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Comparison of results among UBE-TLIF, MIS-TLIF and open TLIF for Meyerding grade I lumbar spondylolisthesis: a retrospective study

BMC Surgery volume 24, Article number: 355 (2024) Cite this article

Abstract

Background

The unilateral biportal endoscopic (UBE) technique has garnered significant attention for its little paraspinal iatrogenic damage, expedited recovery, and low complication rates. This method is also applicable to open transforaminal lumbar interbody fusion (TLIF). Therefore, this study aimed to conduct a comparative analysis of the outcomes associated with unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF), minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and TLIF for Meyerding grade I lumbar spondylolisthesis.

Methods

The study examined the outcomes of 79 patients with Meyerding grade I lumbar spondylolisthesis who underwent single-level intervertebral fusion. Clinical assessments included the measurement of pain levels using the Visual Analogue Scale (VAS) for low back and leg pain, the Oswestry Disability Index (ODI), surgical data, and demographic information. Imaging techniques were utilized to evaluate the fusion rate.

Results

The VAS-Back demonstrated a statistically significant improvement in Group UBE-TLIF compared to the other groups at the one-week postoperative evaluation (p < .05). Additionally, the UBE-TLIF group exhibited a significantly longer total operative time compared to the other groups (p < .05). However, it was noted that the Postop Hemovac drain were significantly greater in the MIS-TLIF and TLIF groups compared to the UBE-TLIF group (p < .05).

Conclusions

The present research demonstrated the effectiveness of UBE-TLIF, MIS-TLIF, and TLIF as surgical approaches for treating Meyerding grade I lumbar spondylolisthesis. Among these methods, UBE-TLIF demonstrated a reduction in Postop Hemovac drain, and an increase in operative duration.

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Background

Lumbar spondylolisthesis is a commonly observed spinal pathology in the adult population, characterized by the displacement of a vertebral body resulting in symptoms such as mechanical low back pain (LBP), radiculopathy, or neurogenic claudication [1, 2]. These symptoms are attributed to the disruption of vertebral stability, resulting in the compression of nerves and blood vessels within the spinal canal [3]. Lumbar interbody fusion (LIF) is a well-established surgical procedure utilized for the treatment of lumbar spondylolisthesis. There are various surgical options available for interbody fusion of the lumbar spine, including posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), among others [4]. This procedure offers numerous benefits, such as restoring spinal alignment in multiple dimensions, stabilizing the spine, and relieving spinal pressure [5]. Several studies have shown that the posterior column structures are crucial for spinal stability and postoperative success. However, open surgical procedures often cause damage to surrounding tissues and destabilize the posterior column, leading to worsened disc degeneration and possible nerve injury [6]. The TLIF procedure has been linked to significant disruption of the posterior column structures, potentially compromising the overall biomechanical integrity of the spine. Furthermore, this method is known to be accompanied by various postoperative complications [7]. To mitigate medical-related injuries and postoperative complications, the surgical approach for TLIF has transitioned from conventional open surgery to a minimally invasive technique known as MIS-TLIF [8, 9]. The MIS-TLIF technique combines traditional TLIF procedures with minimally invasive channels, leading to a less invasive fusion process [10]. However, the MIS-TLIF procedure is hindered by the limitation of the visual field during surgery, which can compromise its effectiveness [11, 12]. The development of spinal endoscopic technology has been accelerated by the increasing acceptance of minimally invasive techniques and the rapid progress in endoscopic technology. Recently, there has been a rising preference among spine surgeons for utilizing UBE, attributed to its perceived advantages in minimizing muscle damage and shortening hospital stays. The utilization of dual channels in surgical techniques enhances the field of view and operating space, thereby facilitating meticulous and comprehensive decompression procedures [13]. This technological advancement enhances surgical adaptability and can be utilized throughout all stages of TLIF surgery [14, 15]. Studies have shown that this approach yields comparable fusion rates and clinical outcomes to traditional TLIF and MIS-TLIF procedures for lumbar spine conditions [16, 17]. UBE-TLIF and MIS-TLIF are further developments in the micro-innovation of TLIF technology. Although UBE technology has generated a great deal of interest among clinicians, there is a lack of comparative studies with other surgical methods and long-term follow-up data. This study retrospectively analyzed the clinical data for patients with single-segment lumbar spondylolisthesis who received UBE-TLIF therapy.

