfaction was evaluated using the modified Macnab criteria. The displacement of the fusion device was also assessed. X-rays were taken preoperatively, at 3 months postoperatively, and at 12 months postoperatively to observe fusion device displacement and measure the intervertebral disc height of the upper and lower segments. The Cobb angle was used to measure lumbar lordosis and segmental lumbar lordosis. CT scans at 3 months postoperatively were used to observe intervertebral fusion, including bridging trabeculae, endplate cysts, and screw loosening. MRI at 1 year postoperatively was used to manually trace the cross-sectional area of the paraspinal muscles to compare muscle atrophy. Results: A total of 150 patients were included in the study, with 71 patients in the ULIF group and 79 patients in the TLIF group. There were no statistically significant differences between the two groups in terms of age, gender, BMI, diagnosis, and surgical segment. The estimated blood loss in the ULIF group was 108.78±58.3 ml, which was significantly less than that in the TLIF group at 199.44±84.91 ml (p<0.001). The postoperative hospital stay was shorter in the ULIF group (p=0.020), although the operation time was longer for ULIF. There were no significant differences in complications between the two groups. Patients in the ULIF group experienced quicker relief from back pain postoperatively, but there were no significant differences between the ULIF and TLIF groups in the VAS, ODI, and satisfaction rates at the final follow-up. At 3 months postoperatively, the ULIF group had more bridging trabeculae, fewer endplate cysts, and less fusion device displacement. There were no significant differences between the two groups in the correction of segmental lumbar lordosis (SL) and overall lumbar lordosis (LL). Additionally, the ULIF group showed less muscle damage. Conclusion: ULIF has the advantages of reducing pain in the short term, less blood loss, and shorter hospital stays. Its more precise handling of the intervertebral space reduces the occurrence of endplate cysts and fusion device displacement, which has certain significance in preventing delayed fusion and nonunion. However, ULIF requires a longer operation time, which increases potential risks for elderly patients or those with poor nutritional status. Although ULIF causes less damage to the bony structure, it has not shown a significant advantage in improving adjacent segment degeneration. Lumbar fusion degenerative lumbar disease minimally invasive UBE ULIF Figures Figure 1 Figure 2 Figure 3 Background Low back pain is one of the most common reasons for patients to seek medical attention. Studies have shown that over 60% of lower back pain cases will recur within a year, and 15–40% of individuals with newly onset lower back and leg pain will experience chronic pain or recurrent episodes[1]. Chronic low back pain is the result of interactions among biological, psychological, and social factors[2]. The structures forming the lumbar spine include muscles, ligaments, fascia, tendons, facet joints, neurovascular components, vertebrae, and intervertebral discs, which are susceptible to biochemical, degenerative changes, and traumatic stressors. Radicular pain often radiates below the knee and may result from mechanical nerve compression and chemical irritation from inflammatory mediators leaking from degenerated intervertebral discs. Degenerative changes in the lumbar spine, such as instability and spondylolisthesis, are common causes of lumbosacral pain, where even minor slippage can lead to nerve compression, spinal canal stenosis, and leg pain[3]. Patients without symptoms or with mild symptoms can alleviate their condition through medication and strengthening exercises for the lower back muscles. Currently, there are no prospective randomized controlled trials to determine non-surgical treatments, but many scholars are studying various approaches to delay or reverse degenerative lumbar diseases. These include biological therapies such as cell transplantation, biomaterials, and altering bioactive factors. When stubborn symptoms or associated sensory-motor impairments do not respond to conservative treatments, surgical intervention becomes crucial[4]. Lumbar fusion surgery is an effective method for alleviating symptoms of degenerative lumbar conditions. It includes several different surgical approaches, such as anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF). The surgeon determines the surgical approach based on the patient's symptoms, signs, auxiliary examinations, and their personal expertise. ALIF (anterior lumbar interbody fusion) involves an anterior approach, thereby to some extent avoiding damage to the posterior spinal structures and offering a natural advantage in restoring lumbar lordosis. However, it does carry increased risks of injuring anterior spinal blood vessels and nerves[5]. Compared to ALIF, TLIF and PLIF are more widely used and have similar clinical outcomes in improving symptoms of lumbosacral pain. The TLIF technique can be considered an improvement over PLIF, utilizing a unilateral transforaminal approach to the disc space, partially removing facet joints to expose nerves laterally, thereby reducing nerve traction and the risk of iatrogenic nerve injury. In addition, TLIF causes less damage compared to PLIF by reducing the need for spinous process removal, thereby preserving the integrity of the posterior column. Meta-analyses have confirmed that TLIF offers advantages in terms of reduced blood loss and shorter surgical times. Multiple studies have demonstrated that TLIF results in good clinical outcomes for patients postoperatively[6]. TLIF does not require exposure of the contralateral intervertebral foramen for fusion, significantly reducing the risk of nerve injury. Although TLIF surgery achieves extensive decompression of neural structures and stabilizes the operative segment, as a traditional open surgery, its main drawbacks include larger surgical trauma and disadvantages for early patient mobility compared to minimally invasive techniques. Additionally, it may cause damage to bony structures and alter biomechanical properties post-fusion, thereby increasing the risk of adjacent segment degeneration[7]. The management of the intervertebral space is crucial for interbody fusion. Bridging bone trabeculae are important indicators for evaluating the fusion process, while the appearance of vertebral endplate cysts is considered an effective predictor of poor fusion. In recent years, endoscopic techniques have gradually matured, offering advantages such as preserving normal tissue structures, minimal trauma, fewer complications, and fast postoperative recovery. Recently, the unilateral biportal endoscopic fusion technique (ULIF) has gained widespread application[4]. Not only does ULIF have a similar operative scope to TLIF, but its endoscopic and working channels also allow direct entry into the intervertebral space for endplate preparation, providing a more direct observation of the extent of endplate handling. This reduces the possibility of excessive residual nucleus pulposus or damage to the bony endplates. In addition, more precise decompression under endoscopy can reduce damage to bony structures. The procedural steps of ULIF are similar to those of TLIF. Therefore, the objectives of this study are: firstly, to compare the postoperative clinical efficacy of ULIF and TLIF; secondly, to observe whether ULIF's advantages in intervertebral space handling lead to better fusion results; and thirdly, to determine whether ULIF causes significantly different muscle damage compared to TLIF Methods This study was approved by the local ethics committee (approval number 2023YLJSA012). Patient data were collected from May 2021 to November 2022 for ULIF and TLIF treatments conducted by our surgical team. The inclusion criteria for patients in the study are as follows: (1) undergoing initial single-segment ULIF or TLIF surgery; (2) diagnosed with degenerative lumbar conditions including spondylolisthesis, segmental instability, or degenerative disc disease with ineffective conservative treatment for more than 3 months; (3) symptoms, signs, and auxiliary examinations consistent with the diagnosis; (4) able to cooperate in answering relevant questions. Exclusion criteria include: (1) revision surgery; (2) severe spinal scoliosis; (3) presence of vertebral fractures or tumors; (4) spinal infectious diseases. Record perioperative indicators for patients, including surgical time, postoperative complications, surgical blood loss calculated using Nadler's and Gross's formulas. Nadler's formula calculates blood volume as follows: Blood Volume = k1 × Height (m) + k2 × Weight (kg) + k3, where for males, k1 = 0.3669, k2 = 0.03219, k3 = 0.6041; and for females, k1 = 0.3561, k2 = 0.03308, k3 = 0.1833. Gross's formula calculates total blood loss as: Total Blood Loss = Blood Volume × (Hct pre-op + Hct post-op) / (2 × Average Hct), where Average Hct = (Hct pre-op + Hct post-op) / 2. Patients' postoperative clinical outcomes were assessed using Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) at preoperative, 1-month, 3-month, and 1-year intervals. Patient satisfaction was evaluated using the modified Macnab criteria. X-rays were taken preoperatively, at 3 months postoperatively, and at 12 months postoperatively to measure the height of upper and lower segment intervertebral spaces. Intervertebral space height measurement was calculated as (height of anterior intervertebral space + height of posterior intervertebral space) / 2. Using Cobb angle measurements to assess lumbar lordosis and segmental lumbar