Early effectiveness of posterior 180-degree decompression via unilateral biportal endoscopy in treatment of lumbar spinal stenosis combined with MSU-1 lumbar disc herniation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHAO Feiyu ¹ , QIU Xiaoting ² , YUAN Jie ¹ , LIU Ruxing ¹ , WEI Xinyuan ¹ , ZHAO Wei ³ ,  WANG Yongfeng ¹

1. Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan Shanxi, 030001, P. R. China;
2. Academy of Medical Sciences, Shanxi Medical University, Taiyuan Shanxi, 030000, P. R. China;
3. Department of Orthopedics, Taiyuan Hospital of Peking University First Hospital, Taiyuan Shanxi, 030009, P. R. China;

Corresponding author：

WANG Yongfeng, Email: wyfwf8@163.com

Keywords：

Lumbar spinal stenosis; lumbar disc herniation; unilateral biportal endoscopy; bilateral decompression; early effectiveness

DOI：

10.7507/1002-1892.202504083

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Objective To evaluate early effectiveness of posterior 180-degree decompression via unilateral biportal endoscopy (UBE) in the treatment of lumbar spinal stenosis (LSS) combined with Michigan State University (MSU)-1 lumbar disc herniation (LDH). Methods A retrospective analysis was conducted on clinical data from 33 patients with LSS combined with MSU-1 LDH, who met selection criteria and were treated between March 2022 and January 2024. All patients underwent UBE-assisted 180-degree spinal canal decompression. The cohort comprised 17 males and 16 females, aged 37-82 years (mean, 67.1 years). Preoperative presentations included bilateral lower limbs intermittent claudication and radiating pain, with disease duration ranging from 5 to 13 months (mean, 8.5 months). Affected segments included L_{3, 4} in 4 cases, L_{4, 5} in 28 cases, and L₅, S₁ in 1 case. LSS was rated as Schizas grade A in 4 cases, grade B in 5 cases, grade C in 13 cases, and grade D in 11 cases. LDH was categorized as MSU-1A in 24 cases, MSU-1B in 2 cases, and MSU-1AB in 7 cases. Intraoperative parameters (operation time, blood loss) and postoperative hospitalization length were recorded. The visual analogue scale (VAS) score and Oswestry Disability Index (ODI) were used to assess the lower limb pain and functional outcomes after operation. Clinical efficacy was evaluated at last follow-up via modified MacNab criteria. Quantitative radiological assessments included dural sac cross-sectional area (DSCA) measurements and spinal stenosis grading on lumbar MRI. Morphological classification of lumbar canal stenosis was determined acoording to the Schizas grading, categorized into four grades. Results The operation time was 60.4-90.8 minutes (mean, 80.3 minutes) and intraoperative blood loss was 13-47 mL (mean, 29.9 mL). The postoperative hospitalization length was 3-5 days (mean, 3.8 days). All patients were followed up 12-16 months (mean, 13.8 months). The VAS score and ODI improved at immediate and 3, 6, and 12 months after operation compared to before operation, and the differences between different time points were significant (P<0.05). At last follow-up, the clinical efficacy assessed by the modified MacNab criteria were graded as excellent in 23 cases, good in 9 cases, and poor in 1 case, with an excellent and good rate of 96.97%. Postoperative lumbar MRI revealed the significant decompression of the dural sac in 32 cases, with 1 case showing inadequate dural expansion. DSCA measurements confirmed progressive enlargement and stenosis reduction over time. The differences were significant (P<0.05) before operation, immediately after operation, and at 6 months after operation. At 6 months after operation, Schizas grading of spinal stenosis improved to grade A in 27 cases and grade B in 6 cases. Conclusion Posterior 180-degree decompression via UBE is a safe and feasible strategy for treating LSS combined with MSU-1 LDH, achieving effective neural decompression while preserving intervertebral disc integrity.

