Biportal Endoscopic Spine Surgery Allows for Complex Procedures With Quicker Recovery

Neurosurgeons at Emory's Healthcare’s Spine Program are now offering a novel, minimally invasive procedure, known as biportal endoscopic spine surgery; Emory is currently the only academic medical center in Georgia to perform this surgery.

Biportal endoscopic spine surgery is considered an improved and more versatile technique compared to uniportal endoscopic spine surgery — another minimally invasive procedure offered at Emory — primarily due to the enhanced surgical maneuverability and visualization afforded by the use of two separate portals instead of one. The biportal system utilizes two small incisions (one for the endoscope and one for the instruments). By allowing the surgeon to use conventional surgical instruments, the biportal procedure is aimed at doing more complex cases than uniportal spine surgery.

Biportal Endoscopic Laminectomy in a 90-Year-Old Woman With High-Risk Comorbidities

A 90-year-old female reported excruciating right leg and back pain that kept her wheelchair-bound and unable to mobilize or transfer independently. She was found to have degenerative lumbar scoliosis and degenerative lumbar spondylolisthesis.

Daniel Refai, MD Given the patient's age and the complexity of the deformity, a traditional approach would have required a major fusion operation to address the malalignment, which was deemed too risky, as was a standard open laminectomy, due to her osteoporosis and overall frailty. She reported that multiple providers had told her there was no alternative, but she was insistent. While hesitant at first, neurosurgeon Daniel Refai, MD, offered the patient the option of a biportal endoscopic laminectomy.

Treatment Strategy

Dr. Refai made two small incisions, each approximately 10 millimeters long, over the affected L4–L5 segment of the spine. (Given the patient’s BMI, an open surgical incision would have measured six inches.)

Traditional surgical instruments were used through the inferior port, allowing the surgeon to cauterize the tissue, drill the lamina, remove the thickened yellow ligament (ligamentum flavum), and decompress the nerve roots. Dr. Refai also used intraoperative navigation — the use of computers and software to compare preoperative and intraoperative imaging to create a three-dimensional model of the patient’s anatomy in real time during surgery; this was the first use of intraoperative navigation in the United States with this procedure type. The operation took approximately 90 minutes. Due to the patient’s age, Dr. Refai kept her overnight and discharged her the next morning.

Post-Procedure Follow-Up

At her six-week follow-up, the patient was standing and walking and reported being about 80-85 percent better, with no pain in her right leg. Her son confirmed that she no longer needed a wheelchair, other than for long distances, and she was able to transfer on her own.

Bipolar Endoscopic Laminectomy for Lumbar Stenosis in an Elderly Man

An elderly male presented to the clinic with severe lumbar radiculopathy, commonly known as sciatica, causing pain radiating down his right leg. His condition was diagnosed as lumbar stenosis at a single spinal segment, with compression of the nerves predominantly on the right side. The cause of the nerve compression was a combination of ligament and joint overgrowth intruding into the spinal canal. The patient had exhausted conservative management, including physical therapy, medications, and injections, which provided only temporary relief before his symptoms returned. The patient’s physiatrist at the Spine Center referred him to a colleague, neurosurgeon Juanmarco Gutierrez, MD, for a consultation.

Treatment Strategy

After determining that the patient was a candidate for the procedure, Dr. Guttierrez performed a biportal endoscopic laminectomy to achieve the necessary nerve decompression while minimizing tissue damage and expediting recovery after surgery.

Historically, this degree of bone removal and decompression—including drilling the laminar bone and shaving the inner third of the overgrown joints—would necessitate an open laminectomy. An open procedure involves significant muscle retraction, blood loss, and a one-to-two-day hospital stay. Despite the complexity of the pathology, the biportal system allowed the surgical team to perform the single-level laminectomy successfully. The surgery took approximately 90 minutes, causing minimal blood loss and minimal disruption to the muscle and soft tissues.

Post-Procedure Follow-up

Immediate post-operative results were excellent: The patient was discharged 2-3 hours after the procedure and left the facility with symptoms that were much improved. At his first post-op visit several weeks later, the patient reported that his quality of life was remarkably improved, with only mild discomfort in his back from time to time that responds to treatment with acetaminophen.

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