Acta Neurochirurgica

https://doi.org/10.1007/s00701-022-05422-4

ORIGINAL ARTICLE - SPINE DEGENERATIVE

Unilateral biportal endoscopic extreme transforaminal lumbar

interbody fusion with large cage combined with endoscopic unilateral
pedicle screw fixation for lumbar degenerative diseases: a technical
note and preliminary effects
Dasheng Tian1,2 · Jianjun Liu1,2 · Bin Zhu1,2 · Lei Chen1,2 · Juehua Jing1,2

Received: 3 October 2022 / Accepted: 6 November 2022

© The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature 2022

Abstract
Objective The purpose of the study was to investigate the feasibility and preliminary effects of unilateral biportal endoscopic
extreme transforaminal lumbar interbody fusion(UBE-eXTLIF) with large cage combined with endoscopic unilateral pedicle
screw fixation for lumbar degenerative diseases.
Methods Patients with lumbar degenerative diseases who received UBE-eXTLIF with large cage combined with endoscopic
unilateral pedicle screw fixation from June 2022 to July 2022 were retrospectively analyzed, including 4 females and 1
males. The clinical symptoms and signs were consistent with the imaging changes. We recorded operation time, length of
postoperative hospital stay, and complications. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and modi-
fied Macnab scale was used to evaluate the clinical efficacy at preoperative, postoperative 1 month, and the last follow-up.
Results The operation was successfully completed in all cases. The operation time was 150–180 min, with an average of
164.60 ± 12.03 min. No serious complications such as dural tears and vascular and nerve injuries occurred during opera-
tion. All the patients got out of bed 1–3 days after surgery and were hospitalized 4–5 days after surgery, with an average
of 4.20 ± 0.45 days. Preoperative VAS scores of low back pain were 6.20 ± 0.84 and respectively decreased to 2.20 ± 0.45
and 1.40 ± 0.55 at postoperative 1 month and at the last follow-up, and the difference was statistically significant (P < 0.05).
Preoperative VAS scores of lower limb pain were 4.60 ± 2.61 and respectively decreased to 1.00 ± 0.71 and 0.60 ± 0.55 at
postoperative 1 month and at the last follow-up, and the difference was statistically significant (P < 0.05). Preoperative ODI
scores were 62.00 ± 3.16 and respectively decreased to 38.00 ± 1.41 and 32.40 ± 3.29 at postoperative 1 month and at the
last follow-up, and the difference was statistically significant (P < 0.05). According to the modified Macnab criteria, the
final outcome was excellent in 4 cases and good in 1 case. Five patients could return to normal activities within 3 weeks.
Conclusions UBE-eXTLIF with large cage combined with endoscopic unilateral pedicle screw fixation can achieve excel-
lent clinical results and may become a new minimally invasive endoscopic fusion method for lumbar degenerative diseases.

Keywords Unilateral biportal endoscopic · eXTLIF · Endoscopic unilateral pedicle screw fixation · Lumbar degenerative
diseases · Preliminary effects

Dasheng Tian and Jianjun Liu contributed equally to the paper.
This article is part of the Topical Collection on Spine degenerative.
* Juehua Jing
jjh_hu@sina.com
1
Department of Orthopaedics & Spine Surgery, The Second
Hospital of Anhui Medical University, Hefei 230601, China
2
Institute of Orthopaedics, Research Center for Translational
Medicine, The Second Hospital of Anhui Medical University,
Hefei 230601, China
Transforaminal lumbar interbody fusion (TLIF) is a gold
standard procedure and commonly used for the treatment
of lumbar degenerative diseases [1]. However, it has dis-
advantages, such as postoperative back pain, large trauma,
as well as more bleeding [2]. Therefore, various types of
minimally invasive spine surgeries have been used to treat
lumbar degenerative disease to overcome these risks [3].
These surgeries can minimize injury to normal anatomi-
cal structures during the procedures. Recently, endoscopic
lumbar interbody fusion surgeries have been attempted for

