Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6, 9253-9268 2024 Publisher: Learning Gate DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate © 2024 by the authors; licensee Learning Gate * Correspondence: lukas-w@fk.unair.ac.id Functional outcomes of open laminectomy, minimally invasive, and endoscopic biportal decompression surgery in lumbar stenosis: systematic review and meta-analysis Mukhlis Aziz1,2 Lukas Widhiyanto1,2*, Pudji Lestari3 1Department of Orthopaedics and Traumatology, Faculty of Medicine Airlangga University, Surabaya, Indonesia; drmukhlisaziz@gmail.com (M.A.) 2Department of Orthopaedics and Traumatology, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; lukas- w@fk.unair.ac.id (L.W.) 3Department of Public Health and Preventive Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; pudjilestari70@fk.unair.ac.id (P.L.) Abstract: Lumbar spinal stenosis (LSS) is a common degenerative condition that often requires decompression surgery. Various techniques, including open laminectomy, minimally invasive unilateral laminotomy bilateral decompression (MIS-ULBD), and unilateral biportal endoscopic (UBE) surgery, are utilized. This study compares the functional outcomes and complications of these methods. A systematic review and meta-analysis were conducted, analyzing studies from PubMed, Springerlink, and other databases. The key variables studied included the Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI), intraoperative blood loss, hospital stay duration, operative time, and postoperative complications. A total of 14 studies with 1,427 patients aged 52.35-74.52 years were included. MIS resulted in shorter operative times compared to UBE, but UBE had a lower complication rate. UBE also demonstrated superior outcomes in terms of VAS pain reduction, ODI scores, and shorter hospital stays compared to both MIS and open laminectomy. UBE and MIS each present post- operative advantages. UBE offers faster recovery and reduced pain, while MIS has the benefit of shorter surgery times. Despite the steep learning curve and more complex instrumentation required, UBE is a safe and effective alternative to traditional decompression techniques, offering better functional outcomes in LSS patients compared to MIS and open laminectomy. Keywords: Functional Outcomes, Lumbar Spinal Stenosis, Minimally Invasive Surgery, Open Laminectomy, Unilateral Biportal Endoscopy. 1. Introduction Lumbar spinal stenosis (LSS) is a condition that results from the narrowing of the spinal canal, which compresses the nerve roots and spinal cord. It is common among the elderly and leads to debilitating symptoms like back pain, leg pain, and neurological deficits. Conservative treatment options include physical therapy, medication, and epidural injections. However, surgery is considered when conservative measures fail. [1–3] Surgical decompression for LSS aims to relieve pressure on the spinal nerves. The primary surgical approaches include open laminectomy, minimally invasive surgery (MIS), and unilateral biportal endoscopy (UBE).