lordosis, where lumbar lordosis measures the angle from the L1 upper endplate to the S1 upper endplate on X-ray, and segmental lumbar lordosis measures the angle between the upper edge of the superior vertebral body and the lower edge of the inferior vertebral body of the operative intervertebral space. Postoperatively at three months, CT scans are used to observe vertebral fusion, including bridging bone trabeculae, vertebral endplate cysts, and screw loosening. Vertebral endplate cysts are defined as new cysts > 2mm appearing at any level of the operated segment. One year postoperatively, MRI is used to observe paraspinal muscle atrophy, and Image J software is used to manually trace and measure paraspinal muscle cross-sectional area (Fig. 1). Procedure ULIF Procedure: The patient is placed prone under general anesthesia. Using a C-arm fluoroscope, the operative level is positioned vertically relative to the ground, and frontal fluoroscopy is used to confirm and mark the channel establishment site. Standard disinfection and draping are performed, and waterproof draping is applied. Starting from the midline of the intervertebral space, symmetric vertical incisions are made approximately 0.5-1.0 cm lateral to the outer edge of the vertebral arches. The working channels are about 1 cm wide, and observation channels are approximately 0.5 cm wide to accommodate the endoscope. Various ULIF instruments are inserted through the working channels for the procedure(Fig. 2). Both channels are bluntly dissected through soft tissues to minimize direct muscle damage. Continuous saline irrigation is used to improve surgical visibility; inadequate irrigation can affect visibility. Under endoscopic guidance, tissues are exposed down to bony structures, with timely hemostasis using electrocautery throughout. Depending on the specifics, drills, bone knives, and chisels are used under endoscopy for precise partial vertebral plate and facet joint removal, with autologous bone collected for grafting. The ligamentum flavum is excised to expose the dura mater or nerve roots for further decompression. The large operational space of ULIF allows for lateral recess and contralateral decompression. Neurolysis probes are used to explore and release nerves, with preemptive hemostasis. RF probes are used to excise intervertebral discs, and under clear endoscopic vision, the endplates are prepared by removing residual nucleus pulposus until visible blood vessels are seen. A funnel-shaped cannula is used for autologous bone grafting into the intervertebral space, followed by insertion of a polyetheretherketone interbody fusion device under fluoroscopic observation. Finally, all instruments are removed, and conventional percutaneous bilateral pedicle screw fixation is performed. A drainage tube is placed as well. TLIF: After successful induction of general anesthesia, the patient is positioned prone. A midline incision approximately 8 centimeters long is made in the lower back, centered on the operative intervertebral space. The incision penetrates through the skin, subcutaneous tissue, and deep fascia. Starting from the more symptomatic approach, the procedure involves fully exposing the vertebral body, superior and inferior facet joints, and the vertebral notch of the upper endplate. Subsequent procedures are similar to ULIF. Discussion The lumbar spine plays a crucial role in human mobility, with a wide range of motion and the ability to bear significant loads, which makes it susceptible to degenerative changes. This susceptibility is especially pronounced among individuals with poor posture, obesity, or those engaged in physically demanding work, all of which accelerate lumbar spine degeneration[1]. For patients experiencing primarily radicular symptoms without clear signs of instability, decompression of the spinal canal alone is often sufficient. This approach aims to alleviate nerve root compression while minimizing alterations to the spine's biomechanics. For patients with lumbar instability, fusion of the affected segment is necessary. In this study, the ULIF group demonstrated early pain relief, less intraoperative blood loss, faster recovery, and shorter hospital stays compared to the TLIF group. Early mobilization helped patients return to normal life quickly. However, at the last follow-up, both groups showed similar clinical outcomes without statistical differences. ULIF surgery prolonged operative time and posed increased surgical risks for elderly patients undergoing prolonged prone anesthesia. With technological advancements, minimally invasive surgery has been widely promoted, supported by multiple studies showing comparable clinical efficacy. A meta-analysis indicated that endoscopic lumbar fusion surgery shows favorable short-term outcomes, with significant improvements in VAS back pain score, VAS leg pain score, and ODI score[8, 9]. This result is consistent with our research findings, indicating that endoscopic lumbar fusion surgery has significant advantages in improving short-term clinical outcomes. Some scholars have achieved good results using single-channel endoscopic fusion, but it has limitations such as restricted visibility and limited operating space, for example, inadequate lateral recess decompression, thereby narrowing its indications[10]. ULIF technology overcomes some of the limitations of single-channel endoscopy and offers an operating space similar to TLIF surgery, with a broad decompression range sufficient for adequate contralateral lateral recess decompression. Therefore, we consider ULIF to be a promising surgical approach. However, some argue that ULIF increases the invasiveness compared to single-channel methods due to the addition of an extra channel. Hence, we also quantitatively studied the damage to muscle tissue. One of the purposes of lumbar spine fusion surgery is intervertebral bone fusion. Therefore, preventing postoperative non-union is crucial for the patient's prognosis. Severe fusion cage displacement may directly lead to fusion failure or cause symptoms due to compression of the dural sac or nerve roots. Fusion cage displacement can occur due to several reasons: firstly, excessive residual nucleus pulposus within the intervertebral space can encase the fusion cage, hindering bony trabecular ingrowth; secondly, improper endplate preparation affects the contact area between the fusion cage and the upper and lower endplates; thirdly, excessive removal of bony structures, such as partial facet joint removal during surgery, compromises the stability of the posterior column; fourthly, improper fusion cage material, placement, type, or bone graft material can lead to compression or micromotion. In our study, both groups of patients used fusion cages made of the same materials. The difference lies in TLIF relying more on the surgeon's experience for intervertebral space handling, which increases the risk of inadequate endplate preparation or damage to the bony endplates. During ULIF surgery, the dual-channel approach allows direct access into the intervertebral space, providing clear visualization under the microscope of the endplate preparation. The anatomical relationship between the cartilaginous and bony endplates is fully exposed, facilitating precise removal of residual nucleus pulposus and observation of blood sinus formation, ensuring optimal contact area between the bone graft and fusion area. When placing the fusion cage, the depth of insertion can be clearly observed, preventing anterior or posterior displacement of the cage. Therefore, we believe ULIF can better facilitate intervertebral fusion, reducing the incidence of fusion cage displacement. Additionally, the lower rate of vertebral endplate cysts in the ULIF group further supports its efficacy. The vertebral endplate cysts may develop due to micro-movements between the endplate and the fusion cage, possibly influenced by the materials used in the fusion cage[11]. sutSumimoto et al.'s study suggests that anatomical factors directly contribute to paraspinal muscle injury. Increasing strength in the lower back is crucial for maintaining lumbar stability. Therefore, minimizing muscle atrophy during surgery is of paramount importance. ULIF achieves decompression and fusion under endoscopic guidance through two channels, employing blunt dissection to minimize muscle damage. Entry into the multifidus muscle interspace reduces muscular trauma to traction injury without substantive destruction. This approach effectively protects paraspinal muscles, aiding in early postoperative pain relief and long-term chronic pain reduction, thereby enhancing postoperative quality of life and facilitating early return to daily activities for muscle conditioning. Moreover, ULIF allows precise vertebral plate removal under endoscopic view, minimizing unnecessary bone injury compared to TLIF, thus preserving lumbar stability and facilitating everyday flexion-extension movements for patients. In our study, ULIF patients demonstrated significant improvement in rapid recovery from preoperative lower back pain. Preoperatively educated patients exhibited varied changes in paraspinal muscle after one year, with ULIF patients showing significantly larger cross-sectional areas and less fat infiltration on MRI compared to TLIF patients. These findings indicate that, under these multifaceted considerations, ULIF minimizes paraspinal muscle damage and better alleviates symptoms for patients. Lumbar spine fusion stabilizes the affected segments, restoring sagittal balance of the lumbar spine. However, the biomechanical changes introduced by fixing the responsible segment are an issue worthy of attention. Despite