Acta Neurochirurgica (2022) 164:2343–2347

https://doi.org/10.1007/s00701-022-05324-5

HOW I DO IT - SPINE DEGENERATIVE

Lumbar interbody fusion with bilateral cages using a biportal

endoscopic technique with a third portal
Chengyue Zhu1,2 · Liangping Zhang3 · Hao Pan1 · Wei Zhang1

Received: 14 July 2022 / Accepted: 20 July 2022 / Published online: 31 July 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature 2022

Abstract
Background Unilateral biportal endoscopic lumbar interbody fusion (ULIF) with one cage results in fewer definitive fusions
(Park et al. in Neurosurg Rev 42(3):753–761, 2019). We succeeded in inserting bilateral cages during ULIF.
Method We attempted posterior ULIF for degenerative lumbar spondylolisthesis with bilateral recess stenosis. With the
help of a third portal, ULIF with bilateral cage insertion was performed under general anaesthesia.
Conclusions We successfully performed ULIF with bilateral cages with the help of a third portal. This procedure may be an
alternative for treating lumbar stenosis with instability.

Keywords Unilateral biportal endoscopy · Lumbar interbody fusion · Bilateral cages · Third portal

Relevant surgical anatomy
Unilateral biportal endoscopic fusion surgery for treating
degenerative lumbar spondylolisthesis with stenosis often
requires bilateral release and decompression; however,
decompression of the contralateral recess has consistently
been difficult (Fig. 1a). An auxiliary portal can be added on
the contralateral side to make the Kerrison rongeur perpen-
dicular to the lamina, facilitating decompression. The bony
space created after contralateral decompression provides an
opportunity for cage implantation. There is an increased risk
of cage failure and adjacent segment degeneration with the
The authors Chengyue Zhu and Liangping Zhang contributed
equally to this work and should be considered co-first authors.
This article is part of the Topical Collection on Spine degenerative
single cage technique, however [5]. A large oblique lum-
bar interbody fusion (OLIF) cage requires a large space
between the exiting root and traversing root [1]. Through
this auxiliary portal, we can implant a conventional cage on
the contralateral side to increase the stability and improve
the fusion rate.
Description of the technique
Surgical instruments
A set of arthroscopic facilities and conventional spine instru-
ments, including Kerrison rongeurs, pituitary forceps, oste-
otome and a tool-kit of radiofrequency (RF) systems and
high-speed diamond burrs (Jiangsu BONSS Medical Tech-
nology, China), were used.

* Wei Zhang Position and creation of the three portals

volcano8060@163.com
1
Department of Orthopaedics, Hangzhou Traditional Chinese Under tracheal intubation anaesthesia, the patient was placed
Medicine Hospital Affiliated to Zhejiang Chinese Medical in the prone position with the abdomen free. The viewing
University, Tiyuchang Road No. 453, Hangzhou 310007, and working portals were made over the pedicles, a third
China portal was made over the base of the superior articular pro-
2
Department of Orthopaedics, Hangzhou Linan cess (SAP) on the contralateral side, and a quarterback K
TCM Hospital, Linan Xishui North Road No. 288, portal was made at the junction of the inferior lamina of the
Hangzhou 311300, China
superior vertebrae and the base of the spinous process (SP)
3
Zhejiang Chinese Medical University, Binwen Road No. 548, (Fig. 1b).
Hangzhou 310053, China

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Fig. 1  a When decompressing the contralateral recess, instruments that must be adjusted medially can cause compression of the nerve root and
dural sac. Changes in the soft tissue portal may lead to poor outflow of irrigation. b Schematic representation of the location of the portals

Ipsilateral facetectomy, flavectomy and discectomy
A radiofrequency probe was used to expose the junc-
tion of the inferior lamina of the superior vertebrae
and the base of the SP, and the lower part of the supe-
rior lamina was removed with a diamond burr until the
proximal insertion of the ligamentum flavum (LF) was
exposed. Similarly, the upper part of the inferior lamina
was removed until the distal insertion of the LF was
exposed. After resection of the facet joints with a swing
saw and osteotome, the LF was dissociated and gradu-
ally resected. Then, the nerve root was carefully exposed
and protected, and ipsilateral discectomy and endplate
preparation were performed.
Contralateral flavectomy, laminotomy, discectomy
and insertion of a cage
The base of the spinous process was partially resected to
make a working space for the endoscope. The LF under
the contralateral lamina was removed, and then the third
portal (Zhang’s portal) was established under ipsilateral
endoscopic monitoring using a guiding rod (Fig. 2). Tools
could be used perpendicular to the lamina and disc through

