Four Years of UBE Evolution: From Lumbar Decompression to Complex Spine Care

UBE | biportal endoscopic spine surgery | lumbar fusion | cervical and thoracic spine | irrigation safety

SUMMARY  A 2020-2024 retrospective on how unilateral biportal endoscopy expanded from lumbar decompression to fusion and selected cervical and thoracic procedures, and why broader indications must be matched by stronger safety systems.

From an emerging technique to a mature surgical tool

Unilateral biportal endoscopy (UBE), also described as biportal endoscopic spine surgery (BESS), creates a water-based operative field through separate viewing and working portals. Unlike uniportal systems that place the camera and instruments within one access route, UBE gives the surgeon independent instrument movement under endoscopic visualization. Standard drills, punches, dissectors, and radiofrequency devices can be used in a way that resembles familiar microscopic or open techniques. Between 2020 and 2024, UBE moved beyond straightforward lumbar disc and stenosis procedures toward reconstruction and more complex multilevel disease.

Lumbar fusion accelerated technical development

UBE-assisted lumbar interbody fusion combines endoscopic decompression with reconstruction of spinal stability. The two-portal arrangement can provide flexible working angles for neural decompression, endplate preparation, and cage insertion. Comparative studies suggest that UBE fusion and minimally invasive transforaminal lumbar interbody fusion can both achieve meaningful pain relief and satisfactory fusion outcomes. UBE may offer advantages in early soft-tissue preservation, blood-loss control, and recovery, but operating time, equipment management, and surgeon experience influence the real-world benefit. It should be viewed as an additional option rather than an automatic replacement for established fusion surgery.

Moving beyond the lumbar spine

With accumulated experience, surgeons have applied UBE to posterior cervical foraminotomy, selected cervical canal procedures, and demanding thoracic conditions such as ossification of the ligamentum flavum. The cervical and thoracic regions allow far less margin for error because the spinal cord is vulnerable and the working space is narrow. Modern strategies emphasize adequate decompression while preserving stabilizing structures and avoiding direct pressure on neural tissue. In thoracic ossification surgery, thinning and separating the lesion from the outside before floating or removing it reflects a broader shift toward minimizing spinal-cord manipulation.

Maturity is not measured by the number of indications

A technique is mature only when patient selection, reproducible steps, training, complication management, and rescue options mature with it. A uniportal approach may remain efficient for a simple soft-disc herniation, while UBE may be more useful for extensive bony stenosis, bilateral decompression, or fusion. Open surgery, microscopy, uniportal endoscopy, and biportal endoscopy are not stages in a contest where one must eliminate the others. They are tools that should be matched to anatomy, pathology, surgeon capability, and the treatment goal.

The next phase: making fluid safety a core competency

Continuous saline irrigation is central to the clear visual field in UBE, but it also introduces fluid-dynamic risks that are less prominent in open surgery. Excessive pressure, impaired outflow, prolonged surgery, or a dural injury may increase epidural pressure, fluid extravasation, and neurologic complications. The next advances in UBE will come not only from navigation, robotics, and new instruments, but also from standardized use of the lowest effective irrigation pressure, reliable outflow, attention to fluid accumulation, and a clear response plan for dural injury.

Medical content notice: This material is intended for professional health communication and website editorial use. It is not a diagnosis, treatment recommendation, or endorsement of a specific procedure. Indications, irrigation settings, and operative plans must be determined by qualified spine, anesthesia, and nursing teams according to the individual patient and institutional standards.