Methods

Patient characteristics

The study retrospectively analyzed the clinical outcomes of patients with single-segment lumbar spondylolisthesis who underwent spine surgery at our institution between June 2021 and September 2022. All surgical interventions were performed by the same spine surgeon. Demographic data of the patients were recorded, and preoperative and postoperative evaluations utilizing computed tomography (CT) and magnetic resonance imaging (MRI) were conducted to accurately assess the placement of the lumbar spondylolisthesis. Anteroposterior and lateral lumbar radiographs were obtained to ascertain the presence of spondylolisthesis.

Inclusion criteria included:① Patients presenting with unilateral low back discomfort or radiating pain in the lower extremities were diagnosed as Meyerding grade I and single segment lumbar spondylolisthesis based on findings from X-ray imaging [18]; ② Following a period of almost three months of conservative therapy, during which there was no significant improvement or exacerbation of symptoms; ③ The follow-up period lasted for more than one year, during which comprehensive data was collected.

Exclusion criteria included: ① Accompanied by diseases such as lumbar infection, lumbar tuberculosis, and lumbar tumors; ② Osteoporosis patients with a T-value of bone density ≤ -2.5SD; ③ Previous history of lumbar spine surgery.

From June 2021 to September 2022, a total of 79 patients meeting the selection criteria were enrolled in the study, comprising 26 cases in the UBE-TLIF group, 28 cases in the MIS-TLIF group, and 25 cases in the TLIF group.

Surgical technique

The entirety of the surgical procedures were performed by a solitary surgeon possessing significant proficiency. All individuals within each experimental cohort were placed in a prone position.

UBE-TLIF group: Surgical segmental vertebral pedicle was identified using fluoroscopy. Punctured vertebral arch projection point. Two 1 cm long vertical skin incisions were made on the lateral aspect of the outer margin of the pedicle. The soft tissues were meticulously dissected. The two portals were referred to as a working portal and an endoscopic portal. Subsequent to employing endoscopic visualization techniques, resection was conducted on the inferior and superior articular processes of the affected side, along with the excision of the ligamentum flavum and a portion of the vertebral lamina. The intervertebral disc was exposed, with the dura and traveling root protected by a dural retractor during this phase. An annulotomy procedure was performed using a surgical knife, followed by a disc with a reamer. The cartilaginous endplate was then carefully excised using a curette and bipolar radiofrequency ablation (bRFA). Allogeneic and autologous bone particles were placed into the anterior disc space, followed by the placement of an intervertebral fusion cage (Polyetheretherketone, NATIONAL MEDICAL PRODUCTS ADMINISTRATION No. 20193130159, from DOUBLE MEDICAL Inc, China). Ultimately, the cage location was verified by the use of fluoroscopy. A surgical drainage tube was inserted into the working port, and bilateral percutaneous pedicle screw (NATIONAL MEDICAL PRODUCTS ADMINISTRATION No. 20193130159, from DOUBLE MEDICAL Inc, China) fixation was performed according to standard procedures (Fig. 1).

MIS-TLIF group: A lateral incision was made on the affected side of the skin, followed by a dissection of the muscular fascia parallel to the cutaneous incision. The quadrant retractor system (ZL 2011 2 0322450.4 / ZL 2011 2 0325713, from SPINENDOS Inc, Germany) was then inserted between the multifidus and longissimus muscles, with subsequent dissection of the subcutaneous tissue and muscle to expose the lamina and articular process. The subsequent methodology had a resemblance to UBE-TLIF, utilizing the same cage (Polyetheretherketone, NATIONAL MEDICAL PRODUCTS ADMINISTRATION No. 20193130159, from DOUBLE MEDICAL Inc, China).