1.	Katz JN, Zimmerman ZE, Mass H, et al. Diagnosis and management of lumbar spinal stenosis: a review. JAMA, 2022, 327(17): 1688-1699.
2.	Zhang AS, Xu A, Ansari K, et al. Lumbar disc herniation: diagnosis and management. Am J Med, 2023, 136(7): 645-651.
3.	Xiong C, Li T, Kang H, et al. Early outcomes of 270-degree spinal canal decompression by using TESSYS-ISEE technique in patients with lumbar spinal stenosis combined with disk herniation. Eur Spine J, 2019, 28(1): 78-86.
4.	Meng S, Xu D, Han S, et al. Fully endoscopic 360° decompression for central lumbar spinal stenosis combined with disc herniation: technical note and preliminary outcomes of 39 cases. J Pain Res, 2022, 15: 2867-2878.
5.	阮立奇, 陈惠国, 王玲, 等. 单侧双通道脊柱内镜下Sublamina入路治疗腰椎间盘突出症合并椎管狭窄的短期疗效. 中国内镜杂志, 2024, 30(1): 79-84.
6.	Chen KT, Choi KC, Song MS, et al. Hybrid interlaminar endoscopic lumbar decompression in disc herniation combined with spinal stenosis. Oper Neurosurg (Hagerstown), 2021, 20(3): E168-E174.
7.	Guterl CC, See EY, Blanquer SB, et al. Challenges and strategies in the repair of ruptured annulus fibrosus. Eur Cell Mater, 2013, 25: 1-21.
8.	Sharifi S, Bulstra SK, Grijpma DW, et al. Treatment of the degenerated intervertebral disc; closure, repair and regeneration of the annulus fibrosus. J Tissue Eng Regen Med, 2015, 9(10): 1120-1132.
9.	Sloan SR, Wipplinger C, Kirnaz S, et al. Combined nucleus pulposus augmentation and annulus fibrosus repair prevents acute intervertebral disc degeneration after discectomy. Sci Transl Med, 2020, 12(534): eaay2380. doi: 10.1126/scitranslmed.aay2380.
10.	Mysliwiec LW, Cholewicki J, Winkelpleck MD, et al. MSU classification for herniated lumbar discs on MRI: toward developing objective criteria for surgical selection. Eur Spine J, 2010, 19(7): 1087-1093.
11.	d’Ercole M, Innocenzi G, Ricciardi F, et al. Prognostic value of Michigan State University (MSU) classification for lumbar disc herniation: is it suitable for surgical selection? Int J Spine Surg, 2021, 15(3): 466-470.
12.	Kim J, Kwon WK, Cho H, et al. Ligamentum flavum hypertrophy significantly contributes to the severity of neurogenic intermittent claudication in patients with lumbar spinal canal stenosis. Medicine (Baltimore), 2022, 101(36): e30171. doi: 10.1097/MD.0000000000030171.
13.	Hermansen E, Myklebust TÅ, Weber C, et al. Postoperative dural sac cross-sectional area as an association for outcome after surgery for lumbar spinal stenosis: clinical and radiological results from the NORDSTEN-spinal stenosis trial. Spine (Phila Pa 1976), 2023, 48(10): 688-694.
14.	Banitalebi H, Espeland A, Anvar M, et al. Reliability of preoperative MRI findings in patients with lumbar spinal stenosis. BMC Musculoskelet Disord, 2022, 23(1): 51. doi: 10.1186/s12891-021-04949-4.
15.	Lønne G, Ødegård B, Johnsen LG, et al. MRI evaluation of lumbar spinal stenosis: is a rapid visual assessment as good as area measurement? Eur Spine J, 2014, 23(6): 1320-1324.
16.	Ogikubo O, Forsberg L, Hansson T. The relationship between the cross-sectional area of the cauda equina and the preoperative symptoms in central lumbar spinal stenosis. Spine (Phila Pa 1976), 2007, 32(13): 1423-1428.
17.	Schizas C, Theumann N, Burn A, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine (Phila Pa 1976), 2010, 35(21): 1919-1924.