[4] Each technique has its advantages and limitations. Open laminectomy is the traditional approach, providing a wide decompression but it is associated with longer recovery and higher complication rates. MIS, which involves smaller incisions and less tissue disruption, offers faster recovery but can be technically demanding. UBE is a relatively new endoscopic technique that provides decompression through small incisions while minimizing tissue trauma.[5,6] This study aims to compare the functional outcomes of these three surgical methods to determine which offers the best balance of efficacy and safety in treating lumbar spinal stenosis. mailto:pudjilestari70@fk.unair.ac.id 9254 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate 2. Materials and Methods This study is a systematic review and meta-analysis comparing the functional outcomes of three surgical techniques used for lumbar spinal stenosis decompression: open laminectomy, minimally invasive surgery, and unilateral biportal endoscopy. The analysis focuses on key outcomes such as pain Visual Analogue Scale, Oswestry Disability Index, blood loss, hospital stay, operative time, failure rate, and complications. This research was conducted between May and April 2024. A comprehensive literature search was conducted using databases such as PubMed, SpringerLink, Science Direct, ResearchGate, Cochrane, and Google Scholar. The search involved combining free-text keywords with Boolean operators (“AND”/“OR”) for precise results (Table 1). • Population: ("Lumbar Spinal Stenosis" OR "LSS") AND ("decompression surgery" OR "spinal decompression") • Intervention: ("decompression surgery" AND ("open laminectomy" OR "minimally invasive surgery" OR "MIS" OR "unilateral biportal endoscopy" OR "UBE")) • Comparison: ("open laminectomy" OR "minimally invasive surgery" OR "MIS" OR "UBE" OR "BESS") AND "comparison" • Outcomes: ("pain VAS" OR "Visual Analog Scale" OR "ODI score" OR "Oswestry Disability Index") AND ("complication" OR "postoperative outcomes") • Inclusion Criteria: ("Lumbar Spinal Stenosis" AND ("decompression surgery" OR "open laminectomy" OR "MIS" OR "UBE")) AND ("minimum 6 months follow-up" OR "postoperative follow-up") • Exclusion Criteria: NOT ("spinal tumors" OR "spinal fractures" OR "spinal infections" OR "pediatric" OR "adolescent") AND NOT ("revision surgery" OR "other surgical techniques") The search adhered to PRISMA guidelines, focusing on studies that included terms related to LSS, decompression surgery, and the surgical techniques under review. From the initial pool of 1126 studies, 14 (4 Randomized Controlled Trials (RCTs) and 10 retrospective studies) were analyzed, involving 1427 patients aged between 52.35 and 74.52 years (Figure 1). 9255 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate Table 1. PICO. Population Intervention Comparison Outcomes Inclusion criteria • Lumbar Spinal Stenosis that has undergone decompression surgery with open laminectomy, MIS, and UBE. • Minimal 6 months follow-up post- operative • Decompression operation Operation method: • Open laminecto my • MIS • UBE • Pain VAS • ODI score • Complication • Blood loss • Hospital stay • Operative tume • Failure rate Exclusion criteria • Patients with concurrent spinal conditions, such as spinal tumors, fractures, or infections. • Studies not providing full-text access or written in non-English