Fig. 1
figure 1

UBE-TLIF surgical procedure: (A) DR in preop; (B) Positioning the pedicle of the vertebral arch; (C) Intraoperative imaging confirmed the position of portal; (D) Cut the lower articular process, and bitted off some upper articular processes; (E) Exposed the nerve root; (F) Exposed the intervertebral disc; (G) Cleaned the intervertebral disc and upper and lower endplates; (H) Compressed the bone graft; (I) Implanted the intervertebral fusion cage; (J) The intraoperative imaging confirmed that the position of the cage was good; K.L. Intraoperative imaging confirmed good internal fixation position

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TLIF group: Fluoroscopy with surgical segment pedicle as a marker. Initially, a skin incision of 3 cm in length was made along the midline. Subsequently, the muscle fascia was incised in alignment with the aforementioned skin incision. The bilateral joint processes were completely exposed, and the surrounding soft tissue was thoroughly cleansed. Subsequently, the decompression process was finished. The surgical procedure involved interbody fusion utilizing a cage (Polyetheretherketone, NATIONAL MEDICAL PRODUCTS ADMINISTRATION No. 20193130159, from DOUBLE MEDICAL Inc, China), containing harvested lamina and facet bone and artificial bone. Bilateral pedicle screws were manually inserted at the anatomical site on the corresponding level, and the placement accuracy of the screws (NATIONAL MEDICAL PRODUCTS ADMINISTRATION No. 20193130159, from DOUBLE MEDICAL Inc, China) was confirmed through fluoroscopy.

Postoperative management

The postoperative treatment protocols were the same across all groups, with all participants receiving prophylactic administration of cefuroxime sodium to prevent infection. The patients underwent mobilization on the first day after their surgery. Analgesia was given only when necessary.

Evaluation

The study recorded and compared various surgical parameters, including surgical time, hospital stay, Postop Hemovac drain, and postoperative complications across three groups. Outcomes included VAS for low back pain and leg pain and scores of ODI, all of which were taken at multiple time points: preoperatively, 1 week, 1 month, 6 months, and 12 months postoperatively during the follow-up period. The minimum clinically important difference (MCID) thresholds for VAS back pain, VAS leg pain, and ODI were established at 1.6, 1.7, and 14.3, respectively, through a review of existing literature [19]. The lumbar lordosis (LL) and disc height (DH) were measured using X-ray and CT imaging techniques both preoperatively and at the final follow-up evaluation. The evaluation of intervertebral fusion status was assessed radiologically via CT at the follow-up using the Bridwell grading system [20]. Additionally, the total fusion rate was calculated.

Statistical analysis

The statistical program SPSS (version 23.0, SPSS) was used to perform the analyses. The count and percentage were used to summarize the categorical data, while the mean and standard deviation were used to summarize the continuous variables. The VAS and the ODI pre- and postoperative ratings were compared using paired t-tests. A t-test that is independent of the group was used to assess the clinical outcome. To evaluate statistical significance, two-sided values of P < .05.

Results

Patient demographics

Table 1 presents comprehensive demographic data about three distinct groupings. The duration of follow-up periods for the UBE-TLIF group was 14.3 ± 3.2 months, for the MIS-TLIF group was 12.9 ± 2.0 months, and for the TLIF group was 14.0 ± 1.9 months. Statistical analysis revealed no significant variances in follow-up duration among the three groups(p > .05, Table 1). No significant differences were observed in age, sex, body mass index (BMI), lesion level, preoperative VAS scores, or ODI scores (p > .05, Table 1).