attempts to reduce spondylolisthesis by traction reduction, significant increases in load and shear stress on adjacent segments after lumbar fusion cannot be altered[12]. After the fusion segment is stabilized, other segments compensate to maintain lumbar spine mobility, often accelerating degeneration in adjacent segments. Accelerated degeneration in adjacent segments often requires timely intervention to prevent further deterioration. Although ULIF cannot directly alter this situation, it enhances lumbar spine stability through muscle strengthening and reduced bone destruction. Therefore, theoretically, ULIF offers some protective effect against adjacent segment diseases. Unfortunately, in our study, despite fewer occurrences of fusion device displacement and vertebral endplate cysts in the ULIF group, X-rays one year post-surgery showed varying degrees of reduction in intervertebral space in fusion segments, similar to the TLIF group. The physiological lordosis of the lumbar spine plays a crucial role in maintaining posture and movement. With degenerative changes in the lumbar spine, the lordosis decreases, altering the distribution of mechanical stress it bears[13]. Improving the lordotic angle of the lumbar spine is closely related to postoperative recovery. For correcting lordotic angles, anterior lumbar interbody fusion surgery offers significant advantages. It provides exposure to the entire ventral surface of the intervertebral space, facilitating better correction of coronal plane imbalance after implantation of the fusion cage and promoting greater restoration of spinal lordosis[14]. Although TLIF is less effective than ALIF in correcting sagittal balance, related studies have shown that TLIF can correct segmental lumbar lordosis Angle. The results of this study showed that the two procedures had similar effects on the correction of segmental lumbar lordosis and lumbar lordosis. ULIF and TLIF have many similarities. Their surgical approaches and the anatomical structures they encounter are similar. Moreover, the surgical instruments used in TLIF can also be utilized in ULIF. Therefore, during ULIF surgery, even if unexpected situations arise, the two longitudinal incisions can be connected in a timely manner, converting it to an open surgery. The difference is that compared to TLIF, ULIF maintains a clear surgical field under the endoscope with timely hemostasis using a high-frequency electric knife and continuous irrigation with saline solution, preventing bleeding from affecting the surgical view. This avoids inadequate decompression and iatrogenic injuries caused by a compromised surgical field. In this study, none of the patients experienced incomplete decompression. The unilateral biportal endoscopic technique allowed for meticulous endplate preparation, minimizing the risk of endplate damage and providing more favorable conditions for postoperative interbody fusion. Finally, our study has several limitations. First, the study was not randomized; second, the sample size was not large enough, and the follow-up period was not long enough; third, the manual measurement of angles and areas may have errors and cannot completely eliminate the interference of metal artifacts after lumbar fusion. Conclusion In summary, we believe that ULIF is a minimally invasive lumbar fusion surgery that is safe and effective for treating degenerative lumbar diseases. It offers similar clinical outcomes to TLIF but with the advantages of being less invasive, causing less bleeding, and promoting quicker recovery. While maintaining the operative range, ULIF also reduces damage to the paraspinal muscles. The more precise handling of the intervertebral space in ULIF decreases the occurrence of vertebral endplate cysts and cage displacement, which is significant in preventing delayed fusion and non-union. However, ULIF requires longer surgical time, which poses potential risks for elderly patients or those with poor nutritional status. Although ULIF is less invasive, the improvement in low back and leg pain symptoms is similar to that of TLIF. Despite less destruction of bony structures with ULIF, it does not show a significant advantage in improving adjacent segment degeneration. Declarations Author Contribution Yongcun Geng (First Author): Conceptualization,Methodology, Software, Investigation,Formal Analysis, Writing - Original Draft;Dengming Yan: Data Curation, Writing -Original Draft;Ming Jiang: Visualization, Investigation;Tao Ma: Resources, Supervision;Junyang Li:Software, Validation;Xiaoshuang Tu: Visualization, Writing - Review& Editing;Jingwei Wu:Visualization, Validation;Senlin Chen:Validation,Writing - Review& Editing;Lumning Nong(Corresponding Author):Conceptualization, Funding Acquisition,Resources, Supervision, Writing - Review& Editing. References Itz CJ, Geurts JW, van Kleef M, Nelemans P: Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care . European Journal of Pain (London, England) 2013, 17 (1). Lall MP, Restrepo E: The Biopsychosocial Model of Low Back Pain and Patient-Centered Outcomes Following Lumbar Fusion . Orthopedic Nursing 2017, 36 (3):213-221. 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Chan AK, Bisson EF, Bydon M, Foley KT, Glassman SD, Shaffrey CI, Wang MY, Park P, Potts EA, Shaffrey ME et al : A Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Grade 1 Degenerative Lumbar Spondylolisthesis: An Analysis of the Prospective Quality Outcomes Database . Neurosurgery 2020, 87 (3):555-562. Park S-M, Park J, Jang HS, Heo YW, Han H, Kim H-J, Chang B-S, Lee C-K, Yeom JS: Biportal endoscopic versus microscopic lumbar decompressive laminectomy in patients with spinal stenosis: a randomized controlled trial . The spine journal : official journal of the North American Spine Society 2020, 20 (2):156-165. Heo DH, Hong YH, Lee DC, Chung HJ, Park CK: Technique of Biportal Endoscopic Transforaminal Lumbar Interbody Fusion . Neurospine 2020, 17 (Suppl 1):S129-S137. Heo DH, Park CK: Clinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery . Neurosurgical focus 2019, 46 (4):E18. Wu Y-S, Zhang H, Zheng W-H, Feng Z-H, Chen Z-X, Lin Y: Hidden blood loss and the influential factors after percutaneous kyphoplasty surgery . European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2017, 26 (7):1878-1883. Quint DJ, Tuite GF, Stern JD, Doran SE, Papadopoulos SM, McGillicuddy JE, Lundquist CA: Computer-assisted measurement of lumbar spine radiographs . Acad Radiol 1997, 4 (11):742-752. Been E, Kalichman L: Lumbar lordosis . The spine journal : official journal of the North American Spine Society 2014, 14 (1):87-97. Fu C-J, Chen W-C, Lu M-L, Cheng C-H, Niu C-C: Comparison of paraspinal muscle degeneration and decompression effect between conventional open and minimal invasive approaches for posterior lumbar spine surgery . Sci Rep 2020, 10 (1):14635. Tables TABLE.1 Baseline data for ULIF and TLIF. ULIF （n=71） TLIF （n=79） P value Sex（male/female） 33/38 25/54 0.063 Age (years) 58.69±15.7 62.49±11.09 0.129 BMI（Kg/m2） 25.53±4.42 26.88±5.91 0.131 Fusion levels 0.941 L3/4 6 7 L4/5 39 41 L5/S1 26 31 Diagnosis 0.962 lumbar spondylolisthesis 42 45 Segmental instability 19 22 lumbar spondylolysis 10 12 TABLE.2 Perioperative period index ULIF TLIF P value Operation time（h） 175.82±75.19 111.75±38.08 <0.001 * Blood loss（ml） 108.78±58.3 199.44±84.91 <0.001 * Postoperative hospital stay（d） 6.1±1.71 7.17±1.88 0.020 * TABLE.3. Comparisons of VAS back, VAS leg, and ODI scores between ULIF and TLIF groups ULIF (n=71) TLIF (n=79) P value VAS back Preoperation 5.68±1.11 5.71±1.26 0.866 1 month after operation 2.36±0.83 2.7±0.94 0.019 * 3 months after operation 1.52±0.67 1.55±0.96 0.790 12 months after operation 1.27±0.77 1.24±0.79 0.832 VAS leg Preoperation 4.73±1.64 4.82±1.44 0.720 1 month after operation 2.64±0.96 2.44±1.01 0.206 3 months after operation 1.61±0.73 1.49±0.86 0.393 12 months after operation 1±0.85 0.99±0.9 0.852 ODI Preoperation 63.27±9.29 63.36±9.68 0.954 1 month after operation 29.99±7.08 33.93±8 0.001 * 3 months after operation 14.62±5.59 15.9±4.83 0.105 12 months after operation 7.08±6.1 8.09±5.15 0.243 VAS, visual analogue scale. ODI, Oswestry Disability Index. 表4.两组患者放射学结果 ULIF （n=71） OTLIF （n=79） P value VEC 10（14.1%） 28（35.4%） 0.003 PSL 1（1.4%） 1（1.3%） 0.724 CM 1（1.4%） 7（8.8%） 0.031 CTB 65（91.5%） 60（75.9%） 0.010 Preoperation paravertebral muscle area 1829.5±125.5 mm 2 1828.9±152.7 mm 2 0.981 12 months after operation paravertebral muscle area 1820.6±141.7 mm 2 1724.4±144.0 mm 2 <0.001 P=0.070 P<0.001 VEC, Vertebral endplate cyst. PSL,e wqCTB, continuous trabecular bone 表5术后一年X线及角度测量结果 L3/4 L4/5 L5/S1 ULIF TLIF p ULIF TLIF p ULIF TLIF p 术前节段前凸角 7.78±0.84 8.63±0.91 0.163 8.99±1.86 8.86±2.01 0.765 9.94±1.69 9.69±1.77 0.583 术后节段前凸角 11.37±1.74 11.91±2.1 0.670 11.94±1.89 12.86±3.42 0.136 11.91±2.35 11.57±1.53 0.531 术前腰椎前凸角 38.49±0.76 38.51±1.99 0.979 38.18±4.1 38.79±4.12 0.507 38.32±5.26 38.82±4.95 0.712 术后节段前凸角 39.82±0.99 40.72±0.99 0.186 39.28±4.18 39.88±3.75 0.501 39.17±5.02 39.84±4.63 0.605 术前上节段椎间隙高度 11.12±1.08 11.16±0.91 0.949 11.12±2.33 11.28±2.24 0.754 11.04±1.9 11.05±1.48 0.981 术后上节段椎间隙高度t 10.76±1.25 10.48±0.87 0.692 9.61±2.6 9.69±1.99 0.880 10.01±1.55 9.75±1.36 0.513 术前下节段椎间隙高度 11.58±0.93 11.38±0.89 0.736 10.01±2.61 10.13±1.98 0.819 - - 术后下节段椎间隙高度 10.56±0.86 9.97±0.44 0.213 9.56±2.48 9.71±1.74 0.749 Additional Declarations No competing interests reported. 