or non-Indonesian languages. • Reviews, or meta- analyses instead of original research. • Pediatric or adolescent patients. • Patients with repetitive or revision spinal surgery • Studies involving other surgical techniques not including open laminectom y, MIS- ULBD, or UBE/BESS . • Studies lacking VAS outcomes or other quantitative pain measurement postoperatively. • Incomplete postoperative data. Note: PICO (Population, Intervention, Comparison, and Outcome) inclusion and exclusion criteria, MIS (Minimally Invasive Surgery), UBE (Unilateral Biportal Endoscopic) 9256 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate Figure 1. PRISMA Diagram used in the study. These studies compared the outcomes of open laminectomy, MIS, and UBE. Meta-analysis was performed using software tools like Microsoft Excel 2019 and Revman 5.4. Both fixed-effect and random-effect models were used depending on the heterogeneity of the studies. Heterogeneity was measured using the I² statistic, with I² values above 50% indicating significant heterogeneity and warranting the use of a random-effects model. 9257 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate 3. Results The analysis included 14 studies (4 randomized controlled trials and 10 retrospective studies) involving a total of 1427 patients with lumbar spinal stenosis, aged between 52.35 and 74.52 years. The studies compared the outcomes of decompression surgeries using open laminectomy, minimally invasive surgery, and unilateral biportal endoscopy (Figure 2) (Table 2). Figure 2. Risk of bias assessment using the Risk of Bias in Non-Randomized Studies tool. (ROBINS-I). 9258 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate Table 2. Demographic results. Writers Year Research Design Operation Method Sample Size (n) Genders (M/F; n) Age (years)* Outcomes Min, WK 2019 R MIS vs. UBE 89 MIS (19/16); UBE (2727) 66.24 VAS back and leg pain, ODI score, complication, failure rate, hospital stay, operative times Park, SM 2020 RCT MIS vs. UBE 64 MIS (18/14); UBE (13/19) 66.65 VAS back and leg pain, ODI score, complication, failure rate, hospital stay, operative times Yamato, Y 2023 R Open vs. MIS 80 Open (22/7); MIS (38/13) 71.9 VAS back and leg pain, ODI score, complication, blood loss, hospital stay, operative times Ohtomo, N 2021 R Open vs. MIS 252 Open (68/54); MIS (69/61) 74.2 VAS back and leg pain, ODI score, complication, blood loss, failure rate, hospital stay, operative times Yang, F 2020 R MIS vs. UBE 61 MIS (10/18); UBE (14/19) 74.52 VAS back and leg pain, ODI score, complication, hospital stay, operative times Kim, JH 2023 RCT Open vs. UBE 45 Open (11/10); UBE (9/15) 65.35 VAS back and leg pain, ODI score, complication, failure rate, hospital stay Hasan, S 2019 R MIS vs. UBE 45 MIS (12/14); UBE (12/7) 68.25 VAS back and leg pain, ODI score, complication, failure rate, blood loss, hospital stay Choi, DJ 2019 R MIS vs. UBE 65 MIS (17/13); UBE (14/21) 65.3 VAS back and leg pain, complication Heo, DH 2019 R MIS vs. UBE 70 MIS (12/21); UBE (15/22) 65.05 VAS back and leg pain, ODI score, complication, operative times Mc Grath. Jr, LB 2019 R MIS vs. UBE 95 MIS (27/18); UBE (27/23) 62 VAS back and leg pain, ODI score, complication, failure