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the treatment of lumbar degenerative diseases [4–6]. Among
them, unilateral biportal endoscopic lumbar interbody fusion
has advantages such as the ability to perform direct neu-
ral decompression as in open surgery, a lower incidence
of neural injury, and endoscopic endplate preparation [7].
Recently, a modified UBE-TLIF technique that used a large-
sized cage was introduced [8]. The goals of this modified
UBE-TLIF technique are to prevent cage subsidence and
enhance of interbody fusion. We called it unilateral biportal
endoscopic extreme transforaminal lumbar interbody fusion
(UBE-eXTLIF).
UBE surgery could perform the neural decompression
under endoscopic view, but percutaneous pedicle screw fixa-
tion requires fluoroscopy or navigation or robotic assistance.
The former has the disadvantage of radiation exposure, and
the latter has the problem of expensive equipment and high
cost. We have used a modified method that performed the
percutaneous pedicle screw insertion under endoscopic
monitoring.
Bilateral pedicle screw fixation is a standard procedure
and commonly used in the fusion surgery. However, the
bilateral pedicle screw fixation could cause more damage
to soft tissue and paravertebral muscles. At the same time,
stress occlusion will occur due to excessive strength, which
leads to bone loss and affects interbody fusion [9]. What’s
more, it will accelerate adjacent segment degeneration [10].
So there have been studies that reported the use of unilateral
pedicle fixation and achieved favorable efficacy in the fusion
surgery [11, 12]. So, in our study, we performed unilateral
pedicle fixation in the surgery.
This paper summarized 5 cases with lumbar degenera-
tive diseases who were treated with UBE-eXTLIF with large
cage combined with endoscopic unilateral pedicle fixation
and presented the surgical technique and analyzed the appli-
cation and clinical efficacy in the treatment of lumbar degen-
erative diseases.
Materials and method
Patient information
A retrospective analysis was performed on 5 patients with
lumbar degenerative diseases treated by UBE-eXTLIF with
large cage combined with endoscopic unilateral pedicle
screw fixation from June 2022 to July 2022. The inclusion
criteria were as follows: (1) Imaging examination (X-rays,
CT, and MRI) confirmed lumbar degenerative diseases
with lumbar spondylolisthesis and lumbar instability; the
symptoms and signs were consistent with imaging; (2) the
responsible segment was single, and the segment was L4-5
or L5-S1; (3) conservative treatment was poor or recurrent
attacks; (4) the patients received UBE-eXTLIF with large
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Acta Neurochirurgica
cage combined with endoscopic unilateral pedicle screw
fixation.
Exclusion criteria were as follows: (1) The responsible
segment was L1-2, L2-3, and L3-4; (2) the responsible seg-
ments ≥ 2; (3) history of prior surgery at the index level;
(4) infectious history of lumbar spine; (5) history of mental
illness.
The study was approved by our institutional review board,
and the informed consent was obtained from all patients.
Surgical procedures
Patients’ preparation
All procedures were performed by single surgeon. After
induction of general anesthesia, patients were positioned
prone with the abdomen free to avoid increased abdominal
pressure.
Position and creation of portals and the surgical field
The target level for surgical decompression was localized
under the C-arm fluoroscopic guidance. Under the guidance
of C-arm fluoroscopy, two portals were made around the
pedicles. The first 0.5-cm-long transverse skin incision for
endoscopic portal was made on the medial border of the
proximal pedicle over the level of inferior border of proxi-
mal pedicle, while the other 1.5-cm-long skin incision for
working portal was made obliquely along the distal pedicle
(Fig. 1A). The left-side approach was preferred by right-
handed surgeons. The creation of two portals and the surgi-
cal field was performed according to previous studies [13].
Unilateral laminotomy and partial facetectomy
The ipsilateral lamina and facet joint were exposed using
RF probes (Fig. 1B). The junction of the outer and infe-
rior margins of the superior articular process was exposed
(Fig. 1C). The entry point of pedicle screw was selected
according to above anatomical structures. Ipsilateral lami-
notomy and partial facetectomy were performed using a
drill, Kerrison punches, and small osteotome (Fig. 1D). The
inferior articular process was removed till the tip of superior
articular process was exposed (Fig. 1E). The tip of superior
articular process was partial removed until the foraminal
area was completely exposed (Fig. 1F). The ipsilateral liga-
mentum flavum was completely removed. We decompressed
the ipsilateral traversing and exiting nerve roots (Fig. 1G).
Bone fragments from the lamina and facet joint were used
as bone fusion material.
Acta Neurochirurgica
Fig. 1  A An endoscopic portal and a working portal were made
around the pedicles (red line for endoscopic portal and blue line for
working portal), and an additional portal was made for the placement
of the large cage (orange line). The fourth portal was made for the
insertion of other pedicle screw (black line); B the ipsilateral facet
joint was exposed using RF probes; C the junction of the outer and
inferior margins of the superior articular process was exposed, and
the entry point of pedicle screw was made using the drill; D ipsilat-