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Nanjing medical University","correspondingAuthor":false,"prefix":"","firstName":"Dengming","middleName":"","lastName":"Yan","suffix":""},{"id":337321983,"identity":"ba6ae9d3-0f31-4143-ae7c-eaef1079b1d4","order_by":2,"name":"Ming Jiang","email":"","orcid":"","institution":"The Third Affiliated Hospital of Nanjing medical University","correspondingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Jiang","suffix":""},{"id":337321984,"identity":"9422510e-fe90-4d17-9395-134c87ee618b","order_by":3,"name":"Tao Ma","email":"","orcid":"","institution":"The Third Affiliated Hospital of Nanjing medical University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Ma","suffix":""},{"id":337321985,"identity":"57851fef-01ea-4059-bec0-d36a030d5ab9","order_by":4,"name":"Junyang Li","email":"","orcid":"","institution":"The Third Affiliated Hospital of Nanjing medical 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13:16:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4762881/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4762881/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62660510,"identity":"d9885668-d42c-4ef2-aeff-333587d9eb13","added_by":"auto","created_at":"2024-08-17 02:34:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":345110,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"F.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4762881/v1/bd34b5b656aa18de278fe5a6.jpg"},{"id":62660508,"identity":"4ef7bf62-180a-4369-b885-1a4d6f7568c1","added_by":"auto","created_at":"2024-08-17 02:34:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":218671,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"F.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4762881/v1/34e62cd64b74267dbd8f1fb0.jpg"},{"id":62661618,"identity":"b7e24fd6-7f5a-482e-a7a6-c344b801b7ac","added_by":"auto","created_at":"2024-08-17 02:42:08","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":181299,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"F.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4762881/v1/75a7356421f7e39f48f37a76.jpg"},{"id":62661619,"identity":"0f33544a-7b74-4b21-b06b-c0764ab3e941","added_by":"auto","created_at":"2024-08-17 02:42:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1540008,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4762881/v1/abf47f94-3d55-4e5c-a511-023df4bd5b89.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Analysis of Clinical Efficacyof Unilateral Biportal Endoscopic and Open Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Degenerative","fulltext":[{"header":"Background","content":"\u003cp\u003eLow back pain is one of the most common reasons for patients to seek medical attention. Studies have shown that over 60% of lower back pain cases will recur within a year, and 15\u0026ndash;40% of individuals with newly onset lower back and leg pain will experience chronic pain or recurrent episodes[1]. Chronic low back pain is the result of interactions among biological, psychological, and social factors[2]. The structures forming the lumbar spine include muscles, ligaments, fascia, tendons, facet joints, neurovascular components, vertebrae, and intervertebral discs, which are susceptible to biochemical, degenerative changes, and traumatic stressors. Radicular pain often radiates below the knee and may result from mechanical nerve compression and chemical irritation from inflammatory mediators leaking from degenerated intervertebral discs. Degenerative changes in the lumbar spine, such as instability and spondylolisthesis, are common causes of lumbosacral pain, where even minor slippage can lead to nerve compression, spinal canal stenosis, and leg pain[3]. Patients without symptoms or with mild symptoms can alleviate their condition through medication and strengthening exercises for the lower back muscles. Currently, there are no prospective randomized controlled trials to determine non-surgical treatments, but many scholars are studying various approaches to delay or reverse degenerative lumbar diseases. These include biological therapies such as cell transplantation, biomaterials, and altering bioactive factors. When stubborn symptoms or associated sensory-motor impairments do not respond to conservative treatments, surgical intervention becomes crucial[4]. Lumbar fusion surgery is an effective method for alleviating symptoms of degenerative lumbar conditions. It includes several different surgical approaches, such as anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF). The surgeon determines the surgical approach based on the patient's symptoms, signs, auxiliary examinations, and their personal expertise. ALIF (anterior lumbar interbody fusion) involves an anterior approach, thereby to some extent avoiding damage to the posterior spinal structures and offering a natural advantage in restoring lumbar lordosis. However, it does carry increased risks of injuring anterior spinal blood vessels and nerves[5]. Compared to ALIF, TLIF and PLIF are more widely used and have similar clinical outcomes in improving symptoms of lumbosacral pain. The TLIF technique can be considered an improvement over PLIF, utilizing a unilateral transforaminal approach to the disc space, partially removing facet joints to expose nerves laterally, thereby reducing nerve traction and the risk of iatrogenic nerve injury. In addition, TLIF causes less damage compared to PLIF by reducing the need for spinous process removal, thereby preserving the integrity of the posterior column. Meta-analyses have confirmed that TLIF offers advantages in terms of reduced blood loss and shorter surgical times. Multiple studies have demonstrated that TLIF results in good clinical outcomes for patients postoperatively[6]. TLIF does not require exposure of the contralateral intervertebral foramen for fusion, significantly reducing the risk of nerve injury. Although TLIF surgery achieves extensive decompression of neural structures and stabilizes the operative segment, as a traditional open surgery, its main drawbacks include larger surgical trauma and disadvantages for early patient mobility compared to minimally invasive techniques. Additionally, it may cause damage to bony structures and alter biomechanical properties post-fusion, thereby increasing the risk of adjacent segment degeneration[7]. The management of the intervertebral space is crucial for interbody fusion. Bridging bone trabeculae are important indicators for evaluating the fusion process, while the appearance of vertebral endplate cysts is considered an effective predictor of poor fusion. In recent years, endoscopic techniques have gradually matured, offering advantages such as preserving normal tissue structures, minimal trauma, fewer complications, and fast postoperative recovery. Recently, the unilateral biportal endoscopic fusion technique (ULIF) has gained widespread application[4]. Not only does ULIF have a similar operative scope to TLIF, but its endoscopic and working channels also allow direct entry into the intervertebral space for endplate preparation, providing a more direct observation of the extent of endplate handling. This reduces the possibility of excessive residual nucleus pulposus or damage to the bony endplates. In addition, more precise decompression under endoscopy can reduce damage to bony structures. The procedural steps of ULIF are similar to those of TLIF. Therefore, the objectives of this study are: firstly, to compare the postoperative clinical efficacy of ULIF and TLIF; secondly, to observe whether ULIF's advantages in intervertebral space handling lead to better fusion results; and thirdly, to determine whether ULIF causes significantly different muscle damage compared to TLIF\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study was approved by the local ethics committee (approval number 2023YLJSA012). Patient data were collected from May 2021 to November 2022 for ULIF and TLIF treatments conducted by our surgical team. The inclusion criteria for patients in the study are as follows: (1) undergoing initial single-segment ULIF or TLIF surgery; (2) diagnosed with degenerative lumbar conditions including spondylolisthesis, segmental instability, or degenerative disc disease with ineffective conservative treatment for more than 3 months; (3) symptoms, signs, and auxiliary examinations consistent with the diagnosis; (4) able to cooperate in answering relevant questions. Exclusion criteria include: (1) revision surgery; (2) severe spinal scoliosis; (3) presence of vertebral fractures or tumors; (4) spinal infectious diseases. Record perioperative indicators for patients, including surgical time, postoperative complications, surgical blood loss calculated using Nadler's and Gross's formulas. Nadler's formula calculates blood volume as follows: Blood Volume\u0026thinsp;=\u0026thinsp;k1 \u0026times; Height (m)\u0026thinsp;+\u0026thinsp;k2 \u0026times; Weight (kg)\u0026thinsp;+\u0026thinsp;k3, where for males, k1\u0026thinsp;=\u0026thinsp;0.3669, k2\u0026thinsp;=\u0026thinsp;0.03219, k3\u0026thinsp;=\u0026thinsp;0.6041; and for females, k1\u0026thinsp;=\u0026thinsp;0.3561, k2\u0026thinsp;=\u0026thinsp;0.03308, k3\u0026thinsp;=\u0026thinsp;0.1833. Gross's formula calculates total blood loss as: Total Blood Loss\u0026thinsp;=\u0026thinsp;Blood Volume \u0026times; (Hct pre-op\u0026thinsp;+\u0026thinsp;Hct post-op) / (2 \u0026times; Average Hct), where Average Hct = (Hct pre-op\u0026thinsp;+\u0026thinsp;Hct post-op) / 2. Patients' postoperative clinical outcomes were assessed using Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) at preoperative, 1-month, 3-month, and 1-year intervals. Patient satisfaction was evaluated using the modified Macnab criteria. X-rays were taken preoperatively, at 3 months postoperatively, and at 12 months postoperatively to measure the height of upper and lower segment intervertebral spaces. Intervertebral space height measurement was calculated