18.	Wu B, Tian X, Shi C, et al. Clinical outcomes of “U” route transforaminal percutaneous endoscopic lumbar discectomy in chronic pain patients with lumbar spinal stenosis combined with disc herniation. Pain Res Manag, 2021, 2021: 6657463. doi: 10.1155/2021/6657463.
19.	Heindel P, Tuchman A, Hsieh PC, et al. Reoperation rates after single-level lumbar discectomy. Spine (Phila Pa 1976), 2017, 42(8): E496-E501.
20.	Serta K, Stephen S, Christoph W, et al. Combined nucleus pulposus augmentation and annulus fibrosus repair prevents intervertebral disc degeneration after discectomy. Neurosurgery, 2019, 66: 310-816. doi:.
21.	Binch AL, Cole AA, Breakwell LM, et al. Expression and regulation of neurotrophic and angiogenic factors during human intervertebral disc degeneration. Arthritis Res Ther, 2014, 16(5): 416. doi: 10.1186/s13075-014-0416-1.
22.	Wang X, Wu H, Zhang Q, et al. NFKB2 inhibits NRG1 transcription to affect nucleus pulposus cell degeneration and inﬂammation in intervertebral disc degeneration. Mech Ageing Dev, 2021, 197: 111511. doi: 10.1016/j.mad.2021.111511.
23.	Jang JW, Lee DG, Park CK. Rationale and advantages of endoscopic spine surgery. Int J Spine Surg, 2021, 15(suppl 3): S11-S20.
24.	Oba H, Takahashi J, Futatsugi T, et al. Study of dural sac cross-sectional area in early and late phases after lumbar decompression surgery. Spine J, 2013, 13(9): 1088-1094.
25.	Yamazaki K, Yoshida S, Ito T, et al. Postoperative outcome of lumbar spinal canal stenosis after fenestration: correlation with changes in intradural and extradural tube on magnetic resonance imaging. J Orthop Surg (Hong Kong), 2002, 10(2): 136-143.
26.	Hermansen E, Moen G, Barstad J, et al. Laminarthrectomy as a surgical approach for decompressing the spinal canal: assessment of preoperative versus postoperative dural sac cross-sectional areal (DSCSA). Eur Spine J, 2013, 22(8): 1913-1919.
27.	Chung SW, Kang MS, Shin YH, et al. Postoperative expansion of dural sac cross-sectional area after unilateral laminotomy for bilateral decompression: correlation with clinical symptoms. Korean J Spine, 2014, 11(4): 227-231.
28.	Yang J, Xiong Y, Hu Y, et al. The reliability, correlation with clinical symptoms and surgical outcomes of dural sac cross-sectional area, nerve root sedimentation sign and morphological grade for lumbar spinal stenosis. BMC Musculoskelet Disord, 2023, 24(1): 225. doi: 10.1186/s12891-023-06353-6.
29.	Sucu HK, Gelal F. Lumbar disk herniation with contralateral symptoms. Eur Spine J, 2006, 15(5): 570-574.
30.	Karabekir HS, Yildizhan A, Atar EK, et al. Effect of ligamenta flava hypertrophy on lumbar disc herniation with contralateral symptoms and signs: a clinical and morphometric study. Arch Med Sci, 2010, 6(4): 617-622.
31.	Kalemci O, Kizmazoglu C, Ozer E, et al. Lumbar disc herniation associated with contralateral neurological deficit: can venous congestion be the cause? Asian Spine J, 2013, 7(1): 60-62.
32.	Yang JS, Zhang DJ, Hao DJ. Lumbar disc herniation with contralateral radiculopathy: do we neglect the epidural fat? Pain Physician, 2015, 18(2): E253-E256.
33.	牛策号, 张春霖, 严旭, 等. 椎体后方结构及对突出椎间盘体积测量的影响. 中国组织工程研究, 2023, 27(18): 2897-2902.
34.	吴彦禹, 张春霖, 邵成龙, 等. 二维距离法和三维体积法对内镜下微创颈椎管成形后突出椎间盘再吸收的定量测量. 中国组织工程研究, 2021, 25(21): 3390-3394.
35.	Zhang C, Fu S, Yan X, et al. Cervical microendoscopic laminoplasty-induced clinical resolution of disc herniation in patients with single- to three-level myelopathy. Sci Rep, 2022, 12(1): 18854. doi: 10.1038/s41598-022-23747-z.