Fig. 2  a Radiographic anteroposterior view of the locations of the portals; b The tip of the guiding rod has broken through the contralateral
superficial layer of the LF; c Overview of Zhang’s portal in ULIF surgery

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Acta Neurochirurgica (2022) 164:2343–2347
Zhang’s portal, and decompression was easily achieved on
the contralateral side. A retractor was inserted from the
working portal to protect the contralateral nerve root. Dis-
cectomy, endplate preparation and cage insertion were per-
formed through Zhang’s portal.
Ipsilateral insertion of a cage
The endoscope was moved to the ipsilateral intervertebral
space, a 1.5 mm Kirschner wire was inserted through the
quarterback K portal percutaneously as a retractor to protect
the nerve root, a cage was inserted (Fig. 3), and ipsilateral
incisions of the two portals were used for insertion of ipsilat-
eral percutaneous pedicle screws. Two more incisions were
made on the contralateral side for contralateral pedicle screw
fixation (Fig. 4).
Indications
The indications for ULIF with bilateral cages were
similar to those of bilateral minimally invasive (MIS)-
transforaminal lumbar fusion (TLIF) or standard
Fig. 3  a Contralateral endplate preparation after decompression; b
A retractor is inserted through the working portal to protect the con-
tralateral traversing root; c Contralateral endoscopic view of the con-
tralateral cage; d A Kirschner wire is inserted in the annulus fibrosis
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posterior lumbar interbody fusion (PLIF). We per-
formed this lumbar interbody fusion procedure for
degenerative spondylolisthesis, isthmic spondylolis-
thesis and lumbar central stenosis with instability. We
did not perform the procedure in patients with lum-
bar foraminal stenosis, high-grade spondylolisthesis,
spondylitis, spinal fractures or tumours.
Limitations
The biportal endoscope-assisted ULIF with bilateral
cages approach has constraints regarding implementing
foraminal decompression. Zhang’s portal does not appear
necessary if decompression and fusion can be performed
through the portals used for the contralateral percutane-
ous pedicle screws, but it is not friendly to right-handed
surgeons, and more injuries can be caused to the paraspi-
nal muscles. Rearranging the endoscope and instruments
during the operation will increase the operation time and
the risk of infections.
as a retractor to protect the ipsilateral nerve root; e Ipsilateral endo-
scopic view of the contralateral cage; f Ipsilateral endoscopic view of
the ipsilateral cage
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Fig. 4  a, b Preoperative X-ray

image demonstrating degenera-
tive spondylolisthesis at levels
L4-5; c, d Preoperative CT and
MRI showing degenerative
spondylolisthesis with central
and recess stenosis at levels
L4-5; e, f Postoperative X-ray
images revealing reduced spon-
dylolisthesis and the insertion
of bilateral conventional cages;
g, h Postoperative CT and MRI
revealing a decompressed recess
and central canal

Fig. 5  a The Kerrison punch

is blocked by the base of the
spinous process; b Through
Zhang’s portal, an efficient
contralateral decompression
can be achieved; c The forceps
cannot resect the contralateral
LF because of obstruction of
the base of the spinous process;
d Through Zhang’s portal, the
contralateral LF can be removed
easily