as (height of anterior intervertebral space\u0026thinsp;+\u0026thinsp;height of posterior intervertebral space) / 2. Using Cobb angle measurements to assess lumbar lordosis and segmental lumbar lordosis, where lumbar lordosis measures the angle from the L1 upper endplate to the S1 upper endplate on X-ray, and segmental lumbar lordosis measures the angle between the upper edge of the superior vertebral body and the lower edge of the inferior vertebral body of the operative intervertebral space. Postoperatively at three months, CT scans are used to observe vertebral fusion, including bridging bone trabeculae, vertebral endplate cysts, and screw loosening. Vertebral endplate cysts are defined as new cysts\u0026thinsp;\u0026gt;\u0026thinsp;2mm appearing at any level of the operated segment. One year postoperatively, MRI is used to observe paraspinal muscle atrophy, and Image J software is used to manually trace and measure paraspinal muscle cross-sectional area (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eULIF Procedure: The patient is placed prone under general anesthesia. Using a C-arm fluoroscope, the operative level is positioned vertically relative to the ground, and frontal fluoroscopy is used to confirm and mark the channel establishment site. Standard disinfection and draping are performed, and waterproof draping is applied. Starting from the midline of the intervertebral space, symmetric vertical incisions are made approximately 0.5-1.0 cm lateral to the outer edge of the vertebral arches. The working channels are about 1 cm wide, and observation channels are approximately 0.5 cm wide to accommodate the endoscope. Various ULIF instruments are inserted through the working channels for the procedure(Fig.\u0026nbsp;2). Both channels are bluntly dissected through soft tissues to minimize direct muscle damage. Continuous saline irrigation is used to improve surgical visibility; inadequate irrigation can affect visibility. Under endoscopic guidance, tissues are exposed down to bony structures, with timely hemostasis using electrocautery throughout. Depending on the specifics, drills, bone knives, and chisels are used under endoscopy for precise partial vertebral plate and facet joint removal, with autologous bone collected for grafting. The ligamentum flavum is excised to expose the dura mater or nerve roots for further decompression. The large operational space of ULIF allows for lateral recess and contralateral decompression. Neurolysis probes are used to explore and release nerves, with preemptive hemostasis. RF probes are used to excise intervertebral discs, and under clear endoscopic vision, the endplates are prepared by removing residual nucleus pulposus until visible blood vessels are seen. A funnel-shaped cannula is used for autologous bone grafting into the intervertebral space, followed by insertion of a polyetheretherketone interbody fusion device under fluoroscopic observation. Finally, all instruments are removed, and conventional percutaneous bilateral pedicle screw fixation is performed. A drainage tube is placed as well.\u003c/p\u003e \u003cp\u003eTLIF: After successful induction of general anesthesia, the patient is positioned prone. A midline incision approximately 8 centimeters long is made in the lower back, centered on the operative intervertebral space. The incision penetrates through the skin, subcutaneous tissue, and deep fascia. Starting from the more symptomatic approach, the procedure involves fully exposing the vertebral body, superior and inferior facet joints, and the vertebral notch of the upper endplate. Subsequent procedures are similar to ULIF.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe lumbar spine plays a crucial role in human mobility, with a wide range of motion and the ability to bear significant loads, which makes it susceptible to degenerative changes. This susceptibility is especially pronounced among individuals with poor posture, obesity, or those engaged in physically demanding work, all of which accelerate lumbar spine degeneration[1]. For patients experiencing primarily radicular symptoms without clear signs of instability, decompression of the spinal canal alone is often sufficient. This approach aims to alleviate nerve root compression while minimizing alterations to the spine's biomechanics.\u003c/p\u003e \u003cp\u003eFor patients with lumbar instability, fusion of the affected segment is necessary. In this study, the ULIF group demonstrated early pain relief, less intraoperative blood loss, faster recovery, and shorter hospital stays compared to the TLIF group. Early mobilization helped patients return to normal life quickly. However, at the last follow-up, both groups showed similar clinical outcomes without statistical differences. ULIF surgery prolonged operative time and posed increased surgical risks for elderly patients undergoing prolonged prone anesthesia. With technological advancements, minimally invasive surgery has been widely promoted, supported by multiple studies showing comparable clinical efficacy. A meta-analysis indicated that endoscopic lumbar fusion surgery shows favorable short-term outcomes, with significant improvements in VAS back pain score, VAS leg pain score, and ODI score[8, 9]. This result is consistent with our research findings, indicating that endoscopic lumbar fusion surgery has significant advantages in improving short-term clinical outcomes. Some scholars have achieved good results using single-channel endoscopic fusion, but it has limitations such as restricted visibility and limited operating space, for example, inadequate lateral recess decompression, thereby narrowing its indications[10]. ULIF technology overcomes some of the limitations of single-channel endoscopy and offers an operating space similar to TLIF surgery, with a broad decompression range sufficient for adequate contralateral lateral recess decompression. Therefore, we consider ULIF to be a promising surgical approach. However, some argue that ULIF increases the invasiveness compared to single-channel methods due to the addition of an extra channel. Hence, we also quantitatively studied the damage to muscle tissue. One of the purposes of lumbar spine fusion surgery is intervertebral bone fusion. Therefore, preventing postoperative non-union is crucial for the patient's prognosis. Severe fusion cage displacement may directly lead to fusion failure or cause symptoms due to compression of the dural sac or nerve roots.\u003c/p\u003e \u003cp\u003eFusion cage displacement can occur due to several reasons: firstly, excessive residual nucleus pulposus within the intervertebral space can encase the fusion cage, hindering bony trabecular ingrowth; secondly, improper endplate preparation affects the contact area between the fusion cage and the upper and lower endplates; thirdly, excessive removal of bony structures, such as partial facet joint removal during surgery, compromises the stability of the posterior column; fourthly, improper fusion cage material, placement, type, or bone graft material can lead to compression or micromotion. In our study, both groups of patients used fusion cages made of the same materials. The difference lies in TLIF relying more on the surgeon's experience for intervertebral space handling, which increases the risk of inadequate endplate preparation or damage to the bony endplates. During ULIF surgery, the dual-channel approach allows direct access into the intervertebral space, providing clear visualization under the microscope of the endplate preparation. The anatomical relationship between the cartilaginous and bony endplates is fully exposed, facilitating precise removal of residual nucleus pulposus and observation of blood sinus formation, ensuring optimal contact area between the bone graft and fusion area. When placing the fusion cage, the depth of insertion can be clearly observed, preventing anterior or posterior displacement of the cage. Therefore, we believe ULIF can better facilitate intervertebral fusion, reducing the incidence of fusion cage displacement. Additionally, the lower rate of vertebral endplate cysts in the ULIF group further supports its efficacy. The vertebral endplate cysts may develop due to micro-movements between the endplate and the fusion cage, possibly influenced by the materials used in the fusion cage[11]. sutSumimoto et al.'s study suggests that anatomical factors directly contribute to paraspinal muscle injury. Increasing strength in the lower back is crucial for maintaining lumbar stability. Therefore, minimizing muscle atrophy during surgery is of paramount importance. ULIF achieves decompression and fusion under endoscopic guidance through two channels, employing blunt dissection to minimize muscle damage. Entry into the multifidus muscle interspace reduces muscular trauma to traction injury without substantive destruction. This approach effectively protects paraspinal muscles, aiding in early postoperative pain relief and long-term chronic pain reduction, thereby enhancing postoperative quality of life and facilitating early return to daily activities for muscle conditioning. Moreover, ULIF allows precise vertebral plate removal under endoscopic view, minimizing unnecessary bone injury compared to TLIF, thus preserving lumbar stability and facilitating everyday flexion-extension movements for patients. In our study, ULIF patients demonstrated significant improvement in rapid recovery from preoperative lower back pain. Preoperatively educated patients exhibited varied changes in paraspinal muscle after one year, with ULIF patients showing significantly larger cross-sectional areas and less fat infiltration on MRI compared to