Table 1 Baseline characteristics of the three groups
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Clinical outcome

All three groups showed statistically significant improvements in their VAS back, VAS leg, and ODI after surgery (p < .05, Fig. 2). These findings met the MCID for VAS back pain, VAS leg pain, and ODI, which were established at 1.6, 1.7, and 14.3. In particular, the UBE-TLIF group had a mean VAS back score of 4.4 ± 1.1 one week after surgery, while the MIS-TLIF group had a mean score of 5.0 ± 0.7 and the TLIF group had a mean score of 5.2 ± 0.8 (Fig. 2). The UBE-TLIF group’s mean VAS back score at one week was significantly lower than that of the other groups (p < .05, Fig. 2). No statistically significant differences were seen among three groups in terms of VAS scores, as well as the ODI scores at baseline and 1, 6, and 12 months post-surgery (p > .05, Fig. 2). However, the VAS back pain scores, VAS leg pain scores, and ODI did not exhibit any significant differences during other follow-up assessments between the three groups (p > .05, Fig. 2).

Fig. 2
figure 2

Clinical outcomes during follow-up (preoperative, postoperative 1 week, postoperative 1 month, postoperative 6 months, and postoperative 12 months). A, VAS of the back. B, VAS of the leg. C, ODI (%). All clinical parameters improved significantly over the baseline value from 1 week after surgery, which lasted until the final follow-up examination (p < .05). VAS of the back was significantly improved in Group UBE-TLIF compared to other groups at 1 week after surgery. VAS, visual analog scale; ODI, Oswestry Disability Index. **** P < .0001

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Radiological outcomes and spinal fusion rate

The imaging examination results indicated that in the UBE-TLIF group, there were 11 cases of grade I, 13 cases of grade II, 2 cases of grade III, and 0 cases of grade IV at the final follow-up (Table 2). The fusion rate for the UBE-TLIF group was 88.5%, for the MIS-TLIF group it was 89.2%, and for the TLIF group it was 92.0%. No statistically significant differences in fusion rate were observed among the three groups (p > .05, Table 2). At the final follow-up, all groups showed significant improvements in LL and DH compared to the preoperative period (p < .05 Table 2). Furthermore, there were no significant differences in these improvements among the groups (p > .05, Table 2) (Figs. 3, 4 and 5).

Fig. 3
figure 3

A 62-year-old female patient with L4/5 lumbar spondylolisthesis (Meyerding grade I) in UBE-TLIF group, (A) Preoperative lateral X-ray films; (B) Lateral X-ray films at 3 days after operation showed that the spondylolisthesis had been reduced; (C) CT at 3 months after operation showed that the intervertebral bone graft was sufficient and the position of the Cage was good; (D) Lateral X-ray films at 1 years after operation showed good reduction of vertebral bodies and bony fusion between vertebral bodies

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Fig. 4
figure 4

A 64-year-old male patient with L4/5 lumbar spondylolisthesis (Meyerding grade I) in MIS-TLIF group. (A) Preoperative lateral X-ray films; (B) Lateral X-ray films at 3 days after operation showed that the spondylolisthesis had been reduced; (C) CT at 3 months after operation showed that the intervertebral bone graft was sufficient and the position of the Cage was good; (D) Lateral X-ray films at 1 years after operation showed good reduction of vertebral bodies and bony fusion between vertebral bodies

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Fig. 5
figure 5

A 30-year-old male patient with L5/S1 lumbar spondylolisthesis (Meyerding grade I) in TLIF group. (A) Preoperative lateral X-ray films; (B) Lateral X-ray films at 3 days after operation showed that the spondylolisthesis had been reduced; (C) CT at 3 months after operation showed that the intervertebral bone graft was sufficient and the position of the Cage was good; (D) Lateral X-ray films at 1 years after operation showed good reduction of vertebral bodies and bony fusion between vertebral bodies

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Table 2 Comparison of radiologic outcomes between the two groups
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Operative data and complications

