Clinical efficacy and safety of unilateral biportal endoscopy for thoracic ossification of ligamentum flavum: A systematic review
Jun Li1
, Linbo Jiang2, Ting Zhang3
1Department of Orthopaedic, Affiliated Hospital of Southwest Jiaotong University, the Third People’s Hospital of Chengdu, Chengdu, China
2Department of Radiology, Affiliated Hospital of Southwest Jiaotong University, the Third People’s Hospital of Chengdu, Chengdu, China
3Department of General Surgery, Center of Obesity and Metabolic Diseases, Affiliated Hospital of Southwest Jiaotong University, the Third People’s Hospital of Chengdu, Chengdu, China
Keywords: Minimally invasive surgery, spinal stenosis, systematic review, thoracic ossification of ligamentum flavum, unilateral biportal endoscopy.
Abstract
Objectives: In this systematic review, we discuss the clinical efficacy and complications of unilateral biportal endoscopy (UBE) in the treatment of thoracic ossification of the ligamentum flavum (TOLF), providing surgeons with evidence-based guidance for optimal treatment decisions.
Materials and methods: We systematically searched the PubMed, EMBASE, Cochrane Library, CNKI, Wanfang, and VIP databases up to January 2025. Inclusion criteria encompassed studies reporting UBE outcomes for single/double-segment TOLF. Data on pain (Visual Analog Scores [VAS]), function (Oswestry Disability index [ODI] and Japanese Orthopaedic Association [JOA]), and complications were pooled using random-effects models. Minimal clinically important difference (MCID) was applied as the evaluative benchmark for clinical significance.
Results: Six studies (n=77) were analyzed. Significant improvements were observed in leg pain (p<0.001; 95% confidence interval [CI]: –6.63 to –3.57; I2=88%), back pain (p<0.0001; 95% CI: –6.36 to –3.83; I2=86%), ODI (p<0.00001; 95% CI: 31.00 to 53.53; I2=95%), and JOA scores (p<0.05; 95% CI: 2.80 to 3.70; I2=86%). The overall complication rate was 28% (2/6 reporting zero complications), predominantly mild (headache, hyperalgesia). Severe complications included dural tears (2.6%) and spinal cord injury (2.6%), with heterogeneity attributed to surgical technique evolution.
Conclusion: Preliminary evidence suggests UBE may be a promising minimally invasive approach for TOLF, potentially offering accelerated recovery and reduced perioperative morbidity. However, given the limited sample size and substantial heterogeneity, these findings require validation through large-scale prospective studies.
Citation: Li J, Jiang L, Zhang T. Clinical efficacy and safety of unilateral biportal endoscopy for thoracic ossification of ligamentum flavum: A systematic review. Jt Dis Relat Surg 2026;37(1):263-272. doi: 10.52312/jdrs.2026.2108.
Contributed to the conceptualization and design of the study: J.L., T.Z.; Conducted a systematic literature search and data analysis, contributing significantly to the interpretation of the data: J.L., L.J.; Was responsible for drafting the manuscript and performing the statistical review: J.L.; Provided a critical review of the manuscript and took primary responsibility for the final content: T.Z. All authors reviewed and approved the final version of the manuscript.
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.
This study was supported by Sichuan Provincial Natural Science Foundation (2024NSFSC1619) and Technological Innovation R&D Project of Chengdu Municipal Science and Technology Bureau (2024-YF05-01281-SN).
The data that support the findings of this study are available from the corresponding author upon reasonable request.