Comparison of Endoscopic Unilateral Laminectomy for Bilateral Decompression (Endo-ULBD) and Posterior Lumbar Interbody Fusion (PLIF) in Managing Multi-Segmental Lumbar Spinal Stenosis: Technique and Early Outcomes

Abstract

Objectives: Lumbar spinal stenosis is a common degenerative spine condition that leads to severe pain and disability. Surgical intervention is often required when conservative treatments fail, but the choice between different surgical techniques remains a topic of ongoing debate. The objective of this study was to provide a comprehensive comparison of the safety and efficacy of endoscopic unilateral laminectomy with bilateral decompression (Endo-ULBD) and posterior lumbar interbody fusion (PLIF) in the treatment of multi-segmental lumbar spinal stenosis (MS-LSS). Furthermore, the text provides detailed technical information regarding the Endo-ULBD procedure.

Methods: This retrospective comparative study was conducted from October 2019 to October 2022 and involved 73 patients diagnosed with MS-LSS. Of the total number of patients, 36 were treated with Endo-ULBD and 37 with PLIF. The technical parameters of both procedures were recorded, including perioperative factors such as patient demographic characteristics (age, gender, BMI), disease duration, number of surgical segments involved, type of anesthesia, duration of surgery, estimated blood loss (EBL), postoperative length of stay, time to discharge, use of intraoperative fluoroscopy, and any intraoperative complications. Clinical outcomes were evaluated using the Visual Analog Scale (VAS), the Japanese Orthopedic Association (JOA) score, and the Oswestry Disability Index (ODI), which were assessed preoperatively and at follow-up. Radiologic improvement was quantified by comparing the preoperative and postoperative dural sac areas. Statistical analyses were conducted using paired t tests with a significance threshold of p < 0.05.

Results: In comparison to the PLIF group, the Endo-ULBD group exhibited a markedly shorter operative time, diminished intraoperative bleeding, accelerated recovery of ambulation, and a shorter postoperative hospitalization period. Moreover, the Endo-ULBD group demonstrated a diminished prevalence of postoperative complications. However, it required a significantly greater number of intraoperative x-ray fluoroscopies than the PLIF group (p < 0.05). Postoperative VAS, ODI, and JOA scores demonstrated notable improvement in both groups, with a more pronounced trajectory observed in the Endo-ULBD cohort during the early postoperative period. Both surgical approaches resulted in a notable enlargement of the dural sac area. Neither group experienced any fatalities, irreversible nerve damage, or paralysis.

Conclusion: Endo-ULBD demonstrated superior early clinical outcomes compared to PLIF, including shorter operative time, reduced blood loss, faster recovery, and fewer complications. Both techniques provided similar improvements in dural sac decompression, but Endo-ULBD may offer a more efficient and minimally invasive treatment option for patients with MS-LSS. However, the high frequency of intraoperative fluoroscopy remains a limitation, highlighting the need for improved surgical techniques and positioning systems.

Keywords

comparative study / endoscopic unilateral laminectomy for bilateral decompression / multi-segmental lumbar spinal stenosis / posterior lumbar interbody fusion

References

[1] R. A. Deyo, S. K. Mirza, B. I. Martin, et al., “Trends, Major Medical Complications, and Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults,” Jama 303 (2010): 1259-1265.

[2] A. Pearson, J. Lurie, T. Tosteson, et al., “Who Should Have Surgery for Spinal Stenosis? Treatment Effect Predictors in SPORT,” Spine (Phila Pa 1976) 37 (2012): 1791-1802, https://doi.org/10.1097/BRS.0b013e3182634b04.

[3] R. J. Mobbs, K. Phan, G. Malham, et al., “Lumbar Interbody Fusion: Techniques, Indications and Comparison of Interbody Fusion Options Including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF,” Journal of spine surgery 1 (2015): 2-18, https://doi.org/10.3978/j.issn.2414-469X.2015.10.05

[4] C. D. Cole, T. D. McCall, M. H. Schmidt, et al., “Comparison of Low Back Fusion Techniques: Transforaminal Lumbar Interbody Fusion (TLIF) or Posterior Lumbar Interbody Fusion (PLIF) Approaches,” Current reviews in musculoskeletal medicine 2 (2009): 118-126.

[5] K. E. Radcliff, C. K. Kepler, M. Maaieh, et al., “What is the Rate of Lumbar Adjacent Segment Disease After Percutaneous Versus Open Fusion?,” Orthopaedic surgery 6 (2014): 118-120, https://doi.org/10.1111/os.12103.

[6] Y. Arai, T. Hirai, T. Yoshii, et al., “A Prospective Comparative Study of 2 Minimally Invasive Decompression Procedures for Lumbar Spinal Canal Stenosis: Unilateral Laminotomy for Bilateral Decompression (ULBD) Versus Muscle-Preserving Interlaminar Decompression (MILD),” Spine 39 (2014): 332-340.

[7] S. Han, X. Zeng, K. Zhu, et al., “Clinical Application of Large Channel Endoscopic Systems With Full Endoscopic Visualization Technique in Lumbar Central Spinal Stenosis: A Retrospective Cohort Study,” Pain and Therapy 11 (2022): 1309-1326.