The duration of operative procedures varied among the groups, with mean times of 184.38 ± 22.02 min in the UBE-TLIF group, 131.71 ± 9.95 min in the MIS-TLIF group, and 122.12 ± 13.64 min in the TLIF group. Notably, the operative time in the UBE-TLIF group was significantly greater than that observed in the MIS-TLIF or TLIF groups (p < .05, Table 3; Fig. 6). The mean hospital day was 16.23 ± 4.02 in the UBE-TLIF group, 13.57 ± 33.16 in the MIS-TLIF group, and 19.32 ± 3.31 in the TLIF group. The hospital day in the UBE-TLIF and MIS-TLIF groups was significantly lower than that in the TLIF group (both p < .05, Table 3; Fig. 6). The mean Postop Hemovac drain was 127.30 ± 14.48 mL in the UBE-TLIF group, 161.28 ± 16.67 mL in the MIS-TLIF group, and 297.32 ± 18.11 mL in the TLIF group. The Postop Hemovac drain in the UBE-TLIF group were significantly lower than those in the MIS-TLIF or TLIF group (both p < .05, Table 3; Fig. 6).

Fig. 6
figure 6

Intra-group comparisons of Operative data. (A) The operative time. (B) Hospital day (C) Postop Hemovac drain. **** P < .0001, ** P < .01

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Table 3 Comparison of surgical technique related outcomes among three groups
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In the UBE-TLIF group, there was one case of incomplete neural decompression and two cases of epidural hematoma, while no occurrences of postoperative infection or dural tear were documented. The MIS-TLIF group exhibited two cases of incomplete neural decompression, one case of epidural hematoma, and one case of dural tear, with no instances of postoperative infection. In the TLIF group, one case of incomplete neural decompression, one case of epidural hematoma, and one case of dural tear were reported, with no instances of postoperative infection. Notably, there was no statistically significant difference in the incidence of complications among the three groups. (p > .05, Table 3) In all three groups, any complications experienced by patients did not necessitate a return to the operating room for treatment.

Discussion

Interbody fusion is a commonly utilized surgical technique in the realm of spinal surgery [21,22,23]. The UBE technology has attracted considerable attention in the medical field due to its numerous advantages, such as reduced trauma, minimal damage to muscle and soft tissue, decreased bleeding, and accelerated postoperative recovery [24, 25]. Moreover, individuals who underwent the UBE procedure exhibited decreased pain scores in comparison to those who underwent open surgery. Furthermore, prior research indicates that UBE surgery results in decreased paravertebral muscle damage when compared to conventional open surgery [26]. These findings suggest that the use of the UBE procedure may effectively decompress the affected area and could potentially be considered as a viable alternative to traditional micro-surgical fusion [27].

Heo conducted a study in which UBE technology was integrated with MIS-TLIF, and the results indicated that UBE-TLIF had a notable positive impact on patients’ VAS scores and ODI [28]. Kim demonstrated significant success in achieving high rates of intervertebral fusion while treating lumbar spondylolisthesis with the use of UBE-TLIF [29]. Hence, this study sought to assess and contrast the clinical effectiveness of the three surgical interventions.

In the present investigation, all participants in each group successfully finished the procedure. In terms of surgical outcomes, our research showed that the UBE-TLIF group lasted longer than the other groups, which may be because of the longer time needed to achieve sufficient pressure reduction under the endoscope. Additionally, the duration of a surgical procedure might be influenced by the loss of blood and the need for adjustments in surgical field clarity [30]. The endoscopic group had decreased levels of postoperative drainage in comparison to the other groups. This may because the UBE technique employs water as a medium and utilizes continual flushing of physiological saline to sustain a clean visual field. Simultaneously, it accomplishes compression and hemostasis on minor blood vessels [28]. Simultaneously, UBE surgery entails comparatively smaller incisions and less direct harm to muscle tissue. A key problem related to intervertebral fusion surgery is the occurrence of problems. There were no significant differences observed in the total occurrence of complications among the three groups, suggesting that UBE technology does not affect the safety of lumbar vertebral fusion surgery. This finding suggests that UBE may serve as a viable alternative to conventional surgery for pain treatment [27]. UBE technology has the potential to decrease the duration of hospital stays by facilitating early postoperative mobilization and enhancing functional recovery. This is maybe attributed to the reduction in Postop Hemovac drain in the immediate postoperative period. Nevertheless, the variability in length of hospital stay is influenced by disparities in social health insurance systems and individual physical characteristics.