TLIF patients. These findings indicate that, under these multifaceted considerations, ULIF minimizes paraspinal muscle damage and better alleviates symptoms for patients. Lumbar spine fusion stabilizes the affected segments, restoring sagittal balance of the lumbar spine. However, the biomechanical changes introduced by fixing the responsible segment are an issue worthy of attention. Despite attempts to reduce spondylolisthesis by traction reduction, significant increases in load and shear stress on adjacent segments after lumbar fusion cannot be altered[12]. After the fusion segment is stabilized, other segments compensate to maintain lumbar spine mobility, often accelerating degeneration in adjacent segments. Accelerated degeneration in adjacent segments often requires timely intervention to prevent further deterioration. Although ULIF cannot directly alter this situation, it enhances lumbar spine stability through muscle strengthening and reduced bone destruction. Therefore, theoretically, ULIF offers some protective effect against adjacent segment diseases. Unfortunately, in our study, despite fewer occurrences of fusion device displacement and vertebral endplate cysts in the ULIF group, X-rays one year post-surgery showed varying degrees of reduction in intervertebral space in fusion segments, similar to the TLIF group. The physiological lordosis of the lumbar spine plays a crucial role in maintaining posture and movement. With degenerative changes in the lumbar spine, the lordosis decreases, altering the distribution of mechanical stress it bears[13]. Improving the lordotic angle of the lumbar spine is closely related to postoperative recovery. For correcting lordotic angles, anterior lumbar interbody fusion surgery offers significant advantages. It provides exposure to the entire ventral surface of the intervertebral space, facilitating better correction of coronal plane imbalance after implantation of the fusion cage and promoting greater restoration of spinal lordosis[14]. Although TLIF is less effective than ALIF in correcting sagittal balance, related studies have shown that TLIF can correct segmental lumbar lordosis Angle. The results of this study showed that the two procedures had similar effects on the correction of segmental lumbar lordosis and lumbar lordosis.\u003c/p\u003e \u003cp\u003eULIF and TLIF have many similarities. Their surgical approaches and the anatomical structures they encounter are similar. Moreover, the surgical instruments used in TLIF can also be utilized in ULIF. Therefore, during ULIF surgery, even if unexpected situations arise, the two longitudinal incisions can be connected in a timely manner, converting it to an open surgery. The difference is that compared to TLIF, ULIF maintains a clear surgical field under the endoscope with timely hemostasis using a high-frequency electric knife and continuous irrigation with saline solution, preventing bleeding from affecting the surgical view. This avoids inadequate decompression and iatrogenic injuries caused by a compromised surgical field. In this study, none of the patients experienced incomplete decompression. The unilateral biportal endoscopic technique allowed for meticulous endplate preparation, minimizing the risk of endplate damage and providing more favorable conditions for postoperative interbody fusion. Finally, our study has several limitations. First, the study was not randomized; second, the sample size was not large enough, and the follow-up period was not long enough; third, the manual measurement of angles and areas may have errors and cannot completely eliminate the interference of metal artifacts after lumbar fusion.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, we believe that ULIF is a minimally invasive lumbar fusion surgery that is safe and effective for treating degenerative lumbar diseases. It offers similar clinical outcomes to TLIF but with the advantages of being less invasive, causing less bleeding, and promoting quicker recovery. While maintaining the operative range, ULIF also reduces damage to the paraspinal muscles. The more precise handling of the intervertebral space in ULIF decreases the occurrence of vertebral endplate cysts and cage displacement, which is significant in preventing delayed fusion and non-union. However, ULIF requires longer surgical time, which poses potential risks for elderly patients or those with poor nutritional status. Although ULIF is less invasive, the improvement in low back and leg pain symptoms is similar to that of TLIF. Despite less destruction of bony structures with ULIF, it does not show a significant advantage in improving adjacent segment degeneration.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYongcun Geng (First Author): Conceptualization,Methodology, Software, Investigation,Formal Analysis, Writing - Original Draft;Dengming Yan: Data Curation, Writing -Original Draft;Ming Jiang: Visualization, Investigation;Tao Ma: Resources, Supervision;Junyang Li:Software, Validation;Xiaoshuang Tu: Visualization, Writing - Review\u0026amp; Editing;Jingwei Wu:Visualization, Validation;Senlin Chen:Validation,Writing - Review\u0026amp; Editing;Lumning Nong(Corresponding Author):Conceptualization, Funding Acquisition,Resources, Supervision, Writing - Review\u0026amp; Editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eItz CJ, Geurts JW, van Kleef M, Nelemans P: \u003cstrong\u003eClinical course of 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\u003cem\u003eExpert review of medical devices \u003c/em\u003e2019, \u003cstrong\u003e16\u003c/strong\u003e(5):373-380.\u003c/li\u003e\n\u003cli\u003eMorgenstern C, Yue JJ, Morgenstern R: \u003cstrong\u003eFull Percutaneous Transforaminal Lumbar Interbody Fusion Using the Facet-sparing, Trans-Kambin Approach\u003c/strong\u003e. \u003cem\u003eClinical spine surgery \u003c/em\u003e2020, \u003cstrong\u003e33\u003c/strong\u003e(1):40-45.\u003c/li\u003e\n\u003cli\u003eWang MY, Grossman J: \u003cstrong\u003eEndoscopic minimally invasive transforaminal interbody fusion without general anesthesia: initial clinical experience with 1-year follow-up\u003c/strong\u003e. \u003cem\u003eNeurosurgical focus \u003c/em\u003e2016, \u003cstrong\u003e40\u003c/strong\u003e(2):E13.\u003c/li\u003e\n\u003cli\u003eChan AK, Bisson EF, Bydon M, Foley KT, Glassman SD, Shaffrey CI, Wang MY, Park P, Potts EA, Shaffrey ME\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eA Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Grade 1 Degenerative Lumbar Spondylolisthesis: An Analysis of the Prospective Quality Outcomes Database\u003c/strong\u003e. \u003cem\u003eNeurosurgery \u003c/em\u003e2020, \u003cstrong\u003e87\u003c/strong\u003e(3):555-562.\u003c/li\u003e\n\u003cli\u003ePark S-M, Park J, Jang HS, Heo YW, Han H, Kim H-J, Chang B-S, Lee C-K, Yeom JS: \u003cstrong\u003eBiportal endoscopic versus microscopic lumbar decompressive laminectomy in patients with spinal stenosis: a randomized controlled trial\u003c/strong\u003e. \u003cem\u003eThe spine journal : official journal of the North American Spine Society \u003c/em\u003e2020, \u003cstrong\u003e20\u003c/strong\u003e(2):156-165.\u003c/li\u003e\n\u003cli\u003eHeo DH, Hong YH, Lee DC, Chung HJ, Park CK: \u003cstrong\u003eTechnique of Biportal Endoscopic Transforaminal Lumbar Interbody Fusion\u003c/strong\u003e. \u003cem\u003eNeurospine \u003c/em\u003e2020, \u003cstrong\u003e17\u003c/strong\u003e(Suppl 1):S129-S137.\u003c/li\u003e\n\u003cli\u003eHeo DH, Park CK: \u003cstrong\u003eClinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery\u003c/strong\u003e. \u003cem\u003eNeurosurgical focus \u003c/em\u003e2019, \u003cstrong\u003e46\u003c/strong\u003e(4):E18.\u003c/li\u003e\n\u003cli\u003eWu Y-S, Zhang H, Zheng W-H, Feng Z-H, Chen Z-X, Lin Y: \u003cstrong\u003eHidden blood loss and the influential factors after percutaneous kyphoplasty surgery\u003c/strong\u003e. \u003cem\u003eEuropean spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society \u003c/em\u003e2017, \u003cstrong\u003e26\u003c/strong\u003e(7):1878-1883.\u003c/li\u003e\n\u003cli\u003eQuint DJ, Tuite GF, Stern JD, Doran SE, Papadopoulos SM, McGillicuddy JE, Lundquist CA: \u003cstrong\u003eComputer-assisted measurement of lumbar spine radiographs\u003c/strong\u003e. \u003cem\u003eAcad Radiol \u003c/em\u003e1997, \u003cstrong\u003e4\u003c/strong\u003e(11):742-752.\u003c/li\u003e\n\u003cli\u003eBeen E, Kalichman L: \u003cstrong\u003eLumbar lordosis\u003c/strong\u003e. \u003cem\u003eThe spine journal : official journal of the North American Spine Society \u003c/em\u003e2014, \u003cstrong\u003e14\u003c/strong\u003e(1):87-97.\u003c/li\u003e\n\u003cli\u003eFu C-J, Chen W-C, Lu M-L, Cheng C-H, Niu C-C: \u003cstrong\u003eComparison of paraspinal muscle degeneration and decompression effect between conventional open and minimal invasive approaches for posterior lumbar spine surgery\u003c/strong\u003e. \u003cem\u003eSci Rep \u003c/em\u003e2020, \u003cstrong\u003e10\u003c/strong\u003e(1):14635.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTABLE.1 Baseline data for ULIF and TLIF.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003eULIF\u003c/p\u003e\n \u003cp\u003e（n=71）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003eTLIF\u003c/p\u003e\n \u003cp\u003e（n=79）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eSex（male/female）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e33/38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e25/54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e58.69\u0026plusmn;15.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e62.49\u0026plusmn;11.