Elsevier

World Neurosurgery

Volume 138, June 2020, Pages e450-e458
World Neurosurgery

Original Article
Biportal Endoscopic Spinal Surgery versus Microscopic Decompression for Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.wneu.2020.02.151Get rights and content

Objective

Recent studies have shown that the clinical outcome in patients treated with the unilateral biportal endoscopic technique, also known as biportal endoscopic spinal surgery (BESS) unilateral laminotomy bilateral decompression (ULBD) in the context of this study, is more favorable compared with those treated with microscopic ULBD. In this systematic review and meta-analysis, we assess the latest evidence on the use of BESS ULBD compared with microscopic ULBD in patients with lumbar spinal stenosis.

Methods

We performed a systematic literature search of studies that compared BESS and microscopic ULBD from several databases.

Results

There were 383 patients from 5 unique studies. Meta-analysis of visual analog scale score for low back pain showed no significant difference at baseline (P = 0.49), at 2–3 months (P = 0.69), and at the final follow-up (P = 0.26). There was no significant difference in visual analog scale score for leg pain and Oswestry Disability Index between the groups preoperatively (P = 0.76 and P = 0.95), at 2–3 months (P = 0.46 and P = 0.92), and at the final follow-up (P = 0.88 and P = 0.58). The mean operation time was similar in the BESS and microsurgery groups (P = 0.36). The BESS group was associated with shorter length of stay (mean difference –2.60 days [–3.39, –1.81]; P < 0.001; I2 = 65%). Complications were similar in both groups (P = 0.26). Individual studies have shown that BESS was associated with early ambulation and less need for opioids.

Conclusions

Current evidence shows a lack of significant differences in terms of efficacy and safety between BESS and microsurgery. Further studies are required before drawing a definite conclusion.

Introduction

Lumbar spinal stenosis refers to the narrowing of the spinal canal, which potentially compresses nerve roots, resulting in neurologic symptoms, including back and leg pain, sciatica, claudication, and walking difficulty.1 This condition is prevalent in the elderly population and often causes a notable decline in functional capability and consequently worsens the quality of life.2,3 Most patients receive conservative treatment in the initial phase. However, disease progression along with the worsening of neurologic symptoms may necessitate surgical intervention. Previous studies have reported that patients receiving surgery have a better clinical outcome compared with those who were treated nonoperatively.4,5

Various less invasive methods have emerged as alternatives to traditional open laminectomy. Furthermore, the less invasive unilateral laminotomy bilateral decompression (ULBD) is associated with shorter operation time and comparable outcome compared with laminectomy.6,7 Postoperative pain, functional disability, and patient satisfaction related to the procedure were similar in unilateral and bilateral laminotomy.8 The use of endoscopes or microscopes through a small incision allowed the surgeon to have a clear working view and to minimize iatrogenic damage to lumbar structures.9,10 These minimally invasive procedures were intended to achieve sufficient decompression of the neural components and limit surgical-related tissue trauma and hence reduce postoperative complications.11,12

Recent studies have shown that the clinical outcome in patients treated with the unilateral biportal endoscopic technique, also known as biportal endoscopic spinal surgery (BESS) ULBD in the context of this study, is more favorable compared with those treated with microscopic ULBD. In this systematic review and meta-analysis, we assess the latest evidence on the use of BESS ULBD compared with microscopic ULBD in patients with lumbar spinal stenosis.

Section snippets

Search Strategy

We performed a systematic literature search of studies that compared BESS and microscopic ULBD with the keywords “biportal endoscopic spinal surgery,” “microscopic decompression surgery,” “spinal stenosis,” and their synonyms from inception until December 2019 using PubMed, EuropePMC, Cochrane Central Database, ScienceDirect, ProQuest, and Clinicaltrials.gov. The records were then systematically evaluated using inclusion and exclusion criteria. We also performed manual sampling of the

Study Selection and Characteristics

A total of 89 studies in the databases were found. After the duplicates were removed, 61 abstracts were screened, and 16 abstracts were relevant to our selection criteria. We assessed the full text for these articles. Ten studies were excluded because of 1) single-arm studies/case-series (n = 7), 2) analysis on learning curve (n = 1), 3) cost-effectiveness analysis (n = 1), and 4) different reporting standard for the outcome (n = 1). As a result, we included 6 studies (5 unique studies) in the

Discussion

This study shows that BESS has comparable efficacy to microscopic ULBD in terms of VAS and ODI. The length of stay was lower in the BESS group. Individual studies have shown that BESS was associated with early ambulation and less need for opioids.

The percutaneous BESS ULBD has the same principle and visual field as microsurgery ULBD. The BESS enables the preservation of normal spine anatomy and provides a clearer operative field for ipsilateral, contralateral, and sublaminar spaces with a high

Conclusions

The evidence shows a lack of significant differences in terms of efficacy and safety between BESS and microsurgery. BESS shows potential benefits in outcomes such as less need for opioids, early ambulation, length of stay, and angle of facetectomy; however, a more solid body of evidence is needed. Further multicenter RCTs are required before drawing a definite conclusion.

CRediT authorship contribution statement

Raymond Pranata: Conceptualization, Methodology, Formal analysis, Investigation, Writing - original draft. Michael Anthonius Lim: Data curation, Investigation, Writing - original draft. Rachel Vania: Data curation, Investigation, Writing - original draft, Project administration. Julius July: Investigation, Writing - review & editing.

References (24)

  • J.N. Weinstein et al.

    Surgical versus nonsurgical therapy for lumbar spinal stenosis

    N Engl J Med

    (2008)
  • C. Thomé et al.

    Outcome after less-invasive decompression of lumbar spinal stenosis: a randomized comparison of unilateral laminotomy, bilateral laminotomy, and laminectomy

    J Neurosurg Spine

    (2005)
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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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