In terms of clinical outcomes. The UBE-TLIF group’s mean VAS back score at one week was significantly lower than that of the other groups. One possible explanation for this phenomenon is that the utilization of the MIS-TLIF and TLIF methods necessitates the excessive stretching of the paravertebral muscle to guarantee the surgical outcome, a process that may potentially result in localized muscle bleeding and subsequent postoperative back discomfort. In contrast to the MIS-TLIF and the TLIF, the UBE employs two distinct mini-channels to facilitate the establishment of a working and endoscopic portal, thereby reducing tissue trauma. And the application of the UBE enhances the surgical field of view within the portal, thereby reducing the risk of nerve root damage during the procedure. Additionally, our study demonstrated that UBE-TLIF yields comparable clinical outcomes to both MIS-TLIF and TLIF procedures at the 12-month postoperative assessment. The fusion rate for the UBE-TLIF group was 88.5%, for the MIS-TLIF group it was 89.2%, and for the TLIF group it was 92.0%. There was no significant difference between the two groups in terms of LL, DH, or fusion rate. Based on the aforementioned efficacy, safety, and other benefits, we believe that the UBE technology exhibits considerable potential.

This study identified several limitations, including its retrospective nature and single-center design, which imposed constraints on the data. Additionally, the limited number of investigated cases further restricted the scope of the research. To enhance the assessment of clinical outcomes following UBE surgery, it is imperative to increase the sample size of patients and ensure their compliance with postoperative follow-up protocols. Furthermore, it is recommended that future research endeavors include a comparison analysis of other fusion surgeries.

Conclusions

The present research demonstrated the effectiveness of UBE-TLIF, MIS-TLIF, and TLIF as surgical approaches for treating Meyerding grade I lumbar spondylolisthesis. Among these methods, UBE-TLIF demonstrated a reduction in Postop Hemovac drain, and an increase in operative duration. However, the validation outcomes of this surgical procedure necessitate the conduct of both extensive long-term follow-up and larger-scale clinical investigations.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Author notes

  1. Yang Wang

    Present address: Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing, China

Authors and Affiliations

  1. Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing, China

    Zhenyuan Lu, Dian Zhong, Yang Liu, Guosheng Zhao & Zhenyong Ke

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  5. Zhenyong Ke
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  6. Yang Wang
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Contributions

Z.L. designed the study, interpreted the data, and wrote the manuscript. D.Z. , Y.L. and G.Z. performed the analyses and contributed to interpreting the data and writing the manuscript. Z.K. and Y.W. contributed to the study design, introduction and discussion, and reviewed and edited the manuscript. All authors reviewed the manuscript. Z.L. had full access to all the data in the study and take full responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding author

Correspondence to Yang Wang.

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Ethics approval and consent to participate

The study was approved by the Institutional Ethics Committee of the Second Affiliated Hospital of Chongqing Medical University, and was conducted according to the ethical standards of Helsinki Declaration (1964) and its subsequent amendments. Informed consent was obtained from all subjects and/or their legal guardians.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Lu, Z., Zhong, D., Liu, Y. et al. Comparison of results among UBE-TLIF, MIS-TLIF and open TLIF for Meyerding grade I lumbar spondylolisthesis: a retrospective study. BMC Surg 24, 355 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02651-5

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02651-5

Keywords

BMC Surgery

ISSN: 1471-2482

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