Technical Refinements for Right-sided Unilateral Biportal Endoscopic Transforaminal Lumbar Interbody Fusion: A Stepwise Operative Workflow
Ashutosh Kumar, Pooja Tataskar, Swarjeeth Nimmakayala, J Anantha Chaitainya, Arun Kumar Srivastava, Kuntal Kanti Das, Ved Prakash Maurya, Pawan Kumar Verma, Anant Mehrotra, Awadesh Kumar JaiswalBackground:
Right-sided unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) presents specific ergonomic and technical challenges, particularly during cranial laminotomy, ligamentum flavum resection, preservation of local autograft, endplate preparation, and management of irrigation. We describe a stepwise set of technical refinements designed to address these challenges while maintaining the established principles of UBE-TLIF.
Technical Description:
The workflow incorporates targeted modifications for right-sided UBE-TLIF. A cranially positioned working portal and caudally positioned viewing portal are planned to optimize triangulation and instrument trajectory. A “feather-brush” laminotomy using progressive cortical thinning with a 4-mm diamond burr facilitates controlled exposure of the ligamentum flavum before Kerrison punch removal. Sequential “Z-sequence” flavotomy maintains anatomical orientation during ligamentum flavum detachment. A three-point drilling technique enables preservation of an intact inferior articular process as structural autograft while simultaneously expanding the operative corridor. Direct intradiscal endoscopic visualization is used for circumferential endplate preparation while preserving the subchondral bone. Gravity-assisted irrigation with continuous outflow and the “fountain sign” provides a practical method for maintaining an appropriate operative field. Portal positioning is additionally planned to facilitate subsequent percutaneous pedicle screw placement.
Conclusion:
These technical refinements address key ergonomic, biological, and fluid-management challenges encountered during right-sided UBE-TLIF. Integration of controlled bone removal, sequential flavectomy, autograft preservation, direct endplate visualization, and standardized irrigation management may improve procedural reproducibility and facilitate safer execution of UBE-TLIF. Prospective comparative studies are required to determine whether these modifications translate into improved clinical or procedural outcomes.