eral partial facetectomy was performed; E the inferior articular pro-
cess was removed till the tip of the superior articular process was
exposed; F the tip of superior articular process was partial removed
until the foraminal area was completely exposed; G the ipsilateral
traversing and exiting nerve roots were decompressed and exposed;
H annulotomy could be performed using a microknife; I the nucleus
pulposus was completely removed using curette and pituitary for-
ceps; J the adequate endplate preparation could be performed under
a magnified endoscopic view; K autologous bone material was put
into the intervertebral space before the placement of the cage; L the
large cage was carefully inserted into the disc preparation site under
the endoscopic monitoring; M the large cage was re-positioned trans-
versely using a cage impactor; N puncture needles were inserted into
the entry point; O, P the position of puncture needles confirmed by
fluoroscopy was satisfactory
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Discectomy and endplate preparation
Annulotomy could be performed using a microknife
(Fig. 1H). The nucleus pulposus was completely removed
using curette and pituitary forceps (Fig. 1I). The cartilagi-
nous endplate was separated from the osseous endplate
under a magnified endoscopic view, and the adequate end-
plate preparation could be performed (Fig. 1J). Endplate
preparation could be achieved without injury to the osseous
endplate.
Placement of a large‑sized cage
Before the insertion of large-sized cage, we made an addi-
tional portal for the lateral insertion of a large-sized cage.
The additional 2-cm-long portal called cage portal was made
3 cm lateral to the pedicle lateral margin over the midline of
intervertebral space to insert a large-sized cage (Fig. 1A). A
trial cage was inserted into disc space to determine the size
of the cage. Cage size was as follows: length, 40 mm; width,
16 mm; and lordotic angle, 6°. Before the placement of the
cage, autologous bone material was put into the interverte-
bral space (Fig. 1K).
On confirmation of the cage size, the large cage filled
with autologous bone material was carefully inserted into
the disc preparation site after slight medial retraction of
the dura and the traversing nerve root and the protection
of the exiting nerve root under the endoscopic monitoring
(Fig. 1L). The large cage was re-positioned transversely
using a cage impactor under endoscopic and C-arm fluoro-
scopic guidance (Fig. 1M). Contralateral decompression was
performed if necessary.
Unilateral percutaneous pedicle screw fixation assisted
with endoscopic technique
After the position of the large cage was correctly identified
with the C-arm fluoroscope, unilateral percutaneous pedicle
screw fixation was performed. The working portal was used
for the insertion of percutaneous pedicle screw and another
1-cm-long vertical skin incision was made 0.5–0.8 cm lateral
to the proximal pedicle lateral margin to place the pedicle
screw. Jamshidi puncture needle required for percutane-
ous pedicle screw placement was inserted into the entry
point through the portals (Fig. 1N). The puncture needles
were inserted into the appropriate depth after the position
confirmed by fluoroscopy was satisfactory (Fig. 1O, P). If
the position was not satisfactory, the position of puncture
needles could be adjusted under endoscopic direct vision
according to the fluoroscopy guidance. After the position
was satisfactory, the guide wire was inserted through the
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Acta Neurochirurgica
puncture needles, and the pedicle screw was placed under
the wire guidance. Finally, the position of the pedicle screw
tail can be checked under endoscopic monitoring.
Closure
Bleeding was controlled in the operating field, and a drain-
age tube was placed in all patients through the cage portal
to prevent hematoma formation, followed by wound closure.
Outcome measures
Operation time, length of postoperative hospital stay, and
complications were recorded. The preliminary effect was
evaluated by Visual Analogue Scale (VAS), Oswestry Dis-
ability Index (ODI), and modified Macnab scale at preopera-
tive, postoperative 1 month, and the last follow-up.
Statistical analysis
Data were statistically described in terms of mean ± standard
deviation (± SD) or frequencies (number of cases) and per-
centages when appropriate. We compared outcomes of dif-
ferent follow-up time using Student’s t test. P values < 0.05
were considered statistically significant. We used SPSS 22.0
(Statistical Package for the Social Science; SPSS Inc., Chi-
cago, IL, USA) for statistical analysis.
Results
Demographic data
The patients who met the inclusion criteria received UBE-
eXTLIF with large cage combined with endoscopic unilat-
eral pedicle screw fixation for lumbar degenerative diseases.
The patients included 1 men and 4 women, with an average
age of 51.60 ± 8.44 years. All cases were at L4/5.
Surgical technique–related outcome
The operative time was 164.60 ± 12.03 min. The postopera-
tive hospital stay was 4.20 ± 0.45 days.
Clinical outcomes
VAS scores of low back pain were significantly improved
when compared with those before operation. Preoperative
VAS scores of low back pain were 6.20 ± 0.84 and respec-
tively decreased to 2.20 ± 0.45 and 1.40 ± 0.55 at postopera-
tive 1 month and at the last follow-up, and the difference was
Acta Neurochirurgica
statistically significant (P < 0.05). The VAS scores of leg