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How to avoid complications
A thin puncture needle can be used as a guide to ensure
that the quarterback K portal and Zhang’s portal are accu-
rately positioned. When inserting the contralateral cage,
the retractor from the working portal should be stabilized,
and a wide and clear view is of utmost importance.
Specific perioperative considerations
Maintaining stable water dynamics is the first step in creat-
ing a safe and complete environment for UBE, we sutured
the Zhang’s portal after inserting the contralateral cage
to avoid vortices generation. Postoperative rehabilitation
is recommended on the 3rd day after removal of drainage
tubes.
Specific information for the patient
Although bilateral cages have advantages including a
higher fusion rate and greater stability [3], there is a pos-
sibility of contralateral nerve root injury due to retrac-
tion of the retractor and crush of the cage. If there was
insufficient space after contralateral decompression, we
applied the unilateral single-cage technique. No studies
have reported the long-term clinical and radiologic results
of ULIF with bilateral cages.
Supplementary information The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00701-0​ 22-0​ 5324-5.
Funding This work was supported by the National Key R&D Program
of China (2019YFC0121400).
Declarations
Ethics approval and consent to participate This study protocol was
approved by the Research Ethics Board of our hospital. The patient
signed a written informed consent form for enrolment in this study.
Conflict of interest The authors declare no competing interests.
References
1. Heo DH, Eum JH, Jo JY, Chung H (2021) Modified far lateral
endoscopic transforaminal lumbar interbody fusion using a
biportal endoscopic approach: technical report and preliminary
results. Acta Neurochir 163(4):1205–1209. https://​doi.​org/​10.​
1007/​s00701-​021-​04758-7
2. Heo DH, Park CK (2019) Clinical results of percutaneous biportal
endoscopic lumbar interbody fusion with application of enhanced
recovery after surgery. Neurosurg Focus 46(4):E18. https://​doi.​
org/​10.​3171/​2019.1.​FOCUS​18695
2347
3. Lee YH, Chung CJ, Wang CW, Peng YT, Chang CH, Chen CH,
Chen YN, Li CT (2016) Computational comparison of three
posterior lumbar interbody fusion techniques by using porous
titanium interbody cages with 50% porosity. Comput Biol Med
71:35–45. https://​doi.​org/​10.​1016/j.​compb​iomed.​2016.​01.​024
4. Lee JH, Lee JH, Yoon KS, Kang SB, Jo CH (2008) Comparative
study of unilateral and bilateral cages with respect to clinical out-
comes and stability in instrumented posterior lumbar interbody
fusion. Neurosurgery 63(1):109–114. https://​doi.​org/​10.​1227/​01.​
NEU.​00003​35077.​62599.​F0
5. Lynch CP, Cha E, Rush Iii AJ, Jadczak CN, Mohan S, Geoghegan
CE, Singh K (2021) Outcomes of transforaminal lumbar interbody
fusion using unilateral versus bilateral interbody cages. Neuro-
spine 18(4):854–862. https://​doi.​org/​10.​14245/​ns.​21422​48.​124
6. Park MK, Park SA, Son SK, Park WW, Choi SH (2019) Clinical
and radiological outcomes of unilateral biportal endoscopic lum-
bar interbody fusion (ULIF) compared with conventional posterior
lumbar interbody fusion (PLIF): 1-year follow-up. Neurosurg Rev
42(3):753–761. https://​doi.​org/​10.​1007/​s10143-​019-​01114-3
Publisher's note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Key points
1. We successfully performed ULIF with bilateral cages using
a biportal endoscopic posterior approach with the help of a third
portal.
2. Compared with conventional standard PLIF, the benefits of
ULIF with bilateral cages included the preservation of the muscles
and ligaments, reduced transfusion requirements [4], and enhanced
postoperative recovery [2].
3. Zhang’s portal was designed over the base of the
contralateral SAP, which provided accessibility to decompress the
recess and implant the cage.
4. Through Zhang’s portal, surgical tools can be used
perpendicular to the spine so that contralateral decompression is
not blocked by the base of the spinous process, allowing a more
convenient and flexible operation (Fig. 5).
5. Contralateral decompression can also cause adhesion lysis,
which is helpful for reduction in lumbar spondylolisthesis.
6. When inserting the contralateral cage, a retractor should be
inserted through the working portal to protect the contralateral
traversing nerve root.
7. The quarterback K portal was placed only at the junction of
the inferior lamina of the superior vertebrae and the base of the
spinous process. A Kirschner wire was used as a root retractor
through the quarterback K portal and did not hinder the use of the
surgical instruments in the working portal, increasing the safety of
the procedure and the comfort of the assistant.
8. The Kirschner wire should not be inserted too deep to
prevent damage to the abdominal organs.
9. After inserting the contralateral cage, it is necessary to
confirm its location through endoscopy and fluoroscopy.
10. Bilateral drainage tubes should be inserted through
the quarterback K portal and Zhang’s portal to avoid epidural
haematoma.
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