1. Katz JN, Zimmerman ZE, Mass H, et al. Diagnosis and management of lumbar spinal stenosis: a review. JAMA, 2022, 327(17): 1688-1699.
2. Zhang AS, Xu A, Ansari K, et al. Lumbar disc herniation: diagnosis and management. Am J Med, 2023, 136(7): 645-651.
3. Xiong C, Li T, Kang H, et al. Early outcomes of 270-degree spinal canal decompression by using TESSYS-ISEE technique in patients with lumbar spinal stenosis combined with disk herniation. Eur Spine J, 2019, 28(1): 78-86.
4. Meng S, Xu D, Han S, et al. Fully endoscopic 360° decompression for central lumbar spinal stenosis combined with disc herniation: technical note and preliminary outcomes of 39 cases. J Pain Res, 2022, 15: 2867-2878.
5. 阮立奇, 陈惠国, 王玲, 等. 单侧双通道脊柱内镜下Sublamina入路治疗腰椎间盘突出症合并椎管狭窄的短期疗效. 中国内镜杂志, 2024, 30(1): 79-84.
6. Chen KT, Choi KC, Song MS, et al. Hybrid interlaminar endoscopic lumbar decompression in disc herniation combined with spinal stenosis. Oper Neurosurg (Hagerstown), 2021, 20(3): E168-E174.
7. Guterl CC, See EY, Blanquer SB, et al. Challenges and strategies in the repair of ruptured annulus fibrosus. Eur Cell Mater, 2013, 25: 1-21.
8. Sharifi S, Bulstra SK, Grijpma DW, et al. Treatment of the degenerated intervertebral disc; closure, repair and regeneration of the annulus fibrosus. J Tissue Eng Regen Med, 2015, 9(10): 1120-1132.
9. Sloan SR, Wipplinger C, Kirnaz S, et al. Combined nucleus pulposus augmentation and annulus fibrosus repair prevents acute intervertebral disc degeneration after discectomy. Sci Transl Med, 2020, 12(534): eaay2380. doi: 10.1126/scitranslmed.aay2380.
10. Mysliwiec LW, Cholewicki J, Winkelpleck MD, et al. MSU classification for herniated lumbar discs on MRI: toward developing objective criteria for surgical selection. Eur Spine J, 2010, 19(7): 1087-1093.
11. d’Ercole M, Innocenzi G, Ricciardi F, et al. Prognostic value of Michigan State University (MSU) classification for lumbar disc herniation: is it suitable for surgical selection? Int J Spine Surg, 2021, 15(3): 466-470.
12. Kim J, Kwon WK, Cho H, et al. Ligamentum flavum hypertrophy significantly contributes to the severity of neurogenic intermittent claudication in patients with lumbar spinal canal stenosis. Medicine (Baltimore), 2022, 101(36): e30171. doi: 10.1097/MD.0000000000030171.
13. Hermansen E, Myklebust TÅ, Weber C, et al. Postoperative dural sac cross-sectional area as an association for outcome after surgery for lumbar spinal stenosis: clinical and radiological results from the NORDSTEN-spinal stenosis trial. Spine (Phila Pa 1976), 2023, 48(10): 688-694.
14. Banitalebi H, Espeland A, Anvar M, et al. Reliability of preoperative MRI findings in patients with lumbar spinal stenosis. BMC Musculoskelet Disord, 2022, 23(1): 51. doi: 10.1186/s12891-021-04949-4.
15. Lønne G, Ødegård B, Johnsen LG, et al. MRI evaluation of lumbar spinal stenosis: is a rapid visual assessment as good as area measurement? Eur Spine J, 2014, 23(6): 1320-1324.
16. Ogikubo O, Forsberg L, Hansson T. The relationship between the cross-sectional area of the cauda equina and the preoperative symptoms in central lumbar spinal stenosis. Spine (Phila Pa 1976), 2007, 32(13): 1423-1428.
17. Schizas C, Theumann N, Burn A, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine (Phila Pa 1976), 2010, 35(21): 1919-1924.
18. Wu B, Tian X, Shi C, et al. Clinical outcomes of “U” route transforaminal percutaneous endoscopic lumbar discectomy in chronic pain patients with lumbar spinal stenosis combined with disc herniation. Pain Res Manag, 2021, 2021: 6657463. doi: 10.1155/2021/6657463.