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e0.129\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eBMI（Kg/m2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e25.53\u0026plusmn;4.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e26.88\u0026plusmn;5.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eFusion levels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e0.941\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eL3/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eL4/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eL5/S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e31\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e0.962\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003elumbar\u0026nbsp;\u003c/p\u003e\n \u003cp\u003espondylolisthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003eSegmental instability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.11392405063291%\" valign=\"top\"\u003e\n \u003cp\u003elumbar spondylolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.050632911392405%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.593128390596746%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTABLE.2 Perioperative period index\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.36889692585895%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003eULIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.678119349005424%\" valign=\"top\"\u003e\n \u003cp\u003eTLIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.36889692585895%\" valign=\"top\"\u003e\n \u003cp\u003eOperation time（h）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e175.82\u0026plusmn;75.19\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.678119349005424%\" valign=\"top\"\u003e\n \u003cp\u003e111.75\u0026plusmn;38.08\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.36889692585895%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss（ml）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e108.78\u0026plusmn;58.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.678119349005424%\" valign=\"top\"\u003e\n \u003cp\u003e199.44\u0026plusmn;84.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.36889692585895%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative hospital\u0026nbsp;\u003c/p\u003e\n \u003cp\u003estay（d）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e6.1\u0026plusmn;1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.678119349005424%\" valign=\"top\"\u003e\n \u003cp\u003e7.17\u0026plusmn;1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.710669077757686%\" valign=\"top\"\u003e\n \u003cp\u003e0.020\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTABLE.3. Comparisons of VAS back, VAS leg, and ODI scores between ULIF and TLIF groups\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003eULIF\u003c/p\u003e\n \u003cp\u003e(n=71)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003eTLIF\u003c/p\u003e\n \u003cp\u003e(n=79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003eVAS back\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e5.68\u0026plusmn;1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e5.71\u0026plusmn;1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.866\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e1 month after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e2.36\u0026plusmn;0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e2.7\u0026plusmn;0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.019\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e3 months after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.52\u0026plusmn;0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e1.55\u0026plusmn;0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.790\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e12 months after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.27\u0026plusmn;0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e1.24\u0026plusmn;0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003eVAS leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e4.73\u0026plusmn;1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e4.82\u0026plusmn;1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e1 month after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e2.64\u0026plusmn;0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e2.44\u0026plusmn;1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e3 months after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1.61\u0026plusmn;0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e1.49\u0026plusmn;0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e12 months after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e1\u0026plusmn;0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e0.99\u0026plusmn;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.852\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003eODI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e63.27\u0026plusmn;9.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e63.36\u0026plusmn;9.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.954\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e1 month after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e29.99\u0026plusmn;7.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e33.93\u0026plusmn;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e3 months after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e14.62\u0026plusmn;5.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e15.9\u0026plusmn;4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.714285714285715%\" valign=\"top\"\u003e\n \u003cp\u003e12 months after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.448979591836736%\" valign=\"top\"\u003e\n \u003cp\u003e7.08\u0026plusmn;6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.489795918367346%\" valign=\"top\"\u003e\n \u003cp\u003e8.09\u0026plusmn;5.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\" valign=\"top\"\u003e\n \u003cp\u003e0.243\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eVAS, visual analogue scale. ODI, Oswestry Disability Index.\u003c/p\u003e\n\u003cp\u003e表4.两组患者放射学结果\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eULIF\u003c/p\u003e\n \u003cp\u003e（n=71）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eOTLIF\u003c/p\u003e\n \u003cp\u003e（n=79）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003eVEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e10（14.1%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e28（35.4%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003ePSL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1（1.4%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e1（1.3%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003eCM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1（1.4%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e7（8.8%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003eCTB\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e65（91.5%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e60（75.9%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperation paravertebral muscle area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1829.5\u0026plusmn;125.5\u003c/p\u003e\n \u003cp\u003emm\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e1828.9\u0026plusmn;152.7\u003c/p\u003e\n \u003cp\u003emm\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e12 months after\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eoperation paravertebral muscle area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1820.6\u0026plusmn;141.7 mm\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003e1724.4\u0026plusmn;144.0 mm\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eP=0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.11111111111111%\" valign=\"top\"\u003e\n \u003cp\u003eP\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.77777777777778%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eVEC, Vertebral endplate cyst. PSL,e wqCTB, continuous trabecular bone\u003c/p\u003e\n\u003cp\u003e表5术后一年X线及角度测量结果\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"603\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.623548922056385%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.016583747927033%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eL3/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.524046434494196%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eL4/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.83582089552239%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eL5/S1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003eULIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003eTLIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003eULIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003eTLIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003eULIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003eTLIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e术前节段前凸角\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e7.78\u0026plusmn;0.84\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003e8.63\u0026plusmn;0.91\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e8.99\u0026plusmn;1.86\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e8.86\u0026plusmn;2.01\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003e0.765\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e9.94\u0026plusmn;1.69\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003e9.69\u0026plusmn;1.77\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e0.583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e术后节段前凸角\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e11.37\u0026plusmn;1.74\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003e11.91\u0026plusmn;2.1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e0.670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e11.94\u0026plusmn;1.89\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e12.86\u0026plusmn;3.42\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e11.91\u0026plusmn;2.35\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003e11.57\u0026plusmn;1.53\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e0.531\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e术前腰椎前凸角\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e38.49\u0026plusmn;0.76\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003e38.51\u0026plusmn;1.99\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e0.979\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e38.18\u0026plusmn;4.1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e38.79\u0026plusmn;4.12\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003e0.507\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e38.32\u0026plusmn;5.26\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003e38.82\u0026plusmn;4.95\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e0.