Biportal Endoscopic Spine Surgery

Biportal endoscopic spine surgery — also called unilateral biportal endoscopy, or UBE — is a keyhole technique that uses two very small skin openings instead of one. Through one portal the surgeon passes a high-definition endoscope to see; through the second, separated by a centimetre or two, they pass their surgical instruments to work. Because the camera and the instruments move independently, the surgeon has much of the freedom and familiar "feel" of microsurgery, but with the magnified, close-up, well-lit endoscopic view and a very small footprint on the body.

It grew out of, and combines, two earlier approaches: the microscope-based techniques many spine surgeons are trained in, and single-channel spinal endoscopy. As with full endoscopic surgery, continuous saline irrigation keeps the field clear, muscle is split rather than cut, and the openings are tiny. The two-portal design makes it especially versatile for wider decompressions — for example clearing narrowing on both sides of the canal — and for procedures where being able to angle the camera and instruments separately is an advantage.

Biportal endoscopy is used for herniated discs, spinal stenosis, and increasingly for fusions, and like other endoscopic techniques it offers a gentler recovery than traditional open surgery.

• People with spinal stenosis needing the canal or nerve exits opened up, including narrowing on both sides
• People with a herniated disc causing nerve pain that has not settled with non-surgical care
• People who would benefit from a keyhole approach but whose problem needs the wider working freedom two portals allow
• Selected people needing a minimally invasive fusion
• Suitability is decided individually by the specialist based on the problem and imaging

• Two small incisions are made a short distance apart, in line with the target. Muscle-splitting dilators create the two channels — one for the endoscope, one for the instruments. Saline flows continuously through the space, giving a clear, magnified view on the screen and helping control bleeding. Because the scope and the instruments enter through separate portals, the surgeon can move them independently, much as they would with two hands under a microscope, but with the camera taken right up to the spine. Using standard, familiar surgical instruments, the surgeon removes the disc fragment or shaves away the bone and thickened ligament trapping the nerves, then confirms the nerves are free. The small openings are closed with a stitch or two each.

• Two tiny incisions rather than a long open wound, with muscle split and preserved rather than cut
• Independent movement of camera and instruments gives excellent surgical freedom — closer to the "feel" of microsurgery than single-channel endoscopy
• A magnified, brightly lit, close-up view of the nerves and the ability to reach both sides of the canal through one approach
• Less blood loss, shorter hospital stay and faster early recovery than open microsurgery in comparative studies
• Faster relief of early post-operative back and leg pain reported versus some other techniques
• Uses standard surgical instruments, which many surgeons find translates well from their existing training
• Preserves more of the spine's natural supporting structures

• Standard surgical risks apply — infection, bleeding, dural tear (a leak of spinal fluid), nerve irritation, and a small risk of nerve injury
• Managing the continuous fluid and the two portals adds technical demands, and the technique has its own learning curve
• Long-term results for stenosis and disc problems are comparable to microsurgery rather than dramatically different, so the main gains are in the gentler approach and early recovery
• As with any decompression or discectomy, a disc can recur or narrowing can progress over time
• Occasionally conversion to an open technique is needed for safety

• Non-surgical care where appropriate — physiotherapy, injections, time
• Full (single-portal) endoscopic spine surgery
• Microdiscectomy or microscope-assisted decompression
• Tubular minimally invasive decompression
• Open surgery for problems unsuited to a keyhole approach

Recovery is typically quick and comfortable. Because the muscles are preserved and the wounds are tiny, many people mobilise the same day and go home within a day or so, with early relief of leg and back pain frequently reported. Return to light activity and desk work is usually within days to a couple of weeks, with heavier activity built up over the following weeks. The long-term outcome for the underlying condition is comparable to established microsurgical techniques, with the advantage of a gentler operation and recovery. Your specialist will tailor expectations to your specific problem.

• —NICE — Low Back Pain and Sciatica in Over 16s (NG59)
• —British Association of Spine Surgeons (BASS)
• —Heo DH et al. — Unilateral biportal endoscopic spine surgery: technique and outcomes (comparative evidence)

This information is for general patient education and is not a substitute for an individual consultation. Always seek personalised advice from a qualified spinal specialist.