19. Heindel P, Tuchman A, Hsieh PC, et al. Reoperation rates after single-level lumbar discectomy. Spine (Phila Pa 1976), 2017, 42(8): E496-E501.
20. Serta K, Stephen S, Christoph W, <i>et al</i>. Combined nucleus pulposus augmentation and annulus fibrosus repair prevents intervertebral disc degeneration after discectomy. Neurosurgery, 2019, 66: 310-816. doi:.
21. Binch AL, Cole AA, Breakwell LM, et al. Expression and regulation of neurotrophic and angiogenic factors during human intervertebral disc degeneration. Arthritis Res Ther, 2014, 16(5): 416. doi: 10.1186/s13075-014-0416-1.
22. Wang X, Wu H, Zhang Q, et al. NFKB2 inhibits NRG1 transcription to affect nucleus pulposus cell degeneration and inﬂammation in intervertebral disc degeneration. Mech Ageing Dev, 2021, 197: 111511. doi: 10.1016/j.mad.2021.111511.
23. Jang JW, Lee DG, Park CK. Rationale and advantages of endoscopic spine surgery. Int J Spine Surg, 2021, 15(suppl 3): S11-S20.
24. Oba H, Takahashi J, Futatsugi T, et al. Study of dural sac cross-sectional area in early and late phases after lumbar decompression surgery. Spine J, 2013, 13(9): 1088-1094.
25. Yamazaki K, Yoshida S, Ito T, et al. Postoperative outcome of lumbar spinal canal stenosis after fenestration: correlation with changes in intradural and extradural tube on magnetic resonance imaging. J Orthop Surg (Hong Kong), 2002, 10(2): 136-143.
26. Hermansen E, Moen G, Barstad J, et al. Laminarthrectomy as a surgical approach for decompressing the spinal canal: assessment of preoperative versus postoperative dural sac cross-sectional areal (DSCSA). Eur Spine J, 2013, 22(8): 1913-1919.
27. Chung SW, Kang MS, Shin YH, et al. Postoperative expansion of dural sac cross-sectional area after unilateral laminotomy for bilateral decompression: correlation with clinical symptoms. Korean J Spine, 2014, 11(4): 227-231.
28. Yang J, Xiong Y, Hu Y, et al. The reliability, correlation with clinical symptoms and surgical outcomes of dural sac cross-sectional area, nerve root sedimentation sign and morphological grade for lumbar spinal stenosis. BMC Musculoskelet Disord, 2023, 24(1): 225. doi: 10.1186/s12891-023-06353-6.
29. Sucu HK, Gelal F. Lumbar disk herniation with contralateral symptoms. Eur Spine J, 2006, 15(5): 570-574.
30. Karabekir HS, Yildizhan A, Atar EK, et al. Effect of ligamenta flava hypertrophy on lumbar disc herniation with contralateral symptoms and signs: a clinical and morphometric study. Arch Med Sci, 2010, 6(4): 617-622.
31. Kalemci O, Kizmazoglu C, Ozer E, et al. Lumbar disc herniation associated with contralateral neurological deficit: can venous congestion be the cause? Asian Spine J, 2013, 7(1): 60-62.
32. Yang JS, Zhang DJ, Hao DJ. Lumbar disc herniation with contralateral radiculopathy: do we neglect the epidural fat? Pain Physician, 2015, 18(2): E253-E256.
33. 牛策号, 张春霖, 严旭, 等. 椎体后方结构及对突出椎间盘体积测量的影响. 中国组织工程研究, 2023, 27(18): 2897-2902.
34. 吴彦禹, 张春霖, 邵成龙, 等. 二维距离法和三维体积法对内镜下微创颈椎管成形后突出椎间盘再吸收的定量测量. 中国组织工程研究, 2021, 25(21): 3390-3394.
35. Zhang C, Fu S, Yan X, et al. Cervical microendoscopic laminoplasty-induced clinical resolution of disc herniation in patients with single- to three-level myelopathy. Sci Rep, 2022, 12(1): 18854. doi: 10.1038/s41598-022-23747-z.

Chinese Journal of Reparative and Reconstructive Surgery

Latest ArticlesEarly effectiveness of posterior 180-degree decompression via unilateral biportal endoscopy in treatment of lumbar spinal stenosis combined with MSU-1 lumbar disc herniation

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