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e术后节段前凸角\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e39.82\u0026plusmn;0.99\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003e40.72\u0026plusmn;0.99\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e39.28\u0026plusmn;4.18\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e39.88\u0026plusmn;3.75\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003e0.501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e39.17\u0026plusmn;5.02\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003e39.84\u0026plusmn;4.63\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e0.605\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e术前上节段椎间隙高度\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e11.12\u0026plusmn;1.08\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003e11.16\u0026plusmn;0.91\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e0.949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e11.12\u0026plusmn;2.33\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e11.28\u0026plusmn;2.24\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003e0.754\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e11.04\u0026plusmn;1.9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003e11.05\u0026plusmn;1.48\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e术后上节段椎间隙高度t\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e10.76\u0026plusmn;1.25\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003e10.48\u0026plusmn;0.87\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e0.692\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e9.61\u0026plusmn;2.6\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e9.69\u0026plusmn;1.99\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003e0.880\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e10.01\u0026plusmn;1.55\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003e9.75\u0026plusmn;1.36\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e0.513\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e术前下节段椎间隙高度\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e11.58\u0026plusmn;0.93\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003e11.38\u0026plusmn;0.89\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e0.736\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e10.01\u0026plusmn;2.61\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e10.13\u0026plusmn;1.98\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003e0.819\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.609271523178808%\" valign=\"top\"\u003e\n \u003cp\u003e术后下节段椎间隙高度\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e10.56\u0026plusmn;0.86\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.251655629139073%\" valign=\"top\"\u003e\n \u003cp\u003e9.97\u0026plusmn;0.44\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e0.213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e9.56\u0026plusmn;2.48\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.437086092715232%\" valign=\"top\"\u003e\n \u003cp\u003e9.71\u0026plusmn;1.74\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.7682119205298%\" valign=\"top\"\u003e\n \u003cp\u003e0.749\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.05960264900662%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.443708609271523%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.278145695364238%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lumbar fusion, degenerative lumbar disease, minimally invasive, UBE, ULIF","lastPublishedDoi":"10.21203/rs.3.rs-4762881/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4762881/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo study the clinical efficacy of unilateral biportal endoscopic lumbar interbody fusion (ULIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of lumbar degenerative diseases, and to compare perioperative indicators, radiological outcomes, and paraspinal muscle atrophy resulting from these two different surgical methods.\u003c/p\u003e\n\u003cp\u003eBackground:\u003c/p\u003e\n\u003cp\u003eTransforaminal lumbar interbody fusion (TLIF) is widely recognized as an effective surgical method to alleviate low back pain. In recent years, unilateral biportal endoscopic lumbar interbody fusion (ULIF) has been increasingly applied.\u003c/p\u003e\n\u003cp\u003eMethods:\u003c/p\u003e\n\u003cp\u003eWe recorded the basic information of patients who underwent single-segment ULIF or TLIF for the first time in our hospital from May 2021 to November 2022, including age, gender, BMI, diagnosis, and surgical segment. Perioperative indicators such as estimated blood loss, operation time, postoperative hospital stay, and complications were observed in both groups. Clinical efficacy was assessed preoperatively and at 1 month, 3 months, and 12 months postoperatively using the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI). Patient satisfaction was evaluated using the modified Macnab criteria. The displacement of the fusion device was also assessed. X-rays were taken preoperatively, at 3 months postoperatively, and at 12 months postoperatively to observe fusion device displacement and measure the intervertebral disc height of the upper and lower segments. The Cobb angle was used to measure lumbar lordosis and segmental lumbar lordosis. CT scans at 3 months postoperatively were used to observe intervertebral fusion, including bridging trabeculae, endplate cysts, and screw loosening. MRI at 1 year postoperatively was used to manually trace the cross-sectional area of the paraspinal muscles to compare muscle atrophy.\u003c/p\u003e\n\u003cp\u003eResults:\u003c/p\u003e\n\u003cp\u003eA total of 150 patients were included in the study, with 71 patients in the ULIF group and 79 patients in the TLIF group. There were no statistically significant differences between the two groups in terms of age, gender, BMI, diagnosis, and surgical segment. The estimated blood loss in the ULIF group was 108.78±58.3 ml, which was significantly less than that in the TLIF group at 199.44±84.91 ml (p\u0026lt;0.001). The postoperative hospital stay was shorter in the ULIF group (p=0.020), although the operation time was longer for ULIF. There were no significant differences in complications between the two groups.\u003c/p\u003e\n\u003cp\u003ePatients in the ULIF group experienced quicker relief from back pain postoperatively, but there were no significant differences between the ULIF and TLIF groups in the VAS, ODI, and satisfaction rates at the final follow-up. At 3 months postoperatively, the ULIF group had more bridging trabeculae, fewer endplate cysts, and less fusion device displacement. There were no significant differences between the two groups in the correction of segmental lumbar lordosis (SL) and overall lumbar lordosis (LL). Additionally, the ULIF group showed less muscle damage.\u003c/p\u003e\n\u003cp\u003eConclusion:\u003c/p\u003e\n\u003cp\u003eULIF has the advantages of reducing pain in the short term, less blood loss, and shorter hospital stays. Its more precise handling of the intervertebral space reduces the occurrence of endplate cysts and fusion device displacement, which has certain significance in preventing delayed fusion and nonunion. However, ULIF requires a longer operation time, which increases potential risks for elderly patients or those with poor nutritional status. Although ULIF causes less damage to the bony structure, it has not shown a significant advantage in improving adjacent segment degeneration.\u003c/p\u003e","manuscriptTitle":"Comparative Analysis of Clinical Efficacyof Unilateral Biportal Endoscopic and Open Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Degenerative","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-17 02:34:03","doi":"10.21203/rs.3.rs-4762881/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2024-07-19T01:30:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-19T00:54:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2024-07-18T13:15:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2818956-ecb8-4045-b194-c1b0c54c8a81","owner":[],"postedDate":"August 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-08-17T02:34:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-17 02:34:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4762881","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4762881","identity":"rs-4762881","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}