pain were significantly improved when compared with those
before operation. Preoperative VAS scores of leg pain were
4.60 ± 2.61 and respectively decreased to 1.00 ± 0.71 and
0.60 ± 0.55 at postoperative 1 month and at the last follow-
up, and the difference was statistically significant (P < 0.05).
ODI scores were significantly improved when compared
with those before operation. Preoperative ODI scores were
62.00 ± 3.16 and respectively decreased to 38.00 ± 1.41 and
32.40 ± 3.29 at postoperative 1 month and at the last follow-
up, and the difference was statistically significant (P < 0.05)
(Table 1). According to the modified Macnab criteria, the
final outcome was excellent in 4 cases and good in 1 case.
Complications
All operations were successfully completed. No serious
complications, such as dural sac tears and vascular and nerve
injuries occurred during operation. Typical case is shown
in Fig. 2.
Discussion
MIS-TLIF is widely accepted and familiar to most spine
surgeons, and the clinical results and fusion rates are sat-
isfactory [14]. Various types of endoscopic fusion surgery
have been attempted for the treatment of lumbar degenera-
tive disease. Some studies have reported that endoscopic
MIS-TLIF showed an acceptable fusion rate [15]. Among
them, endoscopic MIS-TLIF with UBE has been reported
in several studies [7, 16, 17]. However, the fusion surgery
had a lower fusion rate when performed in water because of
lesser amounts of autologous or allograft bone. Therefore,
the modified method was performed to increase the surface
area with a large cage to increase fusion rate and prevent
cage subsidence. Previous studies have proved that clinical
results were satisfactory [8, 18]. In our study, we performed
endoscopic fusion with large cage. Cage size was as fol-
lows: length, 40 mm; width, 16 mm; and lordotic angle, 6°.
Because the width of large cage is 16 mm, the entrance for
the cage must be larger than the conventional MIS-TLIF.
Table 1  Clinical outcomes in different times
Time VAS scores VAS scores ODI (%)
(back pain) (lower limb
pain)
Preoperative 6.20 ± 0.84 4.60 ± 2.61 62.00 ± 3.16
Postoperative 1 month 2.20 ± 0.45 1.00 ± 0.71 38.00 ± 1.41
Final follow-up 1.40 ± 0.55 0.60 ± 0.55 32.40 ± 3.29
P value P < 0.05 P < 0.05 P < 0.05
Values are presented as mean ± standard deviation. P < 0.05 consid-
ered as significant.
So, the ipsilateral facet joint must be removed to secure this
space. The large cage was inserted more laterally than the
conventional MIS-TLIF so that a large cage could be safely
inserted. In addition to the advantage of increasing the sur-
face area with a large cage, a large cage could help to correct
the sagittal imbalance. A 6° angle cage was able to improve
the segmental and lumbar lordosis. What’s more, the large
cage is located at medial margin of both pedicles and can
support the apophyseal ring adequately, so it also helps to
correct the coronal imbalance. The conventional cage was
frequently located at the center of the endplate, which may
result in a high risk of poor outcome because of subsidence
and migration [19]. However, the large cage greatly reduces
this possibility and leads to a higher rate of fusion by main-
taining a stable state.
Bilateral pedicle screw fixation is a standard procedure
in the fusion surgery. Bilateral pedicle screw internal fixa-
tion can immediately reconstruct lumbar stability, restore the
lumbar balance, and promote intervertebral fusion, which
effectively reduces the postoperative lumbar and leg pain
of patients. However, the high rigidity and stress occlusion
of bilateral pedicle screw internal fixation can easily lead
to osteoporosis of fixed segments, which affects the fusion
rate. Moreover, the stress concentration also accelerates
adjacent segment degeneration. So, there have been studies
that reported the use of unilateral pedicle fixation and the
clinical results were satisfactory. The bilateral pedicle fixa-
tion usually results in more damage to soft tissue and para-
vertebral muscles than unilateral pedicle fixation. Previous
studies have reported that there was no significant difference
in the terms of clinical effects, fusion rate, and complications
between bilateral and unilateral pedicle screws [11, 20]. So,
in our study, we performed the unilateral pedicle screw fixa-
tion after completing the intervertebral fusion. The back pain
and leg pain were improved after operation, and ODI scores
were improved during the follow-up, which indicated that
lumbar function was further improved.
Lumbar stability should be achieved by percutaneous
pedicle screw fixation after unilateral biportal endoscopic
decompression and intervertebral fusion. At present, per-
cutaneous pedicle screw placement technology has been
relatively mature, but how to accurately insert percutane-
ous pedicle screws is still a challenge for spine surgeons.
The traditional C-arm X-ray–assisted percutaneous screw
placement is actually a non-direct vision procedure, which
requires repeated fluoroscopy to confirm the anatomical
structure, and it is difficult for surgeons to need transform
the two-dimensional image into three-dimensional anatomi-
cal structure, especially for beginners. Repeated fluoroscopy
increases the operation time, so the surgeon often needs to
wear heavy lead clothes in order to improve the operation
speed, but wearing lead clothes for a long time may affect
the surgeon’s health, causing chronic low back pain, lumbar
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 Acta Neurochirurgica