[8] C. H. Park and S. H. Lee, “Endoscope-Assisted Minimally Invasive Interlaminar Lumbar Decompression for Spinal Stenosis,” Pain Physician 22 (2019): E573.

[9] S. Han, X. Zeng, K. Zhu, et al., “Clinical Application of Large Channel Endoscopic Systems with Full Endoscopic Visualization Technique in Lumbar Central Spinal Stenosis: A Retrospective Cohort Study,” Pain and Therapy 11 (2022): 1309-1326, https://doi.org/10.1007/s40122-022-00428-3.

[10] N. H. Ulrich, J. M. Burgstaller, G. Pichierri, et al., “Decompression Surgery Alone Versus Decompression Plus Fusion in Symptomatic Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study With 3 Years of Follow-up,” Spine 42 (2017): E1077-E1086, https://doi.org/10.1097/brs.0000000000002068.

[11] K. Yoshikane, K. Kikuchi, and K. Okazaki, “Clinical Outcomes of Selective Single-Level Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression of Multilevel Lumbar Spinal Stenosis and Risk Factors of Reoperation,” Global Spine Journal 13 (2023): 1350-1357, https://doi.org/10.1177/21925682211033575.

[12] Z. Xb, M. Hj, B. Geng, et al., “Percutaneous Endoscopic Unilateral Laminotomy and Bilateral Decompression for Lumbar Spinal Stenosis,” Orthopaedic Surgery 13 (2021): 641-650.

[13] J. Yang, C. Guo, Q. Kong, et al., “Learning Curve and Clinical Outcomes of Percutaneous Endoscopic Transforaminal Decompression for Lumbar Spinal Stenosis,” International Orthopaedics 44 (2020): 309-317.

[14] N. Lange, T. Stadtmüller, S. Scheibel, et al., “Analysis of Risk Factors for Perioperative Complications in Spine Surgery,” Scientific Reports 12 (2022): 14350.

[15] A. Steib, F. Hadjiat, W. Skibba, et al., “Focus on Perioperative Management of Anticoagulants and Antiplatelet Agents in Spine Surgery,” Orthopaedics & Traumatology: Surgery & Research 97 (2011): S102-S106.

[16] S. Okuda, A. Miyauchi, T. Oda, et al., “Surgical Complications of Posterior Lumbar Interbody Fusion With Total Facetectomy in 251 Patients,” Journal of Neurosurgery: Spine 4 (2006): 304-309.

[17] C. I. Ju and S. M. Lee, “Complications and Management of Endoscopic Spinal Surgery,” Neurospine 20 (2023): 56.

[18] A. Lin, S. Meng, C. Wang, et al., “Severe Symptomatic Epidural Hematoma Following Percutaneous Endoscopic Unilateral Laminectomy for Bilateral Decompression (Endo-ULBD)—Series Report and Management Strategies,” Orthopaedic Surgery 15 (2023): 2342-2353.

[19] M. Szpalski, R. Gunzburg, and B. Sztern, “An Overview of Blood-Sparing Techniques Used in Spine Surgery During the Perioperative Period,” European Spine Journal 13, no. Suppl 1 (2004): S18-S27, https://doi.org/10.1007/s00586-004-0752-y.

[20] W. Lu, L. Wu, Y. Chen, et al., “Effect of Preoperative Contralateral Foramen Stenosis on Contralateral Root Symptoms After Unilateral Transforaminal Lumbar Interbody Fusion: A Ambispective Cohort Study,” BMC Musculoskeletal Disorders 24 (2023): 291.

[21] M.-C. Kim, J.-U. Park, W.-C. Kim, et al., “Can Unilateral-Approach Minimally Invasive Transforaminal Lumbar Interbody Fusion Attain Indirect Contralateral Decompression? A Preliminary Report of 66 MRI Analysis,” European Spine Journal 23 (2014): 1144-1149.

[22] N. R. Guinn, B. W. Broomer, W. White, et al., “Comparison of Visually Estimated Blood Loss With Direct Hemoglobin Measurement in Multilevel Spine Surgery,” Transfusion 53 (2013): 2790-2794.

[23] J. Álvarez de Mon-Montoliú, J. Castro-Toral, C. Bonome-González, et al., “Meta-Analysis of Learning Curve in Endoscopic Spinal Surgery: Impact on Surgical Outcomes. Global,” Spine Journal (2024): 21925682241307634.

[24] G. Capo, F. Calvanese, A. Vandenbulcke, et al., “Lateral-PLIF for Spinal Arthrodesis: Concept, Technique, Results, Complications, and Outcomes,” Acta Neurochirurgica 166 (2024): 123.

[25] W. Wei, T. Wang, J. Liu, et al., “Biomechanical Effect of Proximal Multifidus Injury on Adjacent Segments During Posterior Lumbar Interbody Fusion: A Finite Element Study,” BMC Musculoskeletal Disorders 24 (2023): 521.

[26] X. Huang, Y. Cai, K. Chen, et al., “Risk Factors and Treatment Strategies for Adjacent Segment Disease Following Spinal Fusion,” Molecular Medicine Reports 31 (2024): 33.

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.