rate, blood loss, hospital stay, operative times Ito, Z 2021 RCT MIS vs. UBE 181 MIS (71/68); UBE (28/14) 65.65 VAS back and leg pain, ODI score, complication, failure rate, operative times Lee, CW 2019 R MIS vs. UBE 236 MIS (21/51); UBE (52/112) 56.27 VAS back and leg pain, ODI score, complication, failure rate, blood loss, hospital stay, operative times Iwai, H 2020 R MIS vs. UBE 114 MIS (29/25); UBE (39/21) 70.75 VAS back and leg pain, complication, hospital stay, operative times Abdala, A 2019 RCT Open vs. MIS 30 Open (8/10); MIS (7/5) 52.35 VAS leg pain, ODI score, complication, blood loss, hospital stay, operative times Note: R = Retrospective; RCT = Randomized Controlled Trial *Data is presented in Mean 9259 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate 3.1. Visual Analogue Scale (VAS) for Back and Leg Pain The results demonstrated that UBE showed a significantly lower VAS for back and leg pain at the final follow-up compared to MIS (p<0.05). However, on both back and leg MIS demonstrated a better ΔVAS (change in VAS from baseline) compared to UBE (p<0.05). The comparison between MIS and open laminectomy did not show a significant difference in VAS scores for either back or leg pain (Table 3) (Figure 3) (Figure 4) (Figure 5) (Figure 6). Figure 3. Forest Plot VAS (Back) pain MIS vs. UBE; a) Final follow up; b) ΔVAS Figure 4. Forest Plot VAS (Back) pain Open vs. MIS; a) Final follow up; b) ΔVAS 9260 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate Figure 5. Forest Plot VAS (Leg) pain MIS vs. UBE; a) Final follow up; b) ΔVAS. Figure 6: Forest Plot VAS (Leg) pain Open vs. MIS; a) Final follow up; b) ΔVAS 9261 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate Table 3. VAS for Back, Leg, and ODI Reference Operation Method Pre-Operative Final Follow-Up Difference (Δ) VAS (Back) VAS (leg) ODI (%) VAS (Back) VAS (leg) ODI (%) VAS (Back) VAS (leg) ODI (%) Min, WK. 2019 MIS 5.34 ± 0.96 7.37 ± 0.94 61.1 ± 4.89 1.88 ± 0.71 2.57 ± 3.19 16.4 ± 6.52 3.46 ± 0.25 4.8 ± 2.25 44.7 ±1.63 UBE 5.27 ± 0.91 7.38 ± 0.65 60.4 ± 6.88 1.64 ± 0.91 2.61 ± 2.86 15.4 ± 8.49 3.63 ± 0 4.77 ± 2.21 55 ± 1.61 Park, SM. 2020 MIS 6.1 ± 2.4 7.4 ± 2.1 47.0 ± 14.4 2.20 ± 2.94 2.20 ± 2.95 18.03 ± 18.80 3.9 ± 0.54 5.2 ± 0.84 28.97 ± 4.4 UBE 6.1 ± 2.6 6.5 ± 1.7 46.2 ± 20.5 2.75 ± 2.70 2.75 ± 2.70 9.79 ± 19.67 3.35 ± 0.1 3.75 ± 1.0 26.41 ± 0.83 Yamato, Y. 2023 Open 6.0 ± 3.1 3.8 ± 3.7 43.6 ± 18.7 3.8 ± 3.2 2.2 ± 2.6 26.2 ± 23.2 2.2 ± 0.1 1.6 ± 1.1 17.4 ± 4.5 MIS 5.7 ± 2.6 5.1 ± 3.1 39.3 ± 16.6 3.4 ± 3.3 2.4 ± 3.1 20.6 ± 20.0 2.3 ± 0.7 2.7 ± 0 18.7 ± 3.4 Ohtomo, N. 2021 Open 5.96 ± 2.8 5.72 ± 3.4 20.2 ± 9.7 2.67 ± 1.2 2.36 ± 2.4 11.8 ± 6.2 3.29 ± 1.6 3.36 ± 1.0 8.4 ± 3.5 MIS 5.92 ± 2.6 5.80 ± 2.7 20.8 ± 8.2 2.43 ± 1.5 2.52 ± 1.6 12.0 ± 5.8 3.49 ± 1.1 3.28 ± 1.1 8.8 ± 2.4 Yang, F. 2020 MIS 4.68 ± 0.94 6.07 ± 0.81 61.86 ± 7.32 2.50 ± 0.75 2.68 ± 1.09 28.75 ± 7.06 2.18 ± 0.19 3.39 ± 0.28 33.1 ± 0.26 UBE 4.70 ± 0.88 5.97 ± 0.85 60.58 ± 5.85 2.21 ± 0.78 2.39 ±1.12 29.42 ± 8.84 2.49 ± 0.1 3.58 ± 0.27 31.16 ± 2.99 Kim, JH. 2023 Open 5.0 ± 2.7 6.7 ± 1.7 42.6 ± 22.0 1.3 ± 1.3 1.6 ± 2.1 31.0 ± 22.6 3.7 ± 1.4 5.1 ± 0.4 11.6 ± 0.6 UBE 5.3 ± 2.4 7.3 ± 1.7 52.9 ± 16.3 2.0 ± 2.2 1.7 ± 2.1 36.8 ± 18.4 