Fig. 2  Female, 58 years old,

L4/5 degenerative lumbar spon-
dylolisthesis. A Preoperative
anteroposterior X-ray image;
B preoperative lateral X-ray
image; C preoperative sagittal
CT image; D preoperative sagit-
tal MR image; E preoperative
axial MR image; F preoperative
3D-CT image; G postoperative
anteroposterior X-ray image;
H postoperative lateral X-ray
image; I postoperative sagittal
CT image; J postoperative sag-
ittal MR image; K kostoperative
axial MR image; L postopera-
tive 3D-CT image

disc herniation, and other problems. O-arm navigation sys-
tem or robot-assisted technology can provide high-quality
images and real-time tracking of surgical instruments dur-
ing the operation and thus have an advantage of high screw
placement accuracy. However, these techniques can reduce
the amount of radiation to the surgeon caused by repeated
C-arm fluoroscopy, but they can increase the amount of radi-
ation to the patients. Although fluoroscopy does not need to
be repeated during the operation, a lot of time is spent in the
preparation stage. Moreover, its promotion and application
are limited in primary hospitals due to its complex opera-
tion process, expensive equipment, long learning curve, and
other characteristics.
The pedicle screw placement technique under endoscopic
guidance does not need to increase the cost of unilateral
biportal endoscopic technique. It can find the anatomical
mark and determine the pedicle screw entry point under
direct vision. The needle position can be adjusted under
direct vision, with less damage and higher accuracy. In
this study, the average fluoroscopy was 4 times per screw

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Acta Neurochirurgica
placement, and the surgeon did not need to wear lead cloth-
ing for protection. With the maturity of surgical techniques,
the number of fluoroscopy is expected to be further reduced.
There are some limitations to our study. First, the size
of the sample is very small and this is not a multi-centered
study. But for endoscopic screw placement technology, it can
be preliminarily proved that this technology is feasible and
relatively safe. Second, this is a retrospective study and lacks
of randomized control group. Third, the follow-up time is
very short. The study still needs long-term follow-up to fur-
ther evaluate the clinical effects. But for endoscopic screw
placement technology, it can be preliminarily proved that
this technology is feasible and relatively safe.
Conclusion
UBE-eXTLIF with large cage combined with endoscopic
unilateral pedicle screw fixation can achieve preliminary
excellent clinical results and may become a new minimally
invasive endoscopic fusion method for lumbar degenerative
diseases.
Funding The work was supported by grants from the Foundation of
Anhui Medical University (No. 2021xkj028) and Clinical Research
and Cultivation Program of the Second Hospital of Anhui Medical
University (2020LCZD05).
Declarations
Ethical approval and informed consent. The study was approved by our
institutional Ethics Committee, and the informed consent was obtained
from all patients.
Conflict of interest The authors declare no competing interests.
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