3.3 ± 0.2 5.6 ± 0.4 16.1 ± 2.1 Hasan, S. 2019 MIS 7.1 ± 2.2 6.3 ± 2.4 46.6 ± 16.0 2.5 ± 3.6 2.22 ± 2.1 22.1 ±16.4 4.6 ± 1.4 4.08 ± 2.4 24.5 ± 16 UBE 5.8 ± 2.9 6.6 ± 2.3 52.8 ± 10.7 1.8 ± 2.0 1.45 ± 1.8 19.9 ± 16.2 4.0 ± 0.9 5.15 ± 2.3 32.9 ± 10.7 Choi, DJ. 2019 MIS 6.8 ± 1.2 7.0 ± 1.1 N/A 3.2 ± 0.9 2.5 ± 0.7 N/A 3.6 ± 0.3 4.5 ± 0.4 N/A UBE 6.8 ± 1.0 6.3 ± 1.1 N/A 2.8 ± 1.0 2.2 ± 0.8 N/A 4.0 ± 0.9 4.1 ± 0.3 N/A Heo, DH. 2019 MIS 6.64 ±1.45 7.67 ± 1.08 56.36 ± 5.91 2.03 ± 0.92 1.94 ± 0.79 22.58 ± 4.57 4.61 ± 0.53 5.73 ± 0.29 33.78 ± 1.34 UBE 7.02 ± 1.34 8.05 ± 1.08 58.68 ± 5.57 1.95 ± 0.81 2.16 ± 0.79 23.14 ± 2.69 5.07 ± 0.51 5.89 ± 0.29 35.54 ± 2.88 McGrath.Jr, LB. 2019 MIS 7.1 ± 0.4 6.3 ± 0.5 47.2 ± 3.1 4.2 ± 0.6 3.0 ± 0.5 35.9 ± 4.1 2.9 ± 0.2 3.3 ± 0 11.3 ± 1 UBE 6.0 ± 0.4 6.2 ± 0.4 51.0 ± 1.9 2.6 ± 0.4 1.3 ± 0.3 20.7 ± 3.4 3.4 ± 0 4.9 ± 0.1 30.3 ± 1.5 Ito, Z. 2021 MIS 3.7 ± 1.1 4.5 ± 1.2 23.3 ± 9.8 1.5 ± 0.6 1.2 ± 0.5 12.5 ± 4.3 2.2 ± 0.5 3.3 ± 0.7 10.8 ± 5.5 UBE 3.9 ± 1.2 3.9 ± 1.3 23.5 ± 9.2 1.3 ± 0.5 1.0 ± 0.4 11.3 ± 5.6 2.6 ± 0.7 2.9 ± 0.9 12.2 ± 3.6 Lee, CW. 2019 MIS 5.09 ± 2.84 6.47 ± 2.73 56..3 ± 6.1 2.83 3.24 45.3 2.26 ± 2.84 3.23 ± 2.73 11 ± 6.1 UBE 5.97 ± 2.77 7.01 ± 2.31 69.8 ± 5.4 2.35 2.46 46.5 3.62 ± 2.77 4.55 ± 2.31 23.3 ± 5.4 9262 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate Iwai, H. 2020 MIS 6.2 ± 2.4 N/A N/A 2.2 ± 2.1 N/A N/A 4.0 ± 0.3 N/A N/A UBE 6.8 ± 1.8 N/A N/A 2.4 ± 1.9 N/A N/A 4.4 ± 0.1 N/A N/A Abdala, A. 2019 Open N/A 8.6 ± 0.84 33.9 ± 9.02 N/A 1.8 ± 0.99 13.1 ± 4.58 N/A 6.8 ± 0.15 20.8 ± 4.44 MIS N/A 8.7 ± 0.95 30.9 ± 5.95 N/A 1.9 ± 0.99 11.3 ± 3.30 N/A 6.8 ± 0.04 19.6 ± 2.65 9263 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate 3.2. Oswestry Disability Index (Odi) UBE showed a significantly better ODI at the final follow-up compared to MIS (p<0.05). MIS demonstrated a better ΔODI compared to UBE (p<0.05). There were no significant differences between MIS and open laminectomy for ODI scores (Table 4) (Figure 5) (Figure 6). Figure 7. Forest Plot ODI score MIS vs. UBE; a) Final follow up; b) ΔODI. Figure 8. Forest Plot ODI score Open vs. MIS; a) Final follow up; b) ΔODI 9264 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate Table 4. Blood Loss, Hospital Stay, Operative Duration, Failure Rate, and Complications. Reference Operation Approach Blood Loss (ml) Hospital Stay (days) Operative duration (hours) Failure Rate (n) Complication (n) Min, WK. 2019 MIS N/A 7.45 ± 2.63 58.85 ± 7.48 1 Dural tear (1); Epidural Hematoma (1) UBE N/A 4.31 ± 1.17 53.68 ± 6.75 1 Dural tear (2); Epidural Hematoma (1) Park, SM. 2020 MIS N/A 2,44 ± 1,4 58.4 ± 33.9 1 Dural tear (2) UBE N/A 1,9 ± 0,68 45.6 ± 16.2 0 Dural tear (2) Yamato, Y. 2023 Open 56.9 ± 54.4 16.0 ± 5.3 94.8 ± 37.3 N/A Dural tear (3); Hemostatic Agent Use (6); Surgical Site Infection (1) MIS 34.2 ± 65.5 8.0 ± 3.7 85.2 ± 34.8 N/A Dural tear (3); Hemostatic Agent Use (10) Ohtomo, N. 2021 Open 144.2 (75- 700) 16.5 100.9 (47-274) 2 Dural tear (3); Urinary tract infection (1); Surgical Site Infection (4); Stroke (1) MIS 30.4 (5-250) 9.7 76.8 (40-169) 1 Dural tear (8); Hematoma (1); Surgical Site Infection (1) Table 4. Blood Loss, Hospital Stay, Operative Duration, Failure Rate, and Complications (continue) Yang, F. 2020 MIS N/A 7.13 (6.08 - 8.11) 72.00 (68.75 - 74.80) 0 Dural tear (1); Urinary tract infection (2); transient delirium (2) UBE N/A 3.65 (2.90 - 4.50) 90.33 (87.13 - 94.75) 0 Dural tear (2); Urinary tract infection (2); acute exacerbation of chronic bronchitis (1); acute left heart failure (1) Kim, JH. 2023 Open N/A 4.8 ± 1.5 N/A 0 Acute embolic cerebral infarction (1); Asymptomatic synovial cysts (1) UBE N/A 3.8 ± 1.9 N/A 1 Operation level mismatch (1); Asymptomatic hematoma (1) Hasan, S. 2019 MIS 30.0 ± 18.9 1.7 ± 1.2 N/A 2 Dural tear (2) UBE 3.1 ± 5.0 0.9 ± 0.8 N/A 2 Dural tear (2) Choi, DJ. 2019 MIS N/A N/A N/A N/A Dural tear (2) UBE N/A N/A N/A N/A Dural tear (2); Root injury (1) Heo, DH. 2019 MIS N/A N/A 56.4 ± 4.7 N/A Dural tear (2); Transient weakness (1); 9265 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate Hematoma (2) UBE N/A N/A 62.4 ± 5.7 N/A Dural tear (1); Hematoma (1) McGrath.Jr, LB. 2019 MIS 51.8 ± 11.0 2.4 ± 0.5 154.1 ± 6.2 2 Dural tear (3); Epidural hematoma (2); Urinary retention (6); Parasthesia (1) UBE 6.5 ± 0.6 0.7 ± 0.1 210.8 ± 9.7 1 Dural tear (1); Parasthesia (3); Disc herniation (1) Ito, Z. 2021 MIS N/A N/A 51.0 ± 12.2 2 Dural tear (8); Hematoma (5) UBE N/A N/A 57.0 ± 10.3 0 Dural tear (2) Lee, CW. 2019 MIS 134.3 ± 35.34 4.85 ± 1.86 52.22 ± 19.07 1 Dural tear (1); Hematoma (1) UBE 35.34 ± 28.87 2.12 ± 1.68 84.17 ± 34.70 0 Dural tear (4) Iwai, H. 2020 MIS N/A 4.7 ± 1.67 54.6 ± 17.6 N/A Dural tear (3); Hematoma (2) UBE N/A 2.1 ± 1.8 77.8 ± 18.8 N/A Dural tear (1); Hematoma (7) Abdala, A. 2019 Open 152 ± 50.95 2.4 ± 0.7 85.5 ± 17.07 N/A Dural tear (2) MIS 127 ± 37.43 1.8 ± 0.42 73.5 ± 14.54 N/A Dural tear (1) 9266 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate 3.3. Blood Loss UBE had significantly lower blood loss compared to MIS (p<0.05), and MIS had significantly lower blood loss compared to open laminectomy (p<0.05) (Figure 7) (Figure 8). Figure 9. Forest Plot Blood Loss MIS vs. UBE Figure 10. Forest Plot Blood Loss Open vs. MIS 3.4. Hospital Stay UBE demonstrated significantly shorter hospital stays compared to MIS (p<0.05), and MIS showed shorter hospital stays compared to open laminectomy (p<0.05) (Figure 9) (Figure 10). Figure 9. Forest Plot Hospital Stay MIS vs. UBE Figure 10. Forest Plot Hospital Stay Open vs. MIS 9267 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate 3.5. Operative Time MIS showed significantly shorter operative time compared to UBE and open laminectomy (p<0.05). The analysis revealed significant heterogeneity in operative times between the studies (Figure 11) (Figure 12). Figure 11. Forest Plot Operative Time MIS vs. UBE Figure 12. Forest Plot Operative Time Open vs. MIS 3.6. Complications and Failure Rate UBE was associated with lower complication and failure rates compared to both MIS and open laminectomy, although the results varied across different studies. These results suggest that UBE may offer superior outcomes in terms of pain relief, functional recovery, and shorter hospital stays, while MIS provides the advantage of reduced operative time and blood loss. 4. Discussion The success rate of open laminectomy for lumbar spinal stenosis (LSS) is around 62-70%, but it is often associated with risks such as local tissue trauma and postoperative spinal instability.[7] These complications are thought to arise due to the extensive retraction and muscle damage involved in the procedure, which leads to prolonged recovery times and poorer quality of life postoperatively. To address these challenges, minimally invasive surgery and unilateral biportal endoscopy were developed as alternatives to reduce tissue damage and improve outcomes.[8] MIS, using a tubular retractor, initially started as a solution for herniated discs but has since evolved to treat central canal stenosis. UBE, a newer technique, allows for better visualization with smaller incisions and has become the standard for many decompression procedures.[2,9–11] The meta-analysis showed that patients treated with UBE had better final follow-up Visual Analogue Scale (VAS) scores for back and leg pain compared to those treated with MIS. However, MIS exhibited better changes in VAS scores from baseline, which could suggest a greater improvement for certain patients. MIS also had more complications, such as dural tears and hematomas, compared to UBE. MIS had a higher failure rate, with 10 patients requiring revision surgery compared to five in the UBE group.[12,13] Although UBE offers superior outcomes in terms of pain relief, hospital stay, and lower complication rates, it does have its challenges. The technique requires a steep learning curve, and 9268 Edelweiss Applied Science and Technology ISSN: 2576-8484 Vol. 8, No. 6: 9253-9268, 2024 DOI: 10.55214/25768484.v8i6.3982 © 2024 by the authors; licensee Learning Gate surgeons may face difficulties achieving complete decompression in the early stages of their experience. This learning curve can result in longer operative times for UBE compared to MIS, as seen in studies where UBE took significantly longer due to the complexity of the technique.[14,15] 5. Conclusion UBE appears to be a safe and effective alternative for the decompression of LSS, especially when performed by experienced surgeons with the proper instrumentation. However, MIS still offers significant benefits for certain patient populations, particularly those with complex cases or higher body mass indexes (BMI), where the use of retractors may offer better visualization and access. Copyright: © 2024 by the authors. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). References [1] Yu B, Zhang J, Pan J, Wang Y, Chen YG, Zhao W, et al. Psychological and Functional Comparison between Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Single-Level Lumbar Spinal Stenosis. Orthop Surg 2021;13(4). [2] Librianto D, Ipang F, Saleh I, Srie Utami W, Aprilya D, Nurhayati R, et al. Comparison of Microscopic Decompression and Biportal Endoscopic Spinal Surgery in the Treatment of Lumbar Canal Stenosis and Herniated Disc: A One-year Follow-up. Open Access Maced J Med Sci 2022;10(B):1188–94. 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Clinical Comparison of Full-Endoscopic and Microscopic Unilateral Laminotomy for Bilateral Decompression in the Treatment of Elderly Lumbar Spinal stenosis: A Retrospective